The social security system was created as a cornerstone of the British Welfare State, designed to provide a safety net to keep people of all ages out of poverty and to tackle one of the Five Giants of the Beveridge Report: want.

Decades later, social security in the UK has gone through numerous changes as the world around it has changed too. And in the last two decades in particular, the benefits system has undergone especially rapid (and often repeated) change.

The social security system interacts with mental health in many different ways. By providing a safety net against poverty, it can (or should) provide a buffer against mental ill health by preventing a major risk factor. The social security system also provides income replacement to people whose earnings are affected by mental ill health – a critically important function in people’s lives when they need it most. And in both cases, it was created to enable people to live with dignity through difficult times: ending the fear and shame associated with its Poor Law predecessors. But as the system has evolved, does it still achieve these important ends?

Recent academic research has sought to understand the impact of a range of changes to the UK benefits system on people’s mental health. Some studies have looked at specific changes to the system over the last ten years and the ways they have affected the mental health of people and communities. Other studies with relevant findings have explored related issues such as minimum wage and employment security regulations, or used international evidence to understand the importance of financial security as a broader concept of relevance to mental health. This blog aims to draw together what we can learn from those studies as a whole.

Methods

Many of the studies that have been carried out have sought to understand the impact of changes to benefits on people’s mental health by comparing experiences before and after they occurred.

• Barr et al (2016) for example explore whether changes in disability benefit assessments between 2010 and 2013 in England were associated with localised changes in suicide rates, self-reported mental health problems and antidepressant prescribing rates
• Similarly, Reeves et al (2016) compare the prevalence of mental health problems among low income renters in the private sector before and after cuts were made to Housing Benefit rates during the same period, using as a ‘control group’ those not receiving Housing Benefit
• And Wickham et al (2020) examined the more recent introduction of Universal Credit by comparing levels of psychological distress (from survey data) before and after people were moved onto the new benefit.

Others have made comparisons between cohorts of people – for example in different areas with different social security or employment regulations.

• Kaufman et al (2019) for example compare different minimum wage levels in the US between states with unemployment and suicide levels
• While Barlow et al (2019) compare the health of people living in European countries with different employment security measures (for example severance payments and notice periods).

Results

All of the studies point to a consistent set of results.

As social security systems become more restrictive, less generous and less trusting, the mental health of the people they support gets worse.

• Reeves and colleagues (2016) find that cuts in Housing Benefit payments between 2011 and 2013 increased depression rates among people in private rented accommodation: equivalent to 26,000 new cases of depression
• Barr and colleagues (2016) find that disability benefit reassessments using the Work Capability Assessment increase mental health problems and rates of antidepressant prescribing, with the greatest impacts in more deprived geographical areas
• Wickham and colleagues find that the move to Universal Credit between 2013 and 2018 increased psychological distress, putting more than 20,000 more people at risk of clinical depression.

Other studies have found that measures that seek to increase the incomes of the poorest or that create greater social security are associated with improved mental health.

• Barlow and colleagues (2019) find that in countries with more generous severance payments, people’s mental health is less likely to decline when they are unemployed
• Kaufman and colleagues (2019) find that higher minimum wages are associated with lower unemployment rates, especially for people with the poorest life chances
• And Ridley and colleagues (2020), reviewing evidence from a range of international studies on the relationship between wealth, income and mental health, find that ‘positive economic shocks’ improve mental health, while losses of income do the opposite.

Conclusions

These are hardly surprising findings. They reflect what many people experience day to day. Economic inequality is toxic to our mental health, and it is especially toxic for people living in poverty (Patel et al., 2018). Employment that pays people enough to live on and provides security boosts our mental health. So does housing security, and living in a safe, decent quality, warm home (Pevalin et al., 2017). But the impact of the benefits system on our mental health goes deeper than its generosity. Its ability to boost mental health is also linked to the relationships it produces: whether people are treated with dignity and respect, and trusted by the system, also matters. And social security is about a lot more than benefits: it has important links to employment policies and regulations, housing and personal finance.

The conclusion these studies point to is that the more restrictive (in every sense) benefits become, the more mental ill health will result. This carries multiple costs. For individuals, families and communities, it means poorer health as well as poorer finances. But there are wider costs, too. More people experiencing depression means more people needing mental health support, and higher antidepressant prescriptions (Thomas et al., 2019). For people with long-term mental health problems, it can bring about a crisis that may result in homelessness or hospitalisation. Saving money in social security payments brings about not just misery and distress but extra costs in health and social care; a false economy that in the most tragic cases may cost lives (Barr et al., 2016).

Strengths and limitations

The studies we’ve reviewed for this blog as part of the Commission for Equality in Mental Health (2020) each provide a glimpse into the specific impacts of single acts of policy or practice change: for better or worse. In the real world, of course, they do not work in isolation. Changes to the UK benefits system in the last two decades, under successive governments, have made it less generous (for people of working age at least), less trusting and more combative. The value of benefit payments as a proportion of average income in the UK has fallen. And some groups of people have experienced particular reductions in the value of multiple benefits; for example those affected by caps on Housing Benefit and other payments. Benefit assessments have also changed, with the introduction of Personal Independence Payment in place of Disability Living Allowance. And the introduction of benefit conditions and payment sanctions for people on out of work benefits has brought greater uncertainty to many.

Together, these changes represent a major challenge to people’s mental health. None of the studies we have reviewed has sought to explore the cumulative impact of these changes. Nor do they look at the many other elements that coalesce to produce the deep and entrenched mental health inequalities that exist today: such as systemic racism, gender inequality and violence, and disability discrimination. These must all be part of the picture of understanding how economic inequality and the operation of our social security system relates to our mental health.

Implications for practice

The evidence that has been amassed about the impact of social security policies on mental health has clear implications for their future direction. A social security system that seeks to protect people from poverty, to reduce inequality and insecurity, and to promote social solidarity will be good for mental health. The Child Poverty Action Group has set out the principles for a benefit system that achieves these goals (Howes, 2019). Implementing those principles would bring significant improvements to mental health and reduced mental health inequality.

For mental health policy and practice, these may seem far from reach. Without a ‘health in all policies’ approach to government, or a ‘wellbeing budgeting’ strategy of the kind being developed in New Zealand (O’Shea and Bell, 2020), they are seen to be beyond the scope of mental health policy in the UK. But there are vital steps that can be taken at every level. For mental health services, maximising people’s incomes – securing benefits people are entitled to and supporting with work when people want it – are important health interventions. Ensuring people have adequate housing – never discharging someone from hospital with no home to go to, making sure their housing rights are upheld at all times – is likewise crucial. And supporting people to deal with problem debts and other financial difficulties can make a big difference.

Further, mental health services can look at what employment opportunities they offer to people in the communities they serve (Molyneux et al., 2020). The role of NHS organisations and local authorities as ‘anchor institutions’ in their local economies has been overlooked for a long time. Yet Lambeth Borough Council and the NHS trusts in its local area recently became Living Wage Employers, guaranteeing to pay a decent wage to all of their staff and keeping thousands of lower paid workers out of poverty.

System change to tackle mental health inequality is long overdue. And addressing income inequality and insecurity must be at the heart of that change. ‘Want’ remains a major challenge for too many people with mental health difficulties. A social security system that reconnects with its founding purpose and values, in the context of the twenty-first century and in the aftermath of the Covid-19 pandemic, could once again slay the giant and dramatically improve health.

Statement of interests

None.

Links

Primary papers

Barlow, P. et al. (2019) Employment relations and dismissal regulations: Does employment legislation protect the health of workers? Social Policy and Administration 2019; 53: 939-957

Barr, B., et al. (2016) ‘First do no harm’: are disability benefit assessments associated with adverse trends in mental health? A longitudinal ecological study Journal of Epidemiology and Community Health 2016; 70:339-345

Kaufman, J., et al (2019) Effects of increased minimum wages by unemployment rate on suicide in the USA Journal of Epidemiology and Community Health 2019; 0:1-6

Pevalin, D. et al. (2017) The impact of persistent poor housing conditions on mental health: A longitudinal population-based study. Preventive Medicine 105 (2017) 304-310

Reeves, A., et al. (2016) Reductions in the United Kingdom’s Government Housing Benefit and Symptoms of Depression in Low-Income Households. American Journal of Epidemiology Vol. 184, No. 6

Ridley MW, Rao G, Frank Schilbach, Vikram H. Patel (2020) Poverty, Depression, and Anxiety: Causal Evidence and Mechanisms. NBER Working Paper No. 27157 Issued in May 2020 NBER Program(s):Development Economics, Health Care, Health Economics https://economics.mit.edu/files/18694.pdf

Wickham, S., et al (2020) Effects on mental health of a UK welfare reform, Universal Credit: a longitudinal controlled study. Lancet Public Health 2020; 5: e157-64

Other references

Commission for Equality in Mental Health (2020) Mental Health for All? Final report. Centre for Mental Health

Howes, S. (2019) Secure futures for children and families. Child Poverty Action Group

Molyneux P, Perkins R and Rinaldi M (2020) Ensuring Appropriate Employment Support for People with Mental Health Problems. NHS Confederation : London

O’Shea, N. and Bell, A (2020) A Spending Review for wellbeing. Centre for Mental Health.

Patel V, Burns JK, Dhingra M, Tarver L, Kohrt BA, Lund C. (2018) Income inequality and depression: a systematic review and meta-analysis of the association and a scoping review of mechanisms. World Psychiatry. 2018 Feb;17(1):76-89. doi: 10.1002/wps.20492.

Thomas, F., et al. (2019) Poverty, pathology and pills (PDF) [Accessed 14 October 2020]

Photo credits

• Photo by Siora Photography on Unsplash