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Since the 1990s (with increasing resolve from 2010) assistance from the welfare state for low-income working-age adults and their children has become ever more ‘conditional’. Help to meet living costs and to find paid work has been accompanied by requirements that recipients behave in certain ways or risk losing that support. Responsibilities have expanded in scope, to cover not just the unemployed, but also lone parents, people with long-term health conditions and now (with the introduction of Universal Credit) low-paid workers. Penalties for failing to do what officials think is best for them have also become more severe. Knowing how successful this approach has been, given the role that income and employment play in determining health and health inequalities, is important. 

So what does the evidence say? A recent international conference in York explored these issues, presenting findings from a 5-year study by the Economic and Social Research Council (ESRC). It concluded that across a range of interventions, conditionality as designed and implemented in the UK has been largely ineffective in achieving its key objective at moving people into sustainable work. Although there were some examples of success, these were rare. 

More pressure on disadvantaged

Conditionality was effective at making people comply with the rules – but this by itself rarely helped people secure a job and was sometimes counterproductive, since participants’ (and officials’) energies were often displaced into activities such as meeting a quota of job applications regardless of their applicability, or attending multiple CV-writing courses. Moreover, loading more pressure onto already disadvantaged low-income individuals was often detrimental to their physical and mental health; it exacerbated anxiety and depression and lowered income, leading (in some cases) to destitution.

What are we to make of this? One place to start might be to examine the wider evidence base. A crude comparison of people into jobs versus individuals sanctioned supports the view of a punitive turn in policy: by 2014/15 in Britain, twice as many people were sanctioned as found work through Department for Work and Pensions (DWP) programmes. A recent research paper by NHS Health Scotland and Glasgow University also concluded that benefits sanctions for jobseekers were largely ineffective at moving people into sustainable work. Indeed, most simply got poorer.

In other research, aspects of conditionality like the steady lowering of the age of the youngest child at which lone parents are required to look for work have been associated with a rise in employment rates among the more highly qualified. Little change was seen among the least qualified, with evidence that mental health deteriorated for those affected. Despite rising employment rates and fewer children in workless households, the anticipated wider gains from welfare reform (in terms of mental health and poverty) have either failed to materialise or are moving in the wrong direction. 

Why is this a public health issue?

People who work in public health should engage, for a number of reasons – not least because it’s the NHS who will foot the bill when the poor health of many of those threatened by conditionality worsens. UK and Scottish policy also aims to increase the number of people with disabilities in employment, with the NHS expected to contribute to this goal. But as sanctions for people on incapacity benefits have been shown to reduce the prospects that people will find work, this seems illogical.

Scottish variant on social security 'exemplar'

What might help? The ESRC study noted that successful transitions into work often required holistic, empathetic interventions tailored towards unique needs. This is the approach advocated in Scotland. We should be cautious about accepting this at face value: one expert questioned whether it might simply legitimise a ‘fixing the individual’ approach, rather than addressing a broken labour market or dysfunctional social security system. There are also questions about its feasibility within current funding constraints. Nevertheless, the Scottish variant on social security and employability was viewed as a potential exemplar by many at the conference in York.

Institutions such as the Scottish Welfare Fund could also be bolder in rejecting destitution as a component of labour market policy. Public attitudes may help rather than hinder: this think-tank research shows that almost no-one supports the idea of leaving someone with depression or a physical disability with zero income if they are sometimes late for a meeting with their Job Centre Coach.

Reform of welfare in the UK has not been fair. Nor has it been beneficial for health or reducing health inequalities so far. It’s time to recognise that it’s not right that people are locked into poverty due to benefit sanctions. Maybe we need to think about whether the problem is not ‘them on welfare’ – but all of us, including those trying to think about and deliver good quality public services.

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