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The government’s underpinning theory that health is harmed by worklessness6 and that cutting state benefits can promote health by disincentivising worklessness contradicts the international development tenet that increasing people’s resources improves health.9 Indeed, non-governmental organisations such as GiveDirectly10 now promote unconditional cash transfers. Pre-pandemic data indicate that countries in the Organisation for Economic Cooperation and Development (OECD) that invested a higher percentage of gross domestic product (GDP) in public and mandatory private spending on benefits, pensions, housing, health, and social care in 201411 had lower potential years of life lost (PYLL) rates, a measure of premature mortality, five years later.12 The UK’s PYLL rate ranked in the middle, likely because of insufficient spending on a highly conditional welfare system requiring costly administration and assessment (£0.28 for every £1 paid in 201813). Overall, countries that perform better have more generous payments and lower levels of conditionality.14 Of the Nordic countries, Sweden and Iceland have lower PYLL rates than Denmark, which has more conditionality, means testing, and social programme spending.15

tion and assessment (£0.28 for every £1 paid in 201813). Overall, countries that perform better have more generous payments and lower levels of conditionality.14 Of the Nordic countries, Sweden and Iceland have lower PYLL rates than Denmark, which has more conditionality, means testing, and social programme spending.15 Research and policy making are disproportionately led by older, privately or Oxbridge educated people in well paid, comfortable jobs.16 17 18 This lived experience is likely to inform generalising assumptions of the relation between work and health.19 Some microsimulation modelling assumes20 that essentially any job is better for health than social security, even if this means a reduction in amount, security, or predictability of income. This reinforces decades of UK government attempts to increase social security conditionality and decrease generosity. However, evidence indicates that poorly paid, insecure, unsafe jobs are as harmful as unemployment for health.21 Around 29% of workers aged 18-20 hold such jobs,22 with bargaining power undermined by age based welfare and minimum wage discrimination.23 For many, employment no longer provides the pathway to property, family, and success it once did, with rising inequalities in wealth and housing contributing to reduced spending power.24

In 2023-24, 39% of families receiving universal credit had at least one person in work.25 Financial insecurity and unpredictability have negative causal effects on health and social outcomes, even in the short term.26 27 Falling below a low income “desperation threshold” is associated with serious deterioration in outcomes.28 This downward spiral creates higher health service costs and broader social and economic dysfunction,24 ensuring that budget increases are outpaced by service demand.7 Our modelling based on long term international data indicates that public spending, including on welfare payments, results in substantial gains in GDP and tax yield and that large cuts over the past 15 years have resulted in compounding losses.7 However, simply increasing the size of conditional welfare payments retains high administration costs, perverse incentives for inactivity, and unfairness for those who work. An alternative is basic income: a largely unconditional, modest, secure, and predictable payment to all citizens.29 Although evidence on basic income is primarily derived from experiments in other nations and modelling of income changes, the predicted health benefits—through improved nutrition and living conditions, long term investment in positive health behaviours, and reduced stress—are substantial.30 Modelling indicates that a modest basic income with no additional government borrowing could result in historically low poverty and inequality rates in the UK.31

ed health benefits—through improved nutrition and living conditions, long term investment in positive health behaviours, and reduced stress—are substantial.30 Modelling indicates that a modest basic income with no additional government borrowing could result in historically low poverty and inequality rates in the UK.31 Poverty and inequality are social determinants of health. The government’s reform proposals6 highlighted evidence that the current system can trap people in inactivity and that associated trends have worsened, ironically alongside decades of increased assessment and ever narrower eligibility criteria. The solution is unlikely to be further reforms that plough the same furrow. An ambitious and generous universal benefit system that protects workers is needed.