Big Questions

COVID-19 has placed science-driven health policy at the forefront of government messaging. The pandemic is merely the latest in a series of issues around which UK governments have expressed a desire to be ‘driven by science’. The aim of the ‘prevention agenda’ is to challenge conceptualization of the NHS as the ‘National Hospital Service’ (see Department of Health and Social Care & Hancock, 2018) in favour of evidence-based measures to avoid illness. This has contributed to interest in efficient, easy to administer ‘upstream interventions’. The Lancet Public Health (2020) has recently examined the effect of such policies, while some have suggested that Universal Basic Income (UBI) – regular, unconditional transfers to citizens – may serve as an effective means of addressing the social determinants of ill-health (see Johnson, Johnson, Nettle & Pickett 2020). The BMJ has called for a trial on health grounds (Painter 2016), both Labour (Labour Party 2019) and the SNP made commitments to trials (Crerar 2020) and the Spanish Government has introduced a UBI-like (Ng 2020a) Minimum Income Guarantee (Ng 2020b) in response to COVID-19. Uniquely, we have developed a model (fig. 1) with three pathways to health impact: improved satisfaction of need via poverty reduction (Johnson, Degerman & Geyer 2019); reduced stress by mitigation of inequality (Johnson & Johnson 2018), and behavioural change associated with reduction in extrinsic mortality cues (Pepper & Nettle 2017).

UBI is often rejected on account of cost (Martinelli 2017) and reluctance to reward inactivity (Anderson 2000). However, there have been no trials of programmes that mirror universality, scale and duration of a likely policy in the UK and no trials have been designed specifically with health in mind. This means that there has been no comprehensive evaluation of dynamic health impact and no evaluation of the returns that this might offer. As such, the evidential basis for assessing UBI’s value as a public health measure is deficient. Lack of concern for health means that health impact from studies has either been omitted or lost. For example, while unconditional cash transfers to recipients of unemployment benefit in Finland improved self-reported wellbeing (Kangas, et al. 2019, 30), the scheme was rejected as a ‘failure’ on account of its neither increasing nor decreasing paid employment (Henley & agencies 2019), even though the data suggested that fear of idleness was unfounded. The failure in framing and measurement of impacts allowed a positive finding to be misrepresented and for health impact to be overlooked.

We have produced a series of scoping papers that establish a cluster of design (Johnson, Johnson, Nettle & Pickett 2020), measurement (Johnson, Johnson & Webber 2020), costing (Johnson, et al. 2020) and political framing (Nettle, et al. 2020) questions that need to be addressed in order for the policy to be evaluated and the case for a trial developed. These questions form the basis for four Work Packages (WP): WP1: How can UBI be designed for health impact?; WP2: How can we evaluate UBI? WP3: Is UBI for health affordable?; WP4: Is UBI politically viable?

These questions are examined through completion of the following objectives:

WP1: How can UBI be designed for health impact?:
Because UBI has been advanced predominantly by economists, trials have been designed specifically with effects on employment, consumption and growth in mind. However, designing schemes to achieve health impact as one of several qualitatively distinct, but related, outcomes, requires a different set of considerations. We
Objective (O) 1: establish size and timing of payment to affect social determinants of health
O2: develop means of supporting disability-related, age-related and housing needs
O3: determine ethically how payment should be weighted against other societal interests, such as with regard to reciprocity, rewarding work and fairness in taxation
04: determine how policy should deal with legal issues related to the introduction of UBI
Key outcome: i) 3 different UBI schemes designed for health impact for examination in WP2(O2) and evaluation in WP3 and 4

WP2: How can an evidential basis be developed by which to evaluate the policy?
Evidence from cash transfer schemes suggests several important health impacts, including reduction in non-communicable disease and improvement in mental health. However, because no representative trial of UBI has been designed or data gathered specifically for health impact, the evidence is not comprehensive. To establish an evidential basis of evaluation in advance of a trial and means of more accurate evaluation during a trial, we
O1: extract data on impact of conditional and unconditional transfers on health for construction of multiple interacting risk factors
O2: establish to what extent evidential gaps can be filled via modelling
O3: develop research protocols to capture comprehensively health impact during different types of trials
O4: establish the cost of conducting research during those different types of trials
Key outcomes: i) a projection of dynamic health impact for each of the schemes; ii) two costed research protocols for different types of trial

WP3: Is UBI affordable?
Economic opposition to a trial has been summarised by Martinelli’s claim that ‘an affordable basic income would be inadequate, and an adequate basic income would be unaffordable’. However, no assessment of UBI has considered the potential economic impact of a successful upstream intervention. This WP uses dynamic modelling to:
O1: calculate the monetised health impact of UBI schemes from WP1
O2: model the short, medium and long-term cost of different UBI schemes derived from WP1
O3: model the overall monetised economic returns on investment from those schemes
O4: evaluate fiscal strategies, through tax and governmental reform, to fill funding gaps
Key outcomes: i) a set of projections of dynamic economic impact for each of the schemes; ii) fiscal strategies to meet funding shortfalls

WP4: Is UBI politically viable?
A body of evidence suggests that voters’ assessments of health and welfare policies do not map onto those voters’ material interests and that politicians’ perspectives on policies’ viability tend to be risk averse. Even if UBI promotes health, the policy may be rejected for political or electoral reasons. This WP uses survey and focus group work to:
O1: establish the constituent features of UBI that affect its perception by the electorate
O2: explore means of framing the policy to appeal to electoral concerns
O3: establish means by which politicians might be persuaded of feasibility
Key outcomes: i) a strategy for politicians wishing to advance the policy