Should government help low-income families get a healthy start?

A healthy diet is important for a whole range of reasons and this is particularly true for children as they grow. The UK government has a number of policies that are designed to improve children’s diets, the most well-known of which is probably free school meals (FSMs). It’s been in the news a lot of late - with London trialling the rollout of free school meals to all children in primary schools in the city.

Rarely in the spotlight, and certainly the much less publicised cousin of FSMs, Healthy Start has existed since 2006. Its focus, just like FSMs, is improving child nutrition, but it often gets forgotten. This can seem to be true even for government - between 2009 and 2021 the value of Healthy Start payments didn’t increase.

Where to (healthily) start?

Healthy Start is basically a payment of at least £17 per month, loaded onto a Mastercard by the Department for Health and Social Care (DHSC) - that’s £4.25 each week. For a household to be eligible it must be in receipt of Universal Credit (the main welfare payment for people who are on low incomes, out of work, or cannot work), be earning less than £408 per month from employment and contain a woman who is at least 10 weeks pregnant or a child under the age of four. Children under one year old get a double payment - £34 a month instead of £17. And the payment is per child - so a household containing a one year old and a three year old would receive £51 per month.  

But, inevitably, there’s a catch - the money can’t just be spent on anything. Instead, it can only be used to buy healthy foods - fruit, vegetables, pulses, and milk. Frozen forms of these are all allowed. So are tinned forms, provided they’re in juice and not syrup or booze. Prepared salads are A-okay, but not if they include things that aren’t fruit, veg, pulses, or - though this would be weird - milk.

The rationale behind the voucher is pretty simple. Families with limited budgets may not feel able to afford healthy food. The goal is to help those at the very bottom of the income distribution to reliably purchase those foods.

Is that how it really works, though?

So, does the policy achieve this aim? Imagine first that Healthy Start doesn’t yet exist and we’re debating whether to introduce it. Imagine further that there are two types of poor household - (1) those that do consume £4.25, the weekly Healthy Start amount, or more of healthy foods in a week, and (2) those that don’t consume £4.25 of healthy foods in a week. Previous research has suggested that as much as 60% of eligible households are of type 2.

When the government introduces Healthy Start, these households suddenly have more to spend. On the face of it, it might seem natural that diets would improve. If the Healthy Start card can only be used on fruit, veg, pulses, and milk, and we assume that any rational person would rather have more food to eat than less, then the card will be duly spent on all those eligible goodies. The obesity crisis is solved as individuals gorge on apples.  

Strictly speaking, this is true. When you get the card out in a supermarket you’ll only be allowed to use it to buy eligible foods. But the same isn’t true of the rest of the household’s budget. So, households of type (1), who already spend £4.25 a week on healthy foods, can simply use the Healthy Start card instead of cash to buy the healthy foods they were already buying and spend the freed-up cash on other things. In other words, Healthy Start acts in the same way as a cash benefit for these households. This is unless there is a “labelling effect” where the fact that the payment is specified for use on healthy foods means households view the money as only to be used for additional healthy purchases to what they were making before.

It’s probably different for households of type (2). We’re assuming that households always prefer more food to less, so their spending should increase on healthy products as they spend the whole Healthy Start amount. Though some cash will still be freed up by the Healthy Start payment that could be spent on other things, they should be getting a higher intake of healthy foods overall.

So there two types of household with potentially different effects. For type (1) it’s unclear if more healthy foods will be bought, and whether diets will improve. For type (2), it seems more likely that Healthy Start should improve shopping habits and diets.

That’s the theory, but is it what we actually see in the real world? Researchers have found, using data on what people buy in the supermarket, that when Healthy Start was introduced spending on fruit and veg increased by roughly the amount of the Healthy Start payment among type (2) households. Type (1) households didn’t change the amount of healthy foods they bought, but they didn’t buy more unhealthy foods either. Researchers also estimated that for type (2) households the Healthy Start payment had a larger impact than an equivalent unrestricted cash benefit, whilst for type (1) households the effect was no different to a cash benefit, which suggests little room for a labelling effect. 

Healthy choices are hard for parents to make, both for themselves and on behalf of their kids. The fact that the policy has a different, bigger, effect than cash for a large chunk of households that get it, and increases the quantity of healthy foods that they buy suggests that the policy is, broadly, achieving its aim, and is having a desirable effect in terms of children’s nutritional intake.

What’s not to like?

One issue is that the policy introduces some strange incentives into the system. The eligibility threshold of £408 in take-home pay creates a cliff edge. Earn £409, an additional £1, and you lose the whole Healthy Start amount. Cliff edges like these were what Universal Credit was supposed to remove, but here they remain, and might act as a disincentive to work more hours and earn more.

Giving people welfare payments for specific things can also raise the prospect of households feeling stigmatised when they use them. This problem was more pronounced in the past when Healthy Start wasn’t used via a debit card but via paper vouchers that were more easily observed by other shoppers and when self-service tills in shops were less common. But feelings of stigma remain a possibility as people spilt their shop into healthy and unhealthy foods as they go through the till.

Opponents might also argue that individuals know how to spend their own money to best improve their children’s wellbeing. Sure, low-income households might like money to buy fruit and veg, but in the midst of a cost of living crisis, they might instead prefer to forego the green stuff and heat their homes instead. In this context, unrestricted cash might be thought to be better, though, of course, for the type (2) households the amount is already acting like a cash benefit.

And what are the limitations?

Of course, getting people to eat more healthily isn’t as simple as debit cards that can only be spent on targeted items. There are other reasons why individuals don’t eat healthily that this policy doesn’t address. One is the question of how easy it is for individuals to make healthy choices on their own. Some, particularly poorer, areas have been described as deserts for healthy food with unhealthy, fast food much more readily available. This is a market structure problem that Healthy Start doesn’t address but may limit its effectiveness.

In the end, the policy broadly seems to achieve its aim in increasing spending on healthy foods among very low-income households. More attention is starting to fall on the policy - in 2021, in response to the COVID-19 pandemic, the value of Healthy Start rose for the first time since 2009, and the recent National Food Strategy suggested widening the pool of people who are eligible for it. Perhaps it’s time in the spotlight is near.