Moves to measure wellbeing must support a social model of health

The Office for National Statistics recently announced the start of further consultation on how to assess the United Kingdom’s progress by more than just its economic performance. This followed the decision by the present UK government to incorporate measures of general wellbeing, including subjective wellbeing, into future National Household Surveys (www.ons.gov.uk/ons/about-ons/consultations/open-consultations/measuring-national-well-being/index.html). The decision recognises the argument that concrete policy goals, such as economic growth and material prosperity, are only the means to human flourishing rather than ends in themselves. The announcement will be well received in many progressive policy circles. The think tank the New Economics Foundation has long advocated a less materially oriented evaluation of whether a country is doing well, including people’s views of their own wellbeing. Similarly, public health professionals committed to a social model of health, with its emphasis on prevention, promotion, and intersectoral partnership, are likely to welcome the inclusion of subjective wellbeing as an important arbiter of policy.

But before the celebrations commence, consider if this might have negative consequences for a social model of health. The move to wellbeing echoes similar initiatives in France and Canada, but the UK will go further and use such data for choice and evaluation of policies. This is an important distinction and should not be glossed over lightly. Gauging what fraction of the population feels its lives are going well presents plenty of methodological challenges, but connecting such measures to choice and evaluation of policies enters a realm of complexity far beyond the reach of mere measurement. Concepts mobilised for policy purposes almost always offer a range of possible, often conflicting, interpretations, so we must reflect on which meanings of the term “wellbeing” are currently favoured and which might best suit the needs of a social model of health. In contemporary UK policy, the concept of wellbeing has a limited set of meanings. Specifically, subjective wellbeing is routinely conflated with happiness and with mental health and resilience.

Although David Cameron may talk of general wellbeing as an alternative to gross domestic product, the media soon blurred this into “happy” talk, including references to a happiness index and questions of how happy we are. One challenge for our statisticians will be to define an appropriate timeframe in which to assess subjective wellbeing. A measurement that can be useful to choose and evaluate policy needs to capture the extent to which we enjoy a sense of flourishing over a reasonable duration of time, but whether this is over some months, a year, or longer may be largely arbitrary. Whatever the decision taken, thinking about time makes clear the need to resist the casual conflation of wellbeing with happiness.

Happiness carries a high emotional load suggestive of fleeting moments of intense conscious uplift. It is the ephemeral quality of happiness that makes it the stuff of poetry and something akin to the holy grail of modern life. Indeed, French statisticians have decided to measure the feeling of missing out on happiness rather than its presence. At the same time, the term conveys a dark side, in the suspicion that any apparent enduring happiness may be founded on ignorance, naivety, and lack of critical insight. The promise of happiness itself is highly political, associated with, and directing us toward, specific life choices. Moreover, putting on a performance of happiness is part of presenting a successful and modern social self. But where this performance does not marry with experience, modern medicine may increasingly be expected to redress the balance through drugs to improve life and lifestyle. Wellbeing as happiness that is delivered through drugs entails a medical practice that might be termed an “individual lifestyle model,” which is far removed from a social model of health.

The routine conflation of subjective wellbeing with mental health seems highly appealing for health professionals: the measurement of subjective wellbeing could position medical expertise and medical concerns centre stage in future evaluation of policy. But tying the meaning of subjective wellbeing to individual states of positive and negative mental health constrains its value for a social model of health in two important ways. Firstly, the concept of subjective wellbeing becomes seen as effectively the property of the health domain. One of the great virtues of wellbeing is that, as a corollary of its rather vague and all embracing character, it can serve as a unifying concept across different sectors. Containing and controlling the concept within a health domain undermines the opportunity to build the intersectoral partnerships that are vital for a social model of health. Secondly, the interpretation of subjective wellbeing as primarily individual and psychological risks a focus on similarly scaled interventions. The past few years have witnessed a surge of interest in the individual and psychological interventions of cognitive behaviour therapy as a route to increase resilience to other stresses of modern living. Without diminishing the value of such interventions, there is nonetheless a danger that the focus of public health policy may be subtly shifting away from the social, economic, and environmental factors within which the need for resilience emerges in the first place.

A policy focus on subjective wellbeing need not automatically undermine a social model of health. However, the current widespread blurring with individual happiness, mental health, and resilience suggests we should go warily. Health professionals must be watchful over uses of policy and vigorously active in analyses of public data to ensure that general wellbeing is harnessed to a continued social model of health.