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Linking Health and Wellbeing in Public Discourse and Policy: The Case of the UK

Santé et bien-être, discours et politique publique au Royaume-Uni
Louise Dalingwater

Résumés

Le bien-être est apparu comme une composante déterminante de la politique de santé au cours de ces dernières années. Au Royaume-Uni, un document d'information publié en 2014 par le ministère de la Santé (Department of Health, 2014) indique qu'il existe une relation bidirectionnelle entre la santé et le bien-être, l’un et l’autre s’influençant mutuellement, sans cependant se confondre. Il existe une relation claire entre la santé et le bien-être et les récentes publications nationales et approches en politique de santé au Royaume-Uni ont incorporé le bien-être dans la plupart des recommandations politiques. Cet article met en évidence les complexités de la formulation et de la mise en œuvre de politiques conjointes de santé et de bien-être au Royaume-Uni. Il commence par examiner les origines du lien santé-bien-être ; il se penche ensuite sur l'articulation entre les politiques et les recommandations en matière de santé et de bien-être à l'aide de documents gouvernementaux. Enfin, il examine les difficultés inhérentes à l'approche d’un cadre commun d’analyse.

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1. Introduction

  • 1 A state of being happy, healthy and prosperous.

1Wellbeing is a much debated and much contested notion. While some may use wellbeing and happiness interchangeably (Layard, 2005), others tend to understand the concept in relation to life satisfaction, quality of life and sustainability (OECD, 2014; Scott, 2012). However, the literature has tended to equate subjective wellbeing to happiness (Diener, 2000; Argyle, 2001). As underlined in the introduction to this special issue, subjective wellbeing has three main components: first, life satisfaction, which is measured by national statistics bodies such as the Organisation for National Statistics (ONS) by asking people how happy they are overall with their life; second, emotions (a low level of negative emotions should result in a high level of wellbeing) and; finally, psychological wellbeing and eudaimonic1 wellbeing (Diener, 2000; Argyle, 2001). Objective wellbeing or material wellbeing is somewhat different and related to real-life conditions: income, housing conditions, conditions at work, educational attainment, home environment, life expectancy, etc.

2It is also useful to contextualise the notion of wellbeing. It is perhaps in the health domain that this term is most frequently used. Yet it is also in the area of health that there is an overlap between subjective and objective wellbeing, in the same way as there can be an overlap between physical and mental health. For example, those suffering from chronic illnesses, such as Parkinson’s disease or cancer patients may also be diagnosed with depression.

3Wellbeing has emerged as a defining feature of health policy in recent years. Good health is considered to be a predictor for, or determinant of, a high level of wellbeing, and also an outcome. There is therefore a clear relationship between health and wellbeing, and recent national publications and policy approaches in the UK have incorporated wellbeing within almost all policy prescriptions. Indeed, the 2014 Department of Health policy brief clearly states that “wellbeing” is a “shared government objective” (Department of Health, 2014). It contends that raising levels of wellbeing can have beneficial effects on health.

  • 2 The European Social Survey for example points to security, safety, work-life balance among other is (...)

4In the literature, health and wellbeing have often been described as bidirectional, whereby health has a significant impact on wellbeing and wellbeing an impact on health (Department of Health, 2014; Royo-Bordonada and Román-Maestre, 2015). Although health does not quite equate to wellbeing, it is considered to be one of the basic ingredients of wellbeing and a significant determinant and outcome. Nevertheless, wellbeing has many other drivers2, health being just one of them.

5From this perspective, it may be misleading to systematically employ the two notions together in policy papers. Wellbeing is a contested notion, which also suggests that articulation of interventions and policies to improve health and wellbeing may also meet with difficulties.

6But UK policymakers are perhaps aware of the conceptual difficulties. There is also a communication strategy at play in linking health and wellbeing, as with mental health. In recent years, more attention has been given by health authorities to improving mental health and wellbeing. Linking mental health to wellbeing is said to reduce the stigma attached to mental illnesses and can thus encourage more people to seek treatment (Department of Health, 2012). The inclusion of wellbeing in health policy is therefore also very much a communication tool because the term wellbeing is considered to be more inclusive and acceptable. It is also clearly a holistic term that can incorporate both physical and mental health.

7This article will thus consider the complexities of formulating and implementing joint health and wellbeing policies in the UK. It will begin by considering the origins of the health-wellbeing linkage. It will then look at health and wellbeing policy articulation and prescriptions using government policy papers and documents. Finally, it will consider the inherent difficulties of the joint framework approach.

2. Origins of the Use of Wellbeing in Political Discourse and Policy Practice

8Wellbeing has been part and parcel of our understanding of health at an international level for many years before it started to be mentioned in national policy papers. Indeed, in the World Health Organization (WHO) Constitution, the founding principles state:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (WHO, 1948)

9However, it was only really in the last decade that the WHO started to establish a set of indicators to measure wellbeing and create a policy framework. This can be explained by the fact that wellbeing is a concept which was first scientifically examined in the field of psychology and it is only more recently that the disciplinary borderline between psychology and other social sciences has become blurred (Coron and Dalingwater, 2017). The WHO Regional Office only recently set up a working group to measure wellbeing as part of the framework of Health 2020: “Measurement of and Target Setting for Well-being” (WHO 2012). It found that wellbeing was multidimensional and as such included both objective and subjective components, and it was in this way that a link between health and wellbeing could be made.

10It is particularly interesting to focus on the UK’s approach to wellbeing measurement and policy implications because this country is regarded as being one of the most advanced countries in terms of measuring subjective wellbeing and developing a wellbeing agenda. Indeed, in recent years, UK policymakers have shown renewed interest in the notion of wellbeing, and especially subjective wellbeing or happiness, and how it might be measured at a national and regional level. In November 2010, the UK’s ONS launched its Measuring National Wellbeing Programme, just after the publication of the Stiglitz 2009 study on alternatives to GDP for the measurement of economic performance and social progress (Stiglitz et al., 2009). It was also inspired by the development of a dashboard of indicators produced by the Organisation for Economic Co-operation and Development (OECD) to measure both objective and subjective wellbeing. The intention was to establish a set of trustworthy indicators to understand and monitor wellbeing in the UK (ONS 2012a: 1). The results could then be used by government, policymakers but also the British population to improve personal or subjective wellbeing (ONS, 2012b: 33). The other important part of the process of wellbeing in the UK was looking at different domains and sectors, including health, and how they impact on subjective wellbeing and within these policy domains how subjective wellbeing might be improved (ONS, 2012b; Bache et al., 2016).

11But interest in the area of subjective wellbeing or happiness had already arisen earlier in the UK and got wider national coverage from 2006 onwards with Layard’s highly publicised academic work Happiness: Lessons from a New Science (2006). Just before the publication of Layard’s well-known book, a framework of wellbeing was introduced at governmental level. The Whitehall Wellbeing Working Group was created and its first meetings were devoted to finding a common approach to wellbeing and incorporating coherent policies to enhance wellbeing (Dalingwater 2017). In one of its first meetings, the Working Group recognized that there was no common definition of wellbeing (Whitehall Wellbeing Working Group, 2006, Dalingwater 2017). The Sustainable Development Unit (SDU) was thus commissioned by central government to explore the use of wellbeing concepts in UK policy making. Following this meeting, SDU staff carried out a series of interviews with government departments to investigate how wellbeing was being used for policy development, what kind of approach and rationale was being used in relation to wellbeing, the strengths and weaknesses of such approaches and the possible benefits and barriers of using the term wellbeing and implementing policies in this area (Dalingwater, 2017).

12The expected outcome was the development of a common understanding of wellbeing for policymakers to act upon at both national and local levels. However, the results of the committee showed that there was confusion between wellbeing and happiness with recent focus being on subjective wellbeing. While the same confusion was not acknowledged in relation to health, they did point out that a number of departmental policy statements related wellbeing to health alone, which made it difficult to give wellbeing a broader meaning across government sectors and departments (Dalingwater, 2017).

13Following this report, and despite the aforementioned difficulties, a statement of common understanding was established cutting across all government departments:

Wellbeing: Statement of Common Understanding

Wellbeing is a positive physical, social and mental state; it is not just the absence of pain, discomfort and incapacity. It arises not only from the action of individuals, but from a host of collective goods and relationships with other people. It requires that basic needs are met, that individuals have a sense of purpose, and that they feel able to achieve important personal goals and participate in society. It is enhanced by conditions that include supportive personal relationships, involvement in empowered communities, good health, financial security, rewarding employment, and a healthy and attractive environment. (Whitehall Wellbeing Working Group, 2006: 3)

14There are striking similarities at the beginning of this definition with the WHO’s aforementioned 1948 definition of health. The Working Group has actually used all the key words present in the WHO’s definition of health: “state” “complete physical, mental and social” “absence of pain” and “incapacity” which is very close in meaning to the WHO’s “infirmity”. It then actually cites a number of determinants that also relate to health. Health and wellbeing have thus become interchangeable notions in official discourse in the UK in line with the WHO’s approach.

15In his speeches in 2006 and 2010 on wellbeing, David Cameron describes both health and wellbeing as interchangeable notions, but also improved mental health as an essential driver of wellbeing.

16In the 2006 speech, he underlines how leading healthy lifestyles can lead to improved health and wellbeing:

Anyone looking at the health of our nation would conclude that some of the biggest prizes in terms of improved health and greater well-being would come through encouraging people to live healthier lifestyles. Smoking. Obesity. Substance and alcohol abuse. Sexual health. These are the four vital challenges of public health. (Cameron, 2006).

17Whereas in the 2010, he describes good mental health as a driver of wellbeing:

I think, actually, in the realm of mental health is an excellent example of a whole area that if you just look at economic growth, you are missing out on a huge part of wellbeing in terms of people’s mental health, in terms of problems of depression. These are all issues that we need to think about properly as a country, rather than just sweep them under the carpet. (Cameron, 2010).

18In various documents that have been written in recent years making explicit reference to the link between health and wellbeing (see Appendix for the most recent documents), the Department of Health acknowledges that its objectives as regards health and wellbeing are inseparable and that this is at the heart of all its activities, priorities and policy documents. Even earlier papers, such as the Public Health White Paper Choosing Health: Making Healthy Choices Easier (Department of Health, 2004) for example, make a number of commitments to include wellbeing in overall health strategy. The comprehensive public health information and intelligence strategy is said for example to aim at “bringing together sources of information on health and wellbeing from routine sources and local studies to give a comprehensive picture of how lifestyle factors affect health” (Department of Health, 2004: 191). Many of the publications point to a bidirectional relationship between health and wellbeing. Some underline how boosting wellbeing can have an effect on health and vice-versa without taking a firm stance as to whether one has more influence than the other. The recent emphasis on including wellbeing analysis in health policies finds support in studies which have shown an important link between health and wellbeing.

3. Literature Review to Support the Link between Health and Wellbeing

19These policy prescriptions are indeed supported by a number of studies which have explored the link between wellbeing and health. Some of the studies point to how reduced wellbeing (or ill-being) may result in poor health, whereas others point to the deterioration of wellbeing (both subjective and objective) as a result of ill health. It is not possible therefore to draw firm conclusions on which is the main driver or whether health and wellbeing influence each other on an equal footing. Studies have established a link for example between low wellbeing and heart disease (atherosclerosis) (Krantz and Manuck, 1984; Kubzansky and Kawachi, 2000; Stewart et al., 2007). Researchers have also found evidence to suggest that it is important to promote happiness because, among other things, happy people have been found to be less susceptible to stress and more likely to choose a healthy lifestyle (Veenhoven 2008). Other studies have found a link between happiness and longer life expectancy (Diener and Chan, 2011), between wellbeing and health outcomes (Howel et al., 2007), between higher wellbeing and stress reduction (Howel et al., 2007) and between higher levels of satisfaction and resistance to cold viruses (Cohen et al. 2003). Studies on the impact of sports, weight watching and reduction of alcohol and tobacco consumption have underlined the link between healthy lives and healthy minds (Sabatini, 2014).

20Research has also shown that self-perceptions of health can have a knock-on effect on happiness. For example, Bok found that a fall by 20% in self-evaluations of health is associated with a significant decline in happiness (a 6% decline) (Bok, 2010). Self-reported health is important because it is connected to conditions that may not be detected through medical tests such as stress, depression, etc. Yet, some of the sickest people may not necessarily be those with the lowest wellbeing. It was found that those individuals who lost a limb or became quadriplegic reported equivalent satisfaction within a year compared to that reported before the accident. However, some other illnesses have shown to have a lasting effect on happiness such as chronic pain, depression or the onset of chronic or fatal disease such as AIDS or cancer (Bok, 2010). Such literature thus gives support to policymakers to link health and wellbeing when formulating policies. However, there are significant challenges to measuring wellbeing and then using those measures for policy prescriptions.

4. Challenges to Using Wellbeing Measures to Inform Wellbeing Policy

21Wellbeing measures still remain at the experimental stage and are not intended to replace other more well-established measures in a variety of policy domains. In 2018, an ONS report on how to use personal well-being data remained rather vague (ONS, 2018). The organization underlined four main uses of personal well-being: monitoring national well-being, use in the policy-making process, international comparisons and allowing individuals to make informed decisions about their own lives. However, the ONS did provide guidance for policy makers to make use of already existing data on personal wellbeing. For example, the Annual Population Survey (APS) provides information which enables comparisons between different ages and ethnic groups, but also differences within areas, in countries or regions. Such information can thus enable policy makers to target certain groups or regions which have the most need for policies to improve wellbeing. The ONS report underlined another significant use which can be made of personal wellbeing data, that is cost-benefit analysis of policy appraisals. Indeed statistics on personal wellbeing can inform governments about which areas of spending are likely to lead to the largest increases in personal wellbeing. A Green book is currently used jointly by HM Treasury and the Department for Work and Pensions (DWP) to propose potential uses of personal well-being measures in social cost-benefit analysis (HM Treasury, 2018).

22The Department of Health has some very specific ways in which it measures wellbeing within the health domain. First, measures are used in relation to mental wellbeing: questions used to measure mental wellbeing aim to assess whether life is worthwhile for example, levels of anxiety, satisfaction with one’s life, etc. Such information is retrieved from the Integrated Household Survey. The Warwick/Edinburgh mental wellbeing scale is also used to measure positive mental wellbeing. Mental illness is measured using a general health questionnaire devised by the Department of Health (where a score of 4 or more indicates mental ill health). Objective wellbeing in the health domain is measured by life expectancy and mortality rates (Department of Health, 2012). However, the New Economic Foundation (NEF), which has actively promoted wellbeing policies, has nevertheless underlined the problems of the governmental wellbeing approach. The organisation argues that the wellbeing evidence that has been collected from measuring subjective wellbeing since 2010 might well be used to provide support for policies that already exist rather than to develop new policy directions or initiatives (NEF 2014). The problem is therefore how to identify the effectiveness of the wellbeing measures to inform policy.

23The other problem is gauging the reliability of wellbeing measures. The essential problem with the current subjective wellbeing measures which involve asking participants how they are feeling today is that responses may be highly transient and there may be a lack of a common understanding of such questions (De Vos, 2012: 185–186; Bache et al., 2015). The answers may be given according to the interviewees’ hopes and wishes for policy implications (Erikson, 1993: 77; Bache et al., 2015). Comparative issues have been seen as the biggest problem because different interpretations of wellbeing are difficult to compare among individuals, across regions, countries and different cultures (Diener, Suh, Lucas, and Smith, 1999; Stutzer and Frey, 2000; Di Tella and MacCulloch, 2008, 29–30; Bache et al., 2015). There is also the argument about to what extent government should be involved in raising levels of wellbeing.

24Different traditions of economic thought affect whether improving wellbeing or happiness is the government’s responsibility. Liberal tradition tends to think that it is not the business of the state and is concerned that the state may become “paternalistic”, “a nanny state” and/or “a big brother society” (NEF, 2014). However, in the area of health, there is support from citizens for the intervention of the government, or at the very least a tax-based public system, to ensure an adequate supply of public health services to the nation (at least in the UK).

5. Health and Wellbeing Policy Implementation in the UK

25If we take a look at the high number of policy papers linking health and wellbeing, it would seem that it is in the area of health, more than other policy areas, that the government has chosen to intervene and incorporate wellbeing (see Appendix). It would be impossible to review all the domains in which wellbeing is linked to health policy in the UK. This section will thus review policy in two areas: mental health and more generally measures to join up health and wellbeing at the local level. In these two domains the linkage between health and wellbeing has been significant.

26In recent years, more attention has been given to mental health within public health policy prescriptions. While there is a dispute on the role of government to formulate policy specifically to enhance subjective wellbeing or happiness, some proponents of increasing happiness, such as the leading British academic on happiness, Lord Layard, claim that the government can have a role in ensuring that misery is avoided. Layard reports that one in six Britons suffer from poor mental health and notably depression and anxiety. He believes that it is the government’s responsibility to mitigate such effects by tackling the root causes among other things (Layard, 2006). However, identifying the root causes of depression and anxiety is not simple and depends very much on the individual. Lots of factors may be involved including past or childhood experiences (abuse, bereavement, bullying), current pressures (long hours, housing or income problems…), drugs and medication and physical conditions (for example Parkinson’s disease can cause depression). Treating the root causes is also very complex.

27Linking mental health to wellbeing is also said to reduce the stigma attached to this disease and thus can allow for more effective treatment of the condition if both the patient and society accept this condition. The inclusion of wellbeing in health policy has thus become a communication tool or strategy with the term wellbeing making certain conditions more inclusive and acceptable. It is also a holistic term that can incorporate both physical and mental health. This is clear from the National Suicide Prevention Strategy for England which targets risk groups which may have not sought help previously. It focuses on the mental wellbeing of the population as a whole rather than mental health (Department of Health, 2002).

28Wellbeing is thus perhaps a way of incorporating mental health within policy without stigmatising those suffering from mild to severe mental health issues. This was the case for example in a Department of Health policy briefing entitled Wellbeing and Health (Department of Health, 2012). The policy paper refers to the correlation between stopping smoking and gains in mental health and subjective wellbeing. Improvements in quality of diet are reported to lead to higher levels of good mental health in adolescents, although the relationship between mental health and diet is said to be complicated. They are thus differentiated but the link between the two is not made very clear. The document leads on to talk about initiatives to treat mental health problems such as cognitive behavioural therapy, self-help and computer-assisted therapy.

  • 3 The NHS Primary Care Trusts were formerly Britain’s National Health Service (NHS) hospital manageme (...)
  • 4 Financial sustainability does not necessarily take into account the human costs. When new structure (...)

29More generally, wellbeing discourse has also been used to join up health and wellbeing initiatives at the local level. Significant power to implement wellbeing initiatives was devolved to local authorities through the Local Government Act 2000 and the subsequent 2011 Act to enable local authorities to “do anything they consider likely to promote the economic, social and environmental wellbeing of their area” and included the creation of Local Strategic Partnership (LSPs). LSPs have been described as the “partnership of partnerships” and are made up of senior officers from the public sector (councils, health officers, police officers, Jobcentre Plus agents, community and voluntary sector representatives). In 2005, Lambeth LSP (Lambeth School Partnership) launched a Mental Health and Wellbeing Promotion Programme. The Liverpool Primary Care Trust also developed the 2010 Year of Health and Wellbeing programme. Lancaster County Council teamed up with the NHS Primary Care Trust (PCT)3 and devoted a significant amount of resources to provide services to support psychological and social wellbeing by setting up a social prescribing project. This involved the use of non-medical interventions to improve wellbeing. In Hertfordshire the county’s schools forum contributed the sum of £250,000 to support the creation of a resilience programme, following a successful pilot programme. Resilience training has also been extended to other initiatives such as ‘Think Family’ and parenting programmes (Local Government Group 2010). The intention is that these programmes eventually become financially self-sustaining4, as training places are sold to other local authorities (Dalingwater, 2017).

30Such initiatives have been continued in recent times (Dalingwater, 2017). The Lyons inquiry reinforced the importance of ‘place shaping’, which it defined as “the creative use of powers and influence to promote the general wellbeing of a community and its citizens” (Lyons, 2010). The 2012 Health and Social Care Act created Health and Wellbeing Boards in each locality to continue this joined up approach to health and wellbeing. Subsequently, Newcastle established Newcastle’s Wellbeing for Life Strategy. The strategy is intended to improve the situation of low employment and poor outcomes for health and education. Other wellbeing projects include the partnership between the Young Foundation, Professor Richard Layard of the Centre for Economic Performance at the London School of Economics, the Improvement and Development Agency (IDeA) and three local authorities: Hertfordshire County Council, Manchester City Council and South Tyneside Metropolitan Borough Council. The aim of the Local Wellbeing Project is to build new communities that can flourish and become socially sustainable to ensure the wellbeing, quality of life and satisfaction of present and future residents. A number of projects have been created such as organising meetings and forums to facilitate contact between neighbours, giving residents opportunities to influence decisions in the community and giving residents the power to control local circumstances through a forum of ideas. The local wellbeing project team set up a series of information campaigns so that these communities understand how they can influence decisions and control local circumstances (Hothi, 2007).

31The 2012 Health and Social Care Act also devolved new responsibilities to local government in public health, as set out in the Health White Paper (Department of Health, 2004). Joint Strategic Needs Assessments (JSNAs) have thus been created focusing on early intervention and prevention and, in addition, joint strategic asset assessments (JSAAs). These work on the aforementioned determinants of ill health, but also on diminished wellbeing. The aim of these initiatives is to give special attention to real needs and assets of an area rather than just on the delivery of traditional services. A series of assessments are produced by health and wellbeing boards. Policy interventions are then taken either by the local authority in the area, the Clinical Commissioning Groups (CCGs) or the NHS Commissioning Board depending on the needs identified. For example, if the local needs assessment identifies poor health outcomes in a specific area, then all three organizations will be involved in initiatives to improve poor health outcomes (Department of Health 2017).

  • 5 The Risk Management Partners claimed that Brent local authority had no right to open up risk manage (...)

32However, the Local Government Group underlined a number of difficulties for local governments to set up a credible health and wellbeing policy. In a review conducted in 2006, it was found that while 92 per cent of aforementioned LSPs were aware of the power of competence to promote wellbeing, only 8 per cent had used it (Local Government Group 2010). The major challenge for local authorities in the use of wellbeing power has been linking wellbeing to health when the former is so ill-defined and can also create legal complexities. Moreover, while the aforementioned Acts of 2000, 2011 and 2012 grant power to local authorities to enact wellbeing policies, they often meet with restrictions because certain policies may be prohibited elsewhere in legislation and the term “wellbeing” remains very elusive. And if enacting wellbeing policies does not coincide with business interests, business associates may argue that wellbeing policies are ineffective, inadequate or impeding growth. This is indeed the danger when wellbeing is both associated and decoupled from policy initiatives. For example, the Brent LBC versus Risk Management Partners court case did not favour the local authority in its use of the wellbeing power in 2009 (Local Government Group 2010)5. The government cannot give a legal endorsement of the use of the wellbeing power so it is left to the courts to decide. In addition, local authorities are restricted by budgetary cuts. The Department for Communities and Local Government underwent a 40% budget cut in the 2011/12 to 2015/6 period, which significantly reduced any action taken under the framework of health and wellbeing policies (Dalingwater, 2017). Moreover, it could be argued that the new approach to combining health and wellbeing, which was reinforced by the 2012 Health and Social Care Act and emphasis on measuring wellbeing, is also a way of shifting the responsibility for health outcomes to the individual and rationing health care.

6. Wellbeing Discourse: Shifting Responsibility and Rationing

33Indeed, in practice, there are a number of concerns about this joined-up approach. Wellbeing, especially subjective wellbeing, is seen as an individual process. Beyond the specific community-based approach, a lot of health and wellbeing projects often focus on individual responsibility and may encourage disengagement of key health actors in the localities. It could be a way of filling a void for those functions that used to be fulfilled by social institutions, which have been taken over by the market (Ferguson, 2015; Li, 2014; White 2017). These “person-centred” policies could in fact be a way of creating a false self (Craib, 1994) or including a false self in a process which is not really inclusive of the individual. Wellbeing has in fact been developed as strongly individualistic, centred on the self and personal entitlements within the framework of self-improvement (Rose, 1998; White 2017).

34Further examination of policy papers makes it clear that developing a more far-reaching wellbeing policy in the regions is intended to reduce the health care burden. Indeed in its document “Wellbeing why it matters to health policy”, the Department of Health claims that “a focus on wellbeing can lead to improved wellbeing and improved health outcomes, which may ultimately reduce the care burden.” (Department of Health, 2013: 3) Wellbeing, and particularly, subjective wellbeing places the emphasis on the ‘individual’, on the ‘personal’ and ‘subjective’ and personal empowerment rather than collective or the community. Indeed, Sointu (2005) and Atkinson & Joyce (2011) show how the notion of wellbeing has moved from relating to the population to concentrate on the individual. Extending policy from health interventions, relating to both mental and physical health, which is generally seen as collective, to wellbeing and health is indeed a way of transferring responsibility to the individual.

35Making an association with wellbeing thus underlines that the individual is responsible for the health care process by taking responsible actions to ensure that the treatment will work, by for example monitoring his or her weight, giving up smoking, reducing drinking, eating more healthily, taking exercise. Health care workers are now strongly encouraged to engage the individual as part of the wellbeing approach to take care of his or her health. Such a rationale began essentially in 1997 with the arrival of the New Labour government and has been continued, based on the notion of agency, autonomy and self-responsibility, as part of the “responsible citizen” mantra. Policy papers make this quite clear as is evident from the quote and diagram below:

You should recognise that you can make a significant contribution to your own, and your family’s good health and well-being, and take some personal responsibility for it. (NHS England, 2009: 9).

36The idea of transforming health completely into a private responsibility and full privatisation of the British National Health Service is unlikely because public support for this institution is very strong. However, making an individual responsible for his or her health and wellbeing has resulted in the rationing of health care. According to Pollock (2004), some surgeons will decline to perform elective surgery if patients do not follow advice such as stopping smoking and losing weight. Moreover, promoting improvements in health and wellbeing through work have been a way of reducing welfare benefits to the disabled and sick. Indeed, in a speech entitled ‘Health and Wellbeing’, David Freud, former Minister for Welfare Reform, claims how getting the sick back to work is important for increased wellbeing:

Work provides more than just an income. Employment can also give people a sense of purpose, some structure to their lives. It can also be an important part of people’s social lives. Quite simply work is good for you. (Freud 2011).

37While research has shown a firm link between unemployment and lower levels of wellbeing, the essential objective in promoting improved health and wellbeing by encouraging these disabled and sick workers back to work is also to reduce payments of disability benefits. Cuts were made to benefits as part of the austerity measures introduced by the UK coalition government of 2010. By 2017, nearly half of disabled (sick or infirm) people had been reassessed and had seen a fall or removal of benefits (Bulman, 2017). A study which collected information from 137 disabled workers and 141 organizations to investigate the effects of welfare reforms since 2010 has shown that in many cases efforts to get people back to work failed and the disabled who were forced back to work were suffering from low levels of wellbeing (Harwood, 2015).

38The individual approach to wellbeing has been reinforced by an emphasis on wellbeing from Sen’s capability approach. This approach essentially focuses on the person and his or her capabilities. Capabilities are important to enable an individual to act in the way that he or she sees fit (Sen, 1983, 160). Think tanks in the UK, such as the New Economic Foundation (NEF), have also developed actions to improve wellbeing which imply individual action: Connect, Be Active, Take Notice, Keep Learning (NEF, 2008). Indeed, the latter all target individual behavior. On the other hand, Layard underscores how important collective, and not just individual projects, are to enhance personal wellbeing (Layard, 2006).

39Emphasis on wellbeing may actually thwart other more collective actions to improve health outcomes. Improvements are much easier to publish in wellbeing and subjective wellbeing than concrete progress in health outcomes. This is because subjective measures of wellbeing are actually measuring modernisation and satisfaction with modernisation rather than real improved quality of life and development (Eckersley, 2013).

40The underlying weakness of bringing in measures and accompanying policies which link wellbeing and health is thus that there is increasing emphasis on the individual and individual satisfaction rather than collective notions of social engagements which are very important in the health sector. Freedom is prioritised for example above collective action. Neoliberal policy approaches put greater emphasis on individual choice and freedom. However, such an approach has also shown to have significant health risks such as isolation and can have a significant impact on mental health. For example, Eckersly noted a link between freedom and increased rates of mental health problems among Western youth (Eckersly 2005, 2009, 2011).

7. Misleading Definitions and Usage

41Moreover, because of the definitional problems associated with wellbeing, the association of health and wellbeing in policy could be quite detrimental to policies which aim to improve health outcomes. It is important to emphasise that health does not quite equate to wellbeing, even though it might be one of the basic ingredients of wellbeing and a significant determinant and outcome. Health alone does not make up wellbeing. The latter has many other drivers, including work and life balance, family and friends, etc. So, health is just one driver among many. Nevertheless, health and wellbeing are indeed systematically used together in policy papers.

42The WHO definition of health which incorporates wellbeing, and on which the UK’s definition of wellbeing is based, can actually lead us to misinterpret the meaning of health. Indeed, if the WHO’s definition is taken literally, it implies that individuals are unhealthy if they are unhappy with their lot in life or if they feel unfulfilled. It can also be interpreted as suggesting those with poor health cannot be happy. This discredits research which has developed coping theory (Lazarus et al., 1974; Costa and McCrae, 1989; Krohne, H. W. and Hindel, C., 1988; Lazarus, 1993), whereby those with a defined disease, illness or disability can actually reach a certain level of happiness if they are well cared for.

43The Department of Health has tried to clarify such a situation admitting that “terminology around wellbeing and health is often used interchangeably, and sometimes, incorrectly used” (Department of Health 2012). It has more recently attempted to clarify the 2006 definition (given above) and defines wellbeing as “an individual’s experience of their life; and a comparison of life circumstances with social norms and values” distinguishing between subjective wellbeing: “how people think and feel about their own wellbeing” (life satisfaction, positive affect, meaningfulness) and objective wellbeing: referring to basic human needs and rights. It gives a further definition of mental wellbeing as “part of overall wellbeing (…) more than just the absence of mental illness (…) a positive state of mind and body, underpinned by social and psychological wellbeing” as opposed to mental illness which is described as “a range of mental health problems that can cause marked emotional or cognitive distress” (Department of Health, 2012). However, subsequent policy papers with policy prescriptions for health and wellbeing make this distinction less clear as discussed earlier.

8. Conclusion

44To conclude, there is some evidence to suggest that linking wellbeing to health may help formulate policy and improve health outcomes, especially in the domain of mental health to remove the stigma surrounding such health issues. At the same time, creating a policy framework which joins up health and wellbeing in the UK can also be seen as a way of shifting the financial burden of health onto the individual, which has led to the rationing of health care and welfare. As time goes on, wellbeing is likely to become devoid of meaning and out of fashion and be replaced by a new definitional communication tool to fit the policy direction of those in power. White goes as far as to say that current references to wellbeing actually reflect cultural anxiety and significant ill-being, which she links to the “erosion of the social” (White, 2017: 133). This might suggest why wellbeing has been used so frequently in the health domain, without necessarily being the most effective tool to guide policy to improve the health of the nation.

Appendix: Recent Policy Papers and Government Documents Linking Health and Wellbeing

  1. Defence people mental health and wellbeing strategy

    • 15 March 2018

    • MOD

    • Policy paper

  2. Women in prison: standards to improve health and wellbeing

  3. Health matters: community-centred health and wellbeing approaches

  4. Wellbeing and mental health: applying All Our Health

  5. Health, Safety & Wellbeing Awards 2017

    • 12 December 2017

    • Highways England

    • Form

  6. The wellbeing of 15-year-olds: analysis of the What About YOUth? survey

    • 17 January 2018

    • PHE

    • Guidance

  7. Wellbeing and health

    • 31 July 2013

    • Cabinet Office and DHSC

    • Research and analysis

    • Part of the collection: National wellbeing

  8. Health and Wellbeing Fund 2017 to 2018: application form

    • 10 October 2017

    • DHSC and PHE

    • Form

  9. Improving health and wellbeing through our national parks

    • 8 September 2017

    • PHE

    • Policy paper

  10. Future of the sea: health and wellbeing of coastal communities

    • 31 August 2017

    • GO-Science

    • Research and analysis

    • Part of the collection: Future of the sea

  11. Five ways to mental wellbeing

  12. Health and wellbeing board duties

    • 17 July 2013

    • DHSC

    • Consultation outcome

45First published during the 2010 to 2015 Conservative and Liberal Democrat coalition government

  1. Wellbeing and health policy

  2. Health and wellbeing of service personnel

    • 1 October 2010

    • MOD

    • Independent report

  3. Preventing homelessness to improve health and wellbeing

    • 1 July 2015

    • PHE

    • Research and analysis

    • Part of the collection: Homes for health

  4. Arts for health and wellbeing: an evaluation framework

  5. Mental health and wellbeing of looked-after children: response

    • 13 September 2016

    • DfE and DHSC

    • Policy paper

  6. JSNAs and joint health and wellbeing strategies

    • 19 January 2012

    • DHSC

    • Guidance

  7. Supporting the health and wellbeing of military families

  8. Health and wellbeing: introduction to the directorate

    • 16 May 2013

    • PHE

    • Guidance

  9. Defence annual health and wellbeing report 2015

  10. Health and wellbeing at work: survey of employees

  11. Health and wellbeing of people in England: 2010

    • 30 November 2010

    • DHSC

    • Policy paper

46First published during the 2010 to 2015 Conservative and Liberal Democrat coalition government

  1. Midwifery services for improved health and wellbeing

  2. Children's and young people's voices on their wellbeing

    • 27 September 2012

    • DfE

    • Research and analysis

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Notes

1 A state of being happy, healthy and prosperous.

2 The European Social Survey for example points to security, safety, work-life balance among other issues: <http://esswellbeingmatters.org/drivers/index.html>.

3 The NHS Primary Care Trusts were formerly Britain’s National Health Service (NHS) hospital management units.

4 Financial sustainability does not necessarily take into account the human costs. When new structures are built, the social cost is not always taken into consideration. Here we are therefore referring to collective wellbeing and sustainability rather than individual wellbeing.

5 The Risk Management Partners claimed that Brent local authority had no right to open up risk management to other providers even if it was to reduce overheads in order to allocate these savings to wellbeing policies.

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Référence électronique

Louise Dalingwater, « Linking Health and Wellbeing in Public Discourse and Policy: The Case of the UK », Revue Interventions économiques [En ligne], 62 | 2019, mis en ligne le 28 juin 2019, consulté le 19 septembre 2019. URL : http://journals.openedition.org/interventionseconomiques/6243 ; DOI : 10.4000/interventionseconomiques.6243

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Auteur

Louise Dalingwater

Maître de conférences, Laboratoire CERVEPAS (CREW), louise.dalingwater@univ-paris3.fr

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