Measuring Wellbeing

Warwick UniversityAn event at Warwick University Medical School on April 8th solved a little mystery. At the same time it exposed three unresolved questions about wellbeing and how it might be measured.

Although advertised as a debate, there was no proposition and no vote. The event was not a debate, but merely a panel discussion. It was based loosely around the Office for National Statistics (ONS) consultation on the measurement of wellbeing that is running until next week, and a representative of the ONS was present. About sixty people attended.

Chairing the discussion, Professor John Bennington of Warwick Business School seemed to assume that the audience was drawn only from the university. I put him right, causing some laughter.

It was when he introduced the panel that a little mystery was solved. The host of previous events at Warwick University, who had introduced herself on those occasions either sotto voce or not at all, turned out to be Sarah Stewart-Brown, Professor of Public Health at Warwick Medical School. (I described those events in Wellbeing and BT.)

The other panellists were Andrew Oswald (Professor of Economics), Scott Weich (Professor of Psychiatry) and Thomas Hennell, Senior Public Health Analyst, allegedly at the North West Regional [sic] Health Authority. I think RHAs were done away with a very long time ago, and it seems likely that Tom Hennell really works for the Department of Health at its regional office in Manchester.

The panellists gave short presentations. I think it is easier to make sense of them if I change the order slightly.

Economics

Andrew Oswald (economics) opened by explaining that gross domestic product (GDP) has long been the way to measure how well a country is doing, but GDP is based only on money. The United Nations uses a hybrid measure (HDI) that includes education and life expectancy, but psychological measurement is now the in thing, and he believes that the move towards psychological measurement is unstoppable:

Happiness is the new GDP.

He did well to provide a clear and simple introduction to the discussion, but it was unfortunate that he simplified quite so much. For example, he made no acknowledgement that it has always been well known by economists that GDP does not measure everything that happens in a society, because much of what happens, and indeed much of what makes people happy, does not depend on money.

He also assumed the truth of the so-called Easterlin paradox, that income growth does not correlate with happiness on a country-by-country basis, even though it has been widely discredited, and Easterlin never claimed that it applied to individuals within the same country (the subject under discussion).

So, although nice and simple, the introduction was subtly misleading.

Public Health

Sarah Stewart-Brown (public health) continued in simplistic vein, making a long series of unsubstantiated and/or meaningless claims. Decide for yourself which this is:

Wellbeing is holistic.

She explained that the focus of public health has been on negative things in people’s lives, on diseases, but she believes that a focus on positive things is also beneficial. To focus on positives is an intervention in its own right, she pointed out more than once, meaning that the choice of what to measure, what to focus on, influences people.

She went into a lot of detail advertising the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS), a questionnaire for measuring how well people think they are. I can only conclude that the WEMWBS incorporates the positive things with which she would like to intervene in people’s lives, although she did not give any actual examples.

Her approach seemed to me very like some kind of political indoctrination. She and her colleagues in Edinburgh sit at their desks in universities deciding what’s best for ordinary people, then they embody that ideology in a questionnaire, and administer the questionnaire to as many people as possible. By asking only those particular questions they hope to influence people to think that those are the only important things in life, then by publishing the results of only those particular questions they hope to influence government in the same way.

In effect, her presentation claimed that the whole debate/discussion about how to measure wellbeing was superfluous — she’s already decided.

Psychiatry

Scott Weich (psychiatry) exposed the first unresolved question of the evening, by challenging two of the assumptions often made about wellbeing:

  • Mental wellbeing is the same as happiness — False
  • There is a continuum from wellbeing to mental disorder — False

He was frustrated at the way these simple but false assumptions had been seized upon by the media and others:

Why let the truth get in the way of a good story?

Analysis of research results, he explained, shows that wellbeing is not the simple concept many people assume it to be. It has at least three dimensions, components that can vary independently, like anxiety, depression and age. This is why some people are both mentally ill and report a high level of wellbeing at the same time. The complex nature of wellbeing means that it is crying out for more research before any firm conclusions can be drawn.

He further criticized the idea of a continuum from flourishing to mental disorder, because it implies most people are only moderately mentally well, and thus that they are in need of intervention. (You can see the imaginary continuum on page 8 of this presentation by Felicia Huppert.) He presented research from New Zealand showing that in fact most people are OK.

These ideas directly contradicted the public health presentation, which showed that because hardly anyone gets a perfect WEMWBS score, almost everyone needs some mental health intervention. However, the contradiction was not debated or discussed.

Analysis

Tom Hennel (analyst) creates statistical models of health based on various surveys. His findings are that variations in health are around three-quarters dependent on individual factors (including age and sex). Wellbeing is one of three factors accounting for the remaining quarter. Income inequality has no effect at all.

He has been investigating the mystery of ill-health in Glasgow compared to Liverpool and Manchester, concluding that people in Glasgow seem to get ill later, stay ill longer, and are more likely to die from illness. However, the reasons for these differences are still not clear.

All the previous panellists had assumed that to find out about people’s wellbeing you have only to ask them, but his approach directly contradicts them, exposing a second unresolved question:

I think of wellbeing as being to do with functionality, not to do with the way you feel.

He noted that many people are inhibited about regarding themselves as ill, so that illness is not simply a matter of diagnosis. Some people are diagnosed but do not regard themselves as ill, while some people regard themselves as ill but are not diagnosed.

This affects recovery too, and he feels that inhibition against construing oneself as ill may be associated with inhibition against recovery, or that some people may suffer from a systematic lack of control that contributes to an inability to recover from illness.

I asked him whether these findings were widely known, and he seemed to think they were, though none of the other panellists ever referred to them, and I have never come across any reference to them in other presentations on wellbeing.

Discussion

There was a panel discussion with individual audience members, and there had also been a little discussion after some of the presentations.

A woman who works for the NHS in public health challenged the idea that there should be any more research. It was important, she said, to get going with promoting wellbeing even though proper research into it has not been done. This extraordinary demand was rebutted by Scott Weich (psychiatry):

We must be really scientifically rigorous when we measure.

Two economists separately asked searching questions about the value of measuring wellbeing at all. One pointed out that a measure of wellbeing tells the government nothing about how to allocate resources, and the other pointed out that if measures of wellbeing are ever used to allocate resources, they cannot be the subjective measures like opinion surveys that are being used now, because people will learn to give false answers.

There were several other questions on the unreliability of self-reported wellbeing, and this exposed the third unresolved question of the evening. The three academic panellists generally thought that self-reported wellbeing was an adequate measure, while the analyst and many audience members thought that the results of questionnaires can be influenced by other factors.

Summing up

The panellists summed up, each restating exactly the position they had held at the start. None of them said they had learned anything at all from the discussion.

Paul Allin, Director of the ONS Measuring Wellbeing programme, which is informally known as “GDP and beyond”, closed the event with a reminder that the ONS consultation ends on April 15th.

For me this event underlined how important it is not to entrust senior academics with important decisions, because the nature of career progression in academia appears to select for dogmatism against any ability to grasp new information. Debate depends on grasping an opposing point of view so accurately that you can expose its flaws, and at this event there was not even an attempt at a debate.

Without intelligent debate, it is not clear to me how anyone will ever answer the three unresolved questions that came up:

  • Whether or not most of the population are somewhat mentally ill and in need of intervention.
  • Whether wellbeing is about how people say they feel or about how people function.
  • Whether self-reported wellbeing is reliable enough for governments to use in allocating resources.

Postscript

While writing this I came across the actual WEMWBS questionnaire. It seems to me that the philosophy it promotes is one of passive contentment. Real people rarely stay passive and content for very long. They fall in love, have children, pursue a career, start a business, write a book, join a club or climb a mountain, and any of these things will reduce their WEMWBS scores.

To put it another way, it looks like WEMWBS cannot distinguish between people who find life challenging and people who set themselves challenges in life. WEMWBS scores are therefore not a meaningful indicator of mental health, and their distribution is no evidence for that imaginary mental health continuum from flourishing to disordered.

I think there are considerable risks in basing public health policy on any particular ideology, and especially so in the case of such a weird ideology as this. I was more convinced by the panellists who argued for better research into the separate dimensions of wellbeing and for objective functional definitions of wellbeing.

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About Rod

Chairman of the Gloucestershire charity Suicide Crisis, Vice Chair of Relate Gloucestershire & Swindon, and an enthusiast for public involvement in the NHS.
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