Alyson Learmonth (Independent Public Health Consultant)
In September 2014 the Chief Medical Officer (CMO) for England published her Annual Report ‘Public Mental Health Priorities: Investing in the Evidence’. The focus on mental health as an issue is a welcome one, as are nearly all of the 14 recommendations. However, the report also includes a number of statements related to difficulties in using the term well-being, such as:
‘After reviewing the evidence I conclude that well-being does not have a sufficiently robust evidence base commensurate with the level of attention and funding it currently receives in public mental health at national and local government level’ (p14).
In April 2013 Local Authorities formally adopted their responsibility for ‘well-being’ through their Health and Well-being Boards, as legislated by the Health and Social Care Act, 2012. The CMO’s report therefore poses a significant challenge to all those tasked with fulfilling the responsibility for promoting well-being at a population level, particularly in the light of the lack of funding associated with austerity measures in local government. This article explores why the concept of well-being might be important to us all, the way the term is being applied by Local Authorities, the context of the CMO’s report, and concludes with a plea to consider the whole system.
The concept of well-being has become a political one over recent years. The New Economics Foundation web site claims that since 1970, the UK’s GDP has doubled, but people’s satisfaction with life has hardly changed; and that 81% of Britons believe that the Government should prioritise creating the greatest happiness, not the greatest wealth. It goes on to say there is a need for new measures aside from economic growth, to tell us how to measure progress as a society.
David Cameron in November 2010 set off a programme of work to define and measure it:
‘today the government is asking the Office of National Statistics to devise a new way of measuring well-being in Britain. And so from April next year, we’ll start measuring our progress as a country, not just by how our economy is growing, but by how our lives are improving; not just by our standard of living, but by our quality of life.’
One concern arising from this emphasis on well-being is that it gives responsibility to individuals to cultivate their own resilience, rather than taking political action and ensuring that government policy arranges for its people to have an adequate income and services to live decently, within the context of a welfare state (Friedli, 2012). At the same time as this focus on individual responsibility, is a push to see mental illness as a physical issue, primarily caused by chemical change in the body, without making the links between external causes of stress, whether social or epigenetic. (Juliette Jowit, Guardian 10.11.2014).
In September 2014, a Cross Party group of MPs called for all political parties to set out their approach to improving well-being as part of their manifestos. Meanwhile the Office of National Statistics have established on their web site ‘Measuring National Well-being’ which includes headline indicators in areas such as health, relationships, education and skills, what we do, where we live, our finances, the economy, governance, the environment and measures of ‘personal well-being’ (individuals’ assessment of their own well-being). Public Health England Business Plan includes the launch of a Health and Well-being Implementation Framework during 2014.
One place to look for the way the concept of ‘well-being’ is currently being applied in practice, is the Health and Well-being Strategies developed by every Local Authority in England. During the summer of 2014, the author undertook a review of the 12 Health and Well-being Strategies (HWBS) in the North East of England, focussed on the issues of inequalities, place-shaping and well-being. The review is undergoing an iterative process with stakeholders before submission for publication in an academic journal, but some preliminary findings follow.
Emotional health and well-being appeared as a top priority in just over half of the HWBS. Five out of twelve HWBS included definitions of well-being. The following quotes provide a flavour of the way the term is being used by Local Authorities:
- ‘Good mental well-being and resilience are fundamental to our physical well-being, relationships, education, training, work and to achieving our potential; it is the foundation for well-being and the effective functioning of individuals and communities.’ (County Durham)
- ‘When we talk about ‘well-being’ we are talking about the widest sense of the word – how happy people are living in Darlington, to what extent is there a lively range of opportunities for them to be involved in, are they healthy and able to live fulfilling lives with access to support when they need it.’ (Darlington)
- ‘Our health and well-being strategy ‘Active, Healthy and Well’ recognises this diversity of health and well-being and the factors which influence and underpin it. The following diagram illustrates the range of factors which determine good health, starting with the individual and moving outwards to include the wider influences of society – from people’s age and hereditary factors, to their social networks and position within society such as their income, employment, education and skills level, social class; their local environment such as housing conditions, crime levels, access to services; and their ability to have control over their life and to lead a life they value (i.e. the social or wider determinants of health)’. (Gateshead)
- ‘Mental well-being is fundamental to quality of life. It is linked to good physical health, with many other benefits for individuals. Communities and environments that support mental well-being are good for all of us, including people with mental health problems. Improving mental well-being and mental health care is about improving outcomes for everyone in society, reducing inequalities and increasing social inclusion. A whole system approach is needed to include a strong element of mental health promotion and early intervention alongside work on treatment and support and promoting social inclusion to tackle stigma and discrimination.’ (Northumberland)
- ‘Health and well-being are concepts which are often defined in different ways by individuals themselves, by groups or by policy and decision makers when assessing local health needs. “Health” as a term includes physical, mental and social health and well-being or quality of life. Promoting health and well-being and improving health is about enabling individuals and communities to reach their full potential – ideally through their own actions and collective activity’. (North Tyneside)
All five definitions address the environmental and social determinants of health, rather than simply focussing on individual lifestyle. While these are similar in terms of what they are describing, the variety of ways well-being is addressed suggests a lack of precision in the use of the term, that will make it difficult to focus and to measure progress.
So, going back to the CMO’s Annual Report mentioned at the start of this article, will surely provide a useful way forward in relation to this problem. Chapter 2 of her report is a review of well-being. She states:
‘public mental health is a complex field to define because it would ideally embrace notions of both good and poor mental health within its scope. In current usage, it has contested boundaries and terminology, and presents challenges in achieving a common understanding that can be applied in everyday practice by the NHS, government departments and executive agencies, service users, patients and funders, as well as by users of research.’
She proceeds to outline the history of the development of political and policy interest in the field of public mental health in Britain, from the publication of the Foresight Report in 2008. While successful in raising attention for the issue, the CMO’s reports finds inadequate evidence for Foresight’s hypothesis that
‘improving the average level of well-being across the population would produce a large decrease in the percentage with mental disorder, and also in the percentage who have sub-clinical disorder (those “languishing”)’.
It addresses this by proposing that future developments use the WHO model for public mental health. This model is based around 3 over-lapping spheres: mental illness prevention; mental health promotion; and treatment, recovery and rehabilitation. The report states that the intersection between ‘mental health promotion’ and ‘mental illness prevention’ requires a stronger evidence base before it would merit expenditure. The CMO therefore recommends that the NHS, PHE and Clinical Commissioning Groups should not commission services that ‘support mental well-being’, but instead focus on investing where there is an evidence base; and that local government bodies cannot be held to account for ‘improving well-being’ until a sufficiently robust set of indicators for use at a population level are developed.
The CMO’s report has been prepared by a team of experts, approximately 60% in psychiatry, and 20% in academic institutions linked to health services research. It included one person from Public Health (in relation to Chapter 16). This narrowness in terms of disciplinary background, experience and professional territory, means that the proposal to reject the use of well-being and recommend the term mental health promotion, may well spark off a semantic debate rather than a more rigorous approach. Cutting off funds for mental well-being approaches through mental health commissioning may be intended to protect the budgets historically set aside for mental health. At the same time giving Local Authorities who may be reluctant to take forward their new legal responsibility for well-being a rationale from the highest authority, may mean that no-one now is willing to pick up responsibility for community based work to promote mental health. Sadly the review does not include any specific recommendations for how research might enable us to understand better the intersection between mental health promotion and mental illness prevention.
It is not incompatible to both understand the wider social determinants of health and well-being, and want evidence-based recommendations. Three chapter length ‘whole system’ case studies (a social problem, a population group and a medically defined condition) are included in a recent book by Brown et al, 2014[i]. Had the CMO’s Annual Report acknowledged the application of complex systems research to change in relation to health, it may have been possible to see a vision of mental health and well-being as the high priority for government and people that it should be, together with some simple rules such as building mental health and well-being into the widest possible definition of public-facing roles and responsibilities.
[i] Jean Brown, Alyson Learmonth and Catherine Mackereth ‘Promoting Public Mental Health and Well-being: principles into practice’ published by Jessica Kingsley, November 2014
Alyson Learmonth retired as Director of Public Health in Gateshead, UK in 2012, after more than 30 years in the NHS. Special interest areas include tackling health inequalities, evidence-based practice and mental health and well-being. She is currently a Trustee for Tyneside Women’s Health, and is a co-author of ‘Promoting Public Mental Health and Well-Being: principles into practice’ (Jessica Kingsley, 2015).