Nobody could possibly be against wellbeing. It would be like opposing motherhood and apple pie. There is a whole spectrum of activities under the wellbeing banner, from the undoubtedly well-meaning patient-centred care at one end, to downright barmy new-age claptrap at the other end. The only question that really matters is, how much of it works?
Let’s start at the fruitcake end of the spectrum.
One thing is obvious. Wellbeing is big business. And if it is no more than a branch of the multi-billion-dollar positive-thinking industry, save your money and get on with your life.
In June 2010, Northamptonshire NHS Foundation Trust sponsored a “Festival of Wellbeing” that included a complementary therapy taster day. In a BBC interview one practitioner used the advertising opportunity, paid for by the NHS, to say “I’m an angelic reiki master teacher and also an angel therapist.” “Angels are just flying spirits, 100 percent just pure light from heaven. They are all around us. Everybody has a guardian angel.” Another said “I am a member of the British Society of Dowsers and use a crystal pendulum to dowse in treatment sessions. Sessions may include a combination of meditation, colour breathing, crystals, colour scarves, and use of a light box.” You couldn’t make it up.
The enormous positive-thinking industry is no better. Barbara Ehrenreich’s (1) book, Smile Or Die: How Positive Thinking Fooled America and the World, explains how dangerous the industry is, because, as much as guardian angels, it is based on myth and delusion. It simply doesn’t work (except for those who make fortunes by promoting it). She argues that it fosters the sort of delusion that gave us the financial crisis (and pessimistic bankers were fired for being right). Her interest in the industry started when she was diagnosed with cancer. “When I was diagnosed, what I found was constant exhortations to be positive, to be cheerful, to even embrace the disease as if it were a gift. If that’s a gift, take me off your Christmas list,” she says. It is quite clear that positive thinking does nothing whatsoever to prolong your life (2,3), any more than it will cure tuberculosis or cholera. “Encouraging patients to “be positive” only may add to the burden of having cancer while providing little benefit” (3). Far from being helpful, it can be rather cruel.
Just about every government department, the NHS, BIS, HEFCE, and NICE, has produced long reports on wellbeing and stress at work. It’s well known that income is correlated strongly with health (4). For every tube stop you go east of Westminster you lose a year of life expectancy (5). It’s been proposed that what matters is inequality of income (6). The nature of the evidence doesn’t allow such a firm conclusion (7), but that isn’t really the point. The real problem is that nobody has come up with good solutions. Sadly the recommendations at the ends of all these reports don’t amount to a hill of beans. Nobody knows what to do, partly because pilot studies are rarely randomised so causality is always dubious, and partly because the obvious steps are either managerially inconvenient, ideologically unacceptable, or too expensive.
Take two examples:
Sir Michael Marmot’s famous Whitehall study (8) has shown that a major correlate of illness is lack of control over one’s own fate: disempowerment. What has been done about it? In universities it has proved useful to managers to increase centralisation and to disempower academics, precisely the opposite of what Marmot recommends. As long as it’s convenient to managers they are not going to change policy. Rather, they hand the job to the HR department which appoints highly paid “change managers,” who add to the stress by sending you stupid graphs that show you emerging from the slough of despond into eternal light once you realise that you really wanted to be disempowered after all. Or they send you on some silly “resilience” course.
A second example comes from debt. According to BIS (9), debt is an even stronger risk factor for mental disorder than low income. So what is the government’s response to that? To treble tuition fees to ensure that almost all graduates will stay in debt for most of their lifetime. And this was done despite the fact that the £9k fees will save nothing for the taxpayer: in fact they’ll cost more than the £3k fees. The rise has happened, presumably, because the ideological reasons overrode the government’s own ideas (9) on how to make people happy.
Nothing illustrates better the futility of the wellbeing industry than the response that is reported to have been given to a reporter who posed as an applicant for a “health, safety, and wellbeing adviser” with a local council. When he asked what “wellbeing” advice would involve, a member of the council’s human resources team said: “We are not really sure yet as we have only just added that to the role. We’ll want someone to make sure that staff take breaks, go for walks — that kind of stuff.”
The latest wellbeing notion to re-emerge is the happiness survey. Jeremy Bentham advocated “the greatest happiness for the greatest number,” but neglected to say how you measure it. A YouGov poll asks, “what about your general well-being right now, on a scale from 1 to 10.” I have not the slightest idea about how to answer such a question. As always some things are good, some are bad, and anyway wellbeing relative to whom? The whole exercise smacks of the sort of intellectual arrogance that led psychologists in the 1930s to claim that they could sum up a person’s intelligence in a single number. That claim was wrong and it did great social harm.
HEFCE has spent a large amount of money setting up “pilot studies” of wellbeing in nine universities. Only one is randomised, so there will be no evidence for causality. The design of the pilots is contracted to a private company, Robertson Cooper, which declines to give full details but it seems likely that the results will be about as useless as the notorious Durham fish oil “trials” (10).
Lastly we get to the sensible end of the spectrum: patient-centred care. Again this has turned into an industry with endless meetings and reports and very few conclusions. Epstein & Street (11) say
“Helping patients to be more active in consultations changes centuries of physician-dominated dialogues to those that engage patients as active participants. Training physicians to be more mindful, informative, and empathic transforms their role from one characterized by authority to one that has the goals of partnership, solidarity, empathy, and collaboration.”
That’s fine, but the question that is constantly avoided is what happens when a patient with metastatic breast cancer expresses a strong preference for Vitamin C or Gerson therapy, as advocated by the YesToLife charity. The fact of the matter is that the relationship can’t be equal when one party, usually (but not invariably) the doctor, knows a lot more about the problem than the other.
What really matters above all to patients is getting better. Anyone in their right mind would prefer a grumpy condescending doctor who correctly diagnoses their tumour, to an empathetic doctor who misses it. It’s fine for medical students to learn social skills but there is a real danger of so much time being spent on it that they can no longer make a correct diagnosis. Put another way, there is confusion between caring and curing (12). It is curing that matters most to patients.
If, as is only too often the case, the patient can’t be cured, then certainly they should be cared for. That’s a moral obligation when medicine fails in its primary aim. There is a lot of talk about individualised care. It is a buzzword of quacks and also of the libertarian wing which says NICE is too prescriptive. It sounds great but it helps only if the individualised treatment actually works.
Nobody knows how often medicine fails to be “patient centred.” Even less does anyone know whether patient-centred care can improve the actual health of patients. There is a strong tendency to do small pilot trials that are as likely to mislead as inform. One properly randomised trial (13) concluded “those committed to achieving the benefits of patient centred consulting should not lose the focus on disease management.” Non-randomised studies may produce more optimistic conclusions (14), but there is no way to tell if this is simply because doctors find it easy to be empathetic with patients who have better outcomes.
Obviously I’m in favour of doctors being nice to patients and to listening to their wishes. But there is a real danger that it will be seen as more important than curing. There is also a real danger that it will open the doors to all sorts of quacks who claim to provide individualised empathic treatment, but end up recommending Gerson therapy for metastatic breast cancer. The new College of Medicine, which in reality is simply a reincarnation of the late unlamented Prince’s Foundation for Integrated Health, lists as its founder Capita, the private healthcare provider that is happy to back the herbalists and homeopaths in the College of Medicine, and, no doubt, to make a profit from selling them to the NHS.
In my own experience as a patient, there is not nearly as much of a problem with patient centred care as the industry makes out. Others have been less lucky, as shown by the mid-Staffordshire disaster (15), That seems to have resulted from PR being given priority over patients. Perhaps all that’s needed is to save money on all the endless reports and meetings (“the best substitute for work”), ban use of PR agencies (paid lying) and to spend the money on a more doctors and nurses so they can give time to people who need it. This is a job that will be hindered considerably by the government’s proposals to sell off NHS work to private providers who will be happy to make money from junk medicine.
(1) Barbara Ehrenreich Smile or Die. Lecture at RSA
(2) Coyne JC, Stefanek M, Palmer SC. Psychotherapy and survival in cancer: the conflict between hope and evidence. Psychol Bull. 2007 May;133(3):367-94
(3) Schofield P, Ball D, Smith JG, Borland R, O’Brien P, Davis S, Olver I, Ryan G, Joseph D. Optimism and survival in lung carcinoma patients. Cancer, 2004 Mar 15;100(6):1276-82.
(4) Marmot, M. (2010) Fair Society, Health Lives. The Marmot Review
(5) London Health Observatory
(6) Wilkinson. R & Pickett, K. 2009 , The Spirit Level, ISBN 978 1 84614 039 6
(7) Lynch J, Smith GD, Harper S, Hillemeier M, Ross N, Kaplan GA, Wolfson M. (2004) Is income inequality a determinant of population health? Part 1. Milbank Q.;82(2). 355-400.
(8) Marmot, M. (2004) Work, Stress and Health. The Whitehall II study
(9) BIS report Mental Capital and Wellbeing
(10) Goldacre, B. (2008). Fish oil exam results fail all the tests.
(12) What “holistic” really means
(13) Kinmonth et al. (1998), Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk British Medical Journal 317 : 1202
(14) Hojat, M. et al. (2011). Physicians’ Empathy and Clinical Outcomes for Diabetic Patients Academic Medicine: 86, 359-364
(15) Delamothe, T. (2010) Repeat after me: “Mid Staffordshire” British Medical Journal; 340:c188.