Positive Health Training Experience - A New Concept of Health from the Netherlands -

Makoto Kosaka, Orange Home-care Clinic

I am a third-year medical resident, working at the Orange Home Care Clinic in Fukui City, Fukui Prefecture from this April, which specializes in home medical care. Dr. Hiroyuki Beniya, the President of Orange, also serves as the representative of Positive Health Japan. Thanks to this connection, I participated in Positive Health training and visited the Netherlands.

Positive Health is a concept born in the Netherlands. The definition of health according to WHO is "not merely the absence of disease, but complete physical, mental, and social well-being." However, one might wonder if anyone truly meets this definition. Positive Health emerged from such skepticism and is a new concept of health as the ability to adapt and manage on one's own when facing social, physical, and emotional challenges. In 2011, Dr. Huber's discourse on Positive Health was published in the British Medical Journal.

Along with 17 other trainees, I attended full-day training sessions in Karuizawa in early April and in Fukui in mid-April, followed by a visit to the Netherlands, the home of Positive Health. The program there was coordinated by Akane Chabot, author of "Positive Health from the Netherlands: Shaping the Future of Community Care" and "Expanding Positive Health to Daily Life: Resilient Health Models from the Netherlands" (both in Japanese), and Dr. Carolin, a local general practitioner (GP).

Positive Health is based on the specific action of "using a spider web diagram (simplified version shown in Figure 1) to talk about oneself." This spider web is a tool where one rates their health status across six dimensions, without the need for comparison with others. It’s okay if some scores are low, as long as the individual considers them unimportant.

Figure 1: Spider Web (Simplified Version) - http://expres.umin.jp/mric/mric_24107.pdf

The focus is not on scoring high, but on the conversation itself. Interestingly, when asked if I have a purpose in life, I might be speechless, but if I first score my sense of purpose out of ten, it sparks thoughts and discussions about why it might have increased since last time. I appreciated how well this system facilitates self-reflection while experiencing it firsthand.

Through these conversations, one can gain a more comprehensive understanding of their physical condition and determine the next steps to take, supported by their own initiative. In the Netherlands, Positive Health is embraced as a national and local governmental concept, much like the SDGs in Japan. However, unlike the SDGs, which focus on the outcomes of initiatives, Positive Health emphasizes the process of self-direction. It is only effective when the individual is ready.

At the individual level, the "spider web" is also used in dialogues between Dutch family doctors and their patients. In Japan, while there is a comprehensive evaluation for the elderly, comparing it with the "spider web" shows that the Japanese index is biased towards three dimensions: physical condition, mental state, and daily living functions. Expanding our perspective to consider the whole patient, not just their illness, could serve an important role in Japan too.

During the training in the Netherlands, we visited several facilities that embody Positive Health, notably the work of Dr. Jung, a family doctor whose approach has also influenced the medical system. He discussed a case with a diabetic patient in his 70s, where they walked together in the woods discussing diet, which led to a significant improvement in the patient's blood sugar levels. The patient found joy in walking and made it a daily routine with friends. Another patient, suffering from loneliness alongside physical pain, stopped visiting after being introduced to a community center where they began baking cookies.

These interventions had significant health impacts, similar to "social prescriptions" in Japan. What is remarkable about Dr. Jung's approach is that he secured financial backing for it.

In the Netherlands, the reimbursement a family doctor receives can vary depending on the contract with the insurance company, regardless of whether the patient visits. Dr. Jung negotiated directly with insurance companies under the philosophy that "we (doctors) are the medicine," shifting the payment model from fee-for-service to per capita payments, extending the consultation time from 10 to 15 minutes per patient.

As a result, while consultation fees increased by 37%, medication costs decreased by 15%, referrals to hospitals decreased by 20% over two years, and overall healthcare costs per person slightly declined. This initiative led the insurance companies to decide to extend the consultation unit for family doctors across the country, a significant change appreciated by them.

This training reaffirmed the potential for dialogue during consultations to become a core part of treatment. However, as a resident like me usually focuses on efficiently and safely managing tasks, there is a constant risk of overusing tests and prescriptions, which Dr. Beniya calls "the trap of advanced training." This timely exposure to Positive Health has made me reevaluate the power of my words and, more importantly, the power of listening, as I approach my daily clinical practice.

The Positive Health training is scheduled to continue next year. If this article has piqued your interest, please contact Positive Health Japan at office.positivehealthjapan@gmail.com.

*This article is a translation of Japanese MRIC published on Juｎ ４, 2023