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From a new definition of health towards person-centred care

Since 2014, a new definition of health has been on the rise: “Health as the ability to adapt and self-manage, in light of the physical, emotional and social challenges of life“. Also known as positive health. Some see this as the solution for all the problems that we currently face within the healthcare sector. Which isn’t strange, if you consider that for decades, the healthcare sector has mainly focused on diseases and medical interventions. However, gradually we find out that this static view on health does not always offer sufficient possibilities to address the needs of people living 24/7 with one or multiple chronic diseases. In this blog, we discuss the new definition of health, and focus on its positive aspects and its shortcomings. We will also highlight what is needed to create a pandemic of health.

A new definition of health

The new definition of health was introduced by Machteld Huber and colleagues in 2014 in the BMJ. Huber turned the WHO definition of health – “a state of complete physical, psychological and social well-being and not only the absence of disease” upside down. Huber states that this definition is out of date, because as defined by it almost no one can be considered healthy. And that it leads to unnecessary and costly medicalization of care. As an alternative, she introduces the definition: “the ability to adapt and direct control of yourself with regard to the physical, emotional and social challenges of life”, which forms the basis for the so called concept of positive health. In this concept, health is no longer seen as the absence or presence of disease, but as the ability of people to deal with (changing) physical, emotional and social life challenges and to manage their own self as much as possible. Health is no longer strictly the domain of healthcare professionals, but a concern of everyone. Huber distinguishes six health dimensions to measure ‘health well-being’: 1) body functions, 2) mental functions and mental experience, 3) spiritual dimension, 4) quality of life, 5) social participation, and 6) daily functioning, which she links to 32 health aspects.

Criticisms

The new definition of health receives a lot of praise, but also encounters criticism. Various scholars have pointed out that it actually isn’t a new definition. Similar health definitions and insights that contain useful elements have arisen in international scientific literature many years ago. Furthermore, the criticism of Huber and colleagues can roughly be divided into three groups: 1) criticism on conceptual and methodological level, 2) as a warning of the possible consequences and 3)on practical implementation and application. We explain them briefly.

Ambiguity

Huber considers health as the “ability to adapt and direct control of yourself”. With this she describes health (rightly) as a complex and dynamic concept. Which is great, but then she reduces (positive) health to six dimensions. Confusing to say the least. Complexity and reductionism do not go well together. It would have been clearer if Huber indicated that reducing health to a number of dimensions is necessary to be able to do research, but also mentions the limitations of this method. Health as a whole is complex and cannot be reduced into six mutually exclusive dimensions. There is a lack of this nuance in Huber’s work.

Confusion

Huber confuses behaviour and health with each other. According to the definition, for example, very sick people could be considered healthy as long as they behave constructively. The confusion arises because Huber uses the term ‘health’ for a condition and for dealing with that condition. This ambiguity means that people can deal with their health and their unhealthiness in a healthy and unhealthy way. For example, depending on the perspective of the assessor, the same person can be called healthy or unhealthy or even healthy and unhealthy at the same time. As a result, Huber’s concept leaves many questions unanswered and can lead to peculiar or incorrect conclusions.

No implementation strategy

In addition, Huber’s theory lacks a clear implementation strategy, and without it the concept will not lead to sustainable changes. People are going to apply the ideas according to their own insights and a proliferation of (small-scale) initiatives arises that ultimately often do not lead to the desired outcome. The so called ‘Positive Health Spider Chart’ – a diagram that incorporates the six dimensions of positive health which care providers can use to map the well-being of the patient – does not provide sufficient direction. It does not indicate which interventions should subsequently be used. Moreover, the focus is only on the individual, while health can also be influenced at family, neighbourhood, regional and national levels.

Healthcare or illness care?

So, should we have to throw the new definition of (positive) health overboard? This a bit short-sighted, because it’s a justified reaction to the medicalization that has characterized healthcare for many years. In the past decade, people are increasingly being deprived of their self-control. It is good that Huber points out that not only the treatment of a disease, but also the promotion of health should be paid attention to. In addition, the definition fits well with the language and ideas of healthcare providers. It meets a need and is therefore widely adopted. The new definition of health has awakened us, but we must not adopt it uncritically. Huber says that a new healthcare system must be based on her definition of health, but an evidence based execution strategy is lacking. The concept of positive health – regardless of how beautiful it may seem in theory – has too narrow a basis (limited to the patient) and is practically not applicable.

The person-centred care model offers a better answer to the problems we face within the healthcare sector. This approach to care, which focuses on self-management, healthy behaviour, job retention and desired quality of life, is more in line with current patient demand. Person-centred care is about the needs and possibilities of a patient. The context and differences in personal characteristics are also considered. A vastly different approach than patient-centred care that predominated for decades (see table below).

Views on healtcare

But what really matters is that we have to separate ourselves from the idea that we have to choose for one or the other solution. It is not either patient-centred care or person-centred care. Both are compatible. You cannot separate one from the other. Both matter, so they must coexist and complement each other.

How do we create a pandemic of health?

A single focus on a disease is too limited. But the same applies to a single focus on a new definition of health or person-centred care. Healthcare is a complex system. There are many factors at different levels, which also influence each other. What we need to do is understand and approach care as a complex system. This means that we have to include all parties involved: patients, caregivers, administrators, industry and policy makers. The Rainbow Model provides an execution strategy of how to realise this. It shows the steps that are needed to create a pandemic of health in the emerging era of value-based care. So, let us stop with chasing down every hype, but opt for a broader vision and then embark upon it with a solid, evidence-based execution strategy. If health care is addressed well at all levels, this translates into quality, patient satisfaction and cost savings, freeing us from all the hypes that would otherwise be waiting for us.

Read more in our whitepaper about how person-centred care can be implemented using the Rainbow Model. Simply download our whitepaper “Value-based healthcare: A call for integrated action” by clicking on the button below.

Pim Valentijn

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