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Perturbing ongoing conversations about systems and complexity in health services and systems

2009; Wiley; Volume: 15; Issue: 3 Linguagem: Inglês

10.1111/j.1365-2753.2009.01164.x

1365-2753

Carmel M. Martin, Joachim P. Sturmberg,

Complex Systems and Decision Making

The term 'unintended consequences'[1] has become ubiquitous [2] in health policy and delivery circles. We argue that this is a sign of the growing unease arising from the realization of the limitations of the still dominant reductionist research approaches, 'evidence' and linear thinking in relation to health system1 and health services2 policy redesigning. Complexity theorists argue that many of the problems of health services and systems will not be solved through the application of more reductionism [3]. The most revered tool in reductionist research is the randomized controlled trial (RCT). However, as Cartwright has pointed out RCTs have very significant limitations for real world problems. 'The claims of . . . RCTs to be the gold standard rest on the fact that the ideal RCT is a deductive method: if the assumptions of the test are met, a positive result implies the appropriate causal conclusion. . . . the benefit that the RCT conclusions follow deductively in the ideal case comes with a great cost: narrowness of scope. . . . (in order) to draw causal inferences about a target population, which method is best depends case-by-case on what background knowledge we have or can come to obtain'[4]. Health services researchers, decision makers and practitioners are now faced with at least two challenges: how to respond to the limitations of current research and decision-making models that have taken us 'just so far'; and how to integrate other sources of evidence into policy and practice in the real world [5]. What matters is making sense of what is relevant, i.e. how a particular intervention works in the dynamics of particular settings and contexts. It is not very useful to change a system based on deductive, in Cartwright's words – average explanations. As Stengers [3] pointed out – the most useful questions addressing complex problems must imply an open situation: 'What will the intervention be able to produce?' and 'What kind of behaviour will emerge? What are our frames of reference? What are our ideas and values in relation to success?' In relation to policy development Glouberman, an applied philosopher adds: 'Frameworks for understanding policy development do not merely describe the process. They invariably indicate what a "well-functioning" process is like. And so they place a value on certain structures and behaviour. As our theories change, so do our views of what is good'[6]. Responses to the challenges to our contemporary frameworks are many and varied. They include the rise of translational research [7], narrative evidence-based medicine [8], the quest for utility in patient-reported outcome measures, together with new statements about trials and multifaceted interventions [9–12]. Acknowledging these challenges is not only a sign of understanding the crisis of scientific knowledge [13], but also evidence that new conversations have started [7,14,15]. Common to complex systems are two fundamental themes – the universal interconnectedness and interdependence of all phenomena, and the intrinsically dynamic nature of reality [16]. 'At each level of complexity we encounter systems that are integrated, self-organizing wholes consisting of smaller parts and, at the same time, acting as parts of larger wholes'[17]. Notable international examples of an emerging and evolving discourse about complex systems in health services research and quality improvement include the Institute of Medicine's report 'Crossing the Quality Chasm'[18] with a resultant series of US quality initiatives, and Glouberman and Zimmerman's report to the Romanow Commission in Canada [19]. Approaches to understanding complex systems developed by Kurtz and Snowden [20] for IBM international e-business management have been successfully applied, with frontline health care providers taking a lead to improve outcomes in the successful redesign of New York State Veteran's Affairs [21]. Other examples include the successes of taking a systems approach to tobacco control on overall smoking rates within the Veterans Affairs health services clients [22] and in the broader health systems against major resistance by the licit and illicit tobacco industry [23,24]. Ongoing challenges to smoking cessation and tobacco control strategies remain. Deprived communities are not only at greater risk from the adverse effects of smoking related morbidity, they are also at greater risk from social factors that predispose to smoking. In addition, social and environmental factors such as unemployment interact with endogenous or biological risk factors such as a predisposition to anxiety or other mental illness. As Galea et al.[25] argued in a overview of the social epidemiology of smoking, there are complex multiple interacting factors at individual and societal levels (biopsychosocial levels). In the future, it is important to make sense of the complexity 'of not only how social factors may influence substance use in isolation but also how social factors may modify relations between biological characteristics and substance use behaviour'[25]. Atun [26], Evans [27] and Shiell [28] have recognized that economic evaluations of a complex adaptive health system need to encompass multiple perspectives and dynamic influences in an environment. For example, opportunity costs result from a decision to take a certain approach that entails not pursuing or even considering some options [29]. These opportunity costs are important in health service decision making, as a basis for efficient use of resources. Reductionist analysis of opportunity costs is content with restricted possibilities, i.e. it accepts the categorical exclusion of certain individuals or community considerations in its economic evaluations, that later show up as unintended consequences on the wider health system. For example, studies exploring the economic impact of doctor behaviours suggest that 'assigning a monetary value (aiming to reduce opportunity costs) to every aspect of a doctor's time and effort may actually reduce productivity, impair the overall quality of performance, and thereby even increase costs' [30]. The focus on the monetary value of narrowly defined tasks incurs an opportunity cost as it undermines doctors' social contract for altruism with patients, society and other professionals [30], outweighing the 'calculated benefits accrued'[31]. This example and others demonstrate that narrowly focused and static evaluations cannot assess the true efficiencies in complex health systems [29]. Somewhat surprisingly, despite the flurry of interest in recent decades, diffusion of knowledge and innovation about complexity and adaptation in systems for health care has been slow [15,28]. Reductionism remains the dominant paradigm and is increasingly influencing policy like the introduction of simple disease management protocols or pay-for-performance targets [30]. Clinician work is increasingly being reduced to a series of discrete activities based on a business model driven by the agenda of cost containment [30] rather than improved patient health. Moreover, there has been almost no discourse to distinguish what is amenable to reductionist approaches and what is not, and how to apply holism and holistic frameworks and approaches. Why might this be the case? Singer, the Director of the Max Planck Institute for Brain Research in Frankfurt, Germany provides important insights towards answering this question [32]. The rise of human culture and civilization, great works of philosophy, literature and art or the modern communication systems via the Internet and the blackberry are not explained by our decentrally organized brains, and the dynamic states and plasticity of the many billions of linked and interacting neurons in the brain. Both our brains and our social organizations have evolved to be complex, dynamic and adaptable with emergent properties not explained by the structures that they contain. Singer reflects, apparently, 'our cognitive abilities have evolved in a world in which there was no advantage to be gained by understanding nonlinear complex multidimensional processes'[32]. Whether or not the current dominance of reductionism [13] is a social or an evolutionary brain phenomenon, in history, there has always been the counter position of holism. As stated by the eminent Greek philosopher Aristotle [33], 'the whole is greater than the sum of the parts'. Thus, despite a tendency to reductionism, 'this does not mean that we cannot or will not develop analytical methods to identify these (complex) system states and to track them chronologically; however, the descriptions will be abstract and vague, and will bear no similarity to our familiar perceptions and concepts'[32]. So we must conterintuitively work to develop appropriate abstract frameworks and categories, and reflect on our ways of knowing, if we are to gain a deeper understanding of the processes that operate in complex systems, and how to intervene more successfully [29,32]. Our main imperative to go beyond the more intuitive and reductive is the lack of success of many well-intended health services interventions [34,35] and the unintended consequences of interventions in the real world of health systems [36–38]. However, many may still see the current limitations in knowledge and practice, as a stimulus to more rules, and greater compartmentalization, categorization, description and reductive measurement of the complex processes of the health systems in which we operate rather than take up the challenges of Singer, Sengers and many others [9]. Yet the imperative to act is now, to communicate through complexity science and knowledge to make visible and comprehensible, the dynamics of health and health care, else approaches based on easily measured phenomenon will prevail in health systems. As Delamothe in the British Medical Journal says, 'In the current financial and political climate is it wise to defend (primary) care solely by invoking its warm fuzzy heart, beating away in its black box, far from the close scrutiny of all but its adepts'[39]? Making a plea for innovation and real world dynamic understandings in a different context, Lawrence Green, an international public health expert says: 'Public health asks of systems science, as it did of sociology 40 years ago, that it help us unravel the complexity of causal forces in our varied populations and the ecologically layered community and societal circumstances of public health practice. We seek a more evidence-based public health practice, but too much of our evidence comes from artificially controlled research that does not fit the realities of practice. What can we learn from our experience with sociology in the past that might guide us in drawing effectively on systems science'[40]? Thus dissatisfaction with the status quo may well be the tipping point away from reductionist approaches [31]. Yet, will the ground work for innovation and change be sufficiently advanced when the time comes, that the reductionist approach can no longer cope with both the enormous amount of information that comes from sciences, technologies and social sciences – and the astonishing complexity that they reveal? Do we have the ways forward towards knowledge frameworks and the methodological developments to support approaches working in complex health services and wider health systems? This new Forum takes up this challenge of accelerating the exposition, understanding and promotion of complexity and health services, research and evaluation of health systems, and bringing together those who are currently working busily away on this complexity enterprise in isolation. We concur with Pizzocaro who stated that 'the awareness of complexity does not imply answering questions or solving problems: rather, it means opening problems up to dynamic reality, as well as increasing the relative level of awareness. Thus, the notion of complexity – whatever the discipline, strongly supports the possibility that – given a form of scientific investigation – questions and answers may change, as well as the nature of questions and answers upon which scientific investigation is built'[41]. In this sense, complexity may be seen as an opportunity rather than a constraint, and consequently assumed as a challenge [42]. Some 'wicked questions' might include: what might complexity formulations look like? How can we make sense of the impact of the capacity of an individual, an organization or a system to adapt to local needs and constraints to improve quality of life? How can we increase patient, practitioner, and health system intelligence and adaptability to changing needs? We need to continue to perturb, reflect and act on the vast knowledge that exists within and outside of our individual disciplines, including linking with other systems approaches such as systems biology and systems in biomedicine. Vast amounts of knowledge about our systems will likely emerge by looking at what we know through new eyes. Thus, in particular, we need to think deeply about changes to our conceptual frameworks and principles, and the methods we use. On the whole, complexity theory and science provide approaches to an uncertain and dynamic reality to make sense of dynamic emergent reality, which changes as we observe it. Embracing or reframing theories and designing research as we proceed will inform the dynamic health systems in which we operate. Broad areas of theoretical and scientific development that signify important emerging influences in shaping health and health care systems are: philosophy, conceptual, and theoretical debates and developments; non-linear dynamics and mathematical analyses of complex adaptive care; and narratives and participatory action research to make sense of and to shape local system design. Different research strategies and multiple methods are needed to make sense of complex health care systems that encompass systems and subsystems of systems biology and translational medicine; clinical care and patient-centred medicine; health service organization and evaluation; health policy and determinants of health; and education for medicine, nursing, pharmacy, dentistry, therapists and all health workers. It is helpful to see evidence in terms of simple and complicated systems, and complex and chaotic systems, and the transitions between these states. We hope that the new Forum and debates will address questions about and provide examples of how complexity in health systems research can be approached – theoretically and methodologically? What are the tools of the trade – do they differ from or are they located within current mainstream research? Or is it that philosophy and theoretical frameworks are different? We will be publishing peer reviewed research papers using mathematical dynamics and clustering, philosophical analysis, narrative research and economic evaluation. The next issue will explore a variety of approaches contributing to a broader understanding of the complex nature of health and health care. The third forum will examine health system reform issues from a complexity perspective. Health policy is the theme of the fourth forum. The final forum focuses on education and economics. We hope to provide a stimulus for health services research and policy to open up to look outside the box – the nature of human health, environment, socioeconomics, organization, informatics, education, work practices etc – all of which are the scope of the Forum and journal. The editors of the new Forum hope that it will evolve into a full Supplement from 2010 onwards, and we are keenly looking forward to your comments and inputs. The trick in any great social project is to stop looking at the discrete elements and start trying to understand the complex relationships between them. By studying fascinating real-life examples of social change through this systems-and-relationships lens, for example one can begin to tease out the rules of engagement between patients, health care providers, organizations and circumstance [43].