One of the biggest stories this week is that US President Barack Obama has signed a landmark healthcare bill into law – the largest expansion of the US federal social safety net since the 1960s. But work by leading healthcare analysts around the world would indicate that the safe passage of the bill is only the starting point.
In a paper for the Commission on the Future of Healthcare, Sholom Glouberman and Brenda Zimmerman illustrate how attempts to intervene in complex health care systems often treat them as if they were merely complicated, or even worse, simple.
The table below sets out the now well-known framework which they use to make these distinctions. Glouberman and Zimmerman argue that such conceptual mismatches between reforms and reality can compound healthcare failures in dramatic ways. They give a number of examples of how this has happened in the Canadian Medicare system.
The authors liken the pervasiveness of existing ‘complicated’ approaches to healthcare reforms to an often-told story of a man who is stumbling around near a lamppost:
…He is asked what he is doing and says that he is looking for his car keys. “Oh, where do you think you lost them?”
“Down the block near my car,” he says.
“So why are you looking for them here?”
“Because the light is better.”
The sophistication of our models, theories and language for complicated problems can be as seductive as the lamplight. They provide better “light” and clarity and yet can lead to approaches that are ill-equipped to address complex adaptive systems…” (emphasis added)
They aren’t the only ones to see potential for complexity science in bringing about healthcare improvements. Paul Plesk, Director of the Academy for Large Scale Change at the UK’s NHS Institute of Innovation, uses the same distinction between complicated and complex systems as a way of demonstrating how ‘directed creativity’ can be utilised in change processes. The World Health Organization has also been using complexity approaches in its work on knowledge management, and on analysing disrupted health systems in conflict-affected countries.
The Healthcare Commission paper sets out four clusters of differences between complicated and complex systems, all of which have relevance for healthcare reforms.
Theory of systems First, the theory of health systems is enhanced by ideas of real-world systems which behave in nonlinear and unpredictable ways. It isn’t just a case of pulling levers, and ignoring noise and fluctuations. Instead, the key is to embrace uncertainty, tension, noise – to work with these factors as givens rather than as aberrations.
Causality The second set of differences is about how change happens, specifically how causality is not one-way but dynamic with multiple feedback processes. This means accepting dynamics of change as two-way, unpredictable and never-ending:
Evidence The third set of differences relates to evidence, and how complexity means that certain kinds of evidence – much of which would be dismissed if health systems were seen as merely complicated – needs to be understood. Specifically: outliers, historical anomalies, and patterns of behavior and relationships all need to be examined and understood.
Planning and decision-making The fourth area relates to planning and decision making, and how overall system-wide properties emerge from many small-scale decisions. Therefore the key is not to plan everything in advance, but to put in place a process of strategic learning that will allow for corrections, shifts, and even wholesale changes in approach.
- to articulate an approach to the complex issues faced in changing healthcare systems
- to resist the technical bias to analysis which assumes the problem is a complicated one
- to resist political influences that promote particular approaches and mindsets, and reduces engagement with complexity
In the face of such vociferous opposition, the need to question existing assumptions and mindsets may seem irrelevant. But it is arguably even more important in such settings. As Muhammed Yunus, founder of Grameen Bank, put it recently, when talking about the rise of microfinance: “[the] greatest challenge has been to change the mindset of people.”
In this light, perhaps the true test of the healthcare reforms will not merely be new legislation, budget and policy frameworks, technical fixes, unseen compromises and political victories. Perhaps the true test of the reforms will be whether they bring about change in mindsets.