Complexity and quality in healthcare… why it can’t be simple

We discussed earlier the problem of general practice being viewed as straightforward when those of us who work in the area usually find it anything but simple. But we have also recognised that we lack a language to describe why things are not simple. Complexity theory can offer us some new ideas about why this might be so and why attempts to quantify and measure every bit of care provided can miss out an important dimension.

Complexity theory

Complexity theory states that a complex system is one where different independent agents interact with each other to produce an outcome that is more than the sum of its parts and not wholly predictable¹. Illness is a complex phenomenon because has multiple interacting elements – pathology, daily living, social context and cultural context. Complexity is also evident in the healthcare system – patient interaction, health professionals/teams, practice contexts, system culture, resources and priorities^2,3.

Complexity theory helps us understand the challenges of everyday practice in many ways. We recognise two. It helps us broaden our focus beyond simply looking at pathology (does this person have condition x and can we treat it?) It also reminds us that the effect of healthcare may not always go as planned. Therefore care that is too narrowly focused on one specific metric – for example reducing blood pressure – may not be successful in improving overall health.

Rewilding healthcare

Recently GP and researcher Iona Health wrote an editorial calling for a ‘rewilding’ of general practice. Rewilding is an ecological term and refers to environment restoration not through traditional methods of ecosystem control – removing invasive species, planting etc but simply by allowing nature to flourish and natural regeneration to happen.

This may seem like a far fetched metaphor but stay with it for a moment…..we often think of healthcare/primary care as like a machine that can be ‘fixed’ by top- down solutions and goals and targets. By comparing healthcare to a living, resilient but also fragile ecosystem Heath makes the point that creating space for relationships and allowing personalised care to flourish will bring better health outcomes created from the bottom up rather than by top down control. But to achieve this we need clinicians empowered and confident in the extended skills of professional practice to generate knowledge in practice in context – practice based evidence. And to apply it, use it, critique it. In other words, we need to optimise/strengthen the knowledge work of everyday clinical practice. We will also need to create (build into our working day) space for communities of practice and making space for the critical creation of the practice based knowledge we need to drive quality care for our patients.

References

1. Manson, S. M. (2001). Simplifying complexity: a review of complexity theory. Geoforum, 32(3), 405–414. https://doi.org/https://doi.org/10.1016/S0016-7185(00)00035-X
2. Lipsitz LA. Understanding Health Care as a Complex System: The Foundation for Unintended Consequences. JAMA. 2012;308(3):243–244. doi:10.1001/jama.2012.7551
3. Sturmberg JP, O’Halloran DM, Martin CM. Understanding health system reform—a complex adaptive systems perspective. J Eval Clin Pract. 2012;18(1):202-20822221420