Common system characteristics

In this step, we consider some of the common characteristics of a system, how they operate, and the relationship between them.

According to De Savigny and Adam (2009: 31), most systems (including health systems) are:

• Self-organising
• Constantly changing
• Tightly linked
• Governed by feedback
• Non-linear
• History dependent
• Counter-intuitive
• Resistant to change

Let’s explore these eight characteristics in more detail.

The dynamics of a system arise spontaneously from its internal structure and therefore it can be classified as self-organising. This means that no individual element determines the nature of the system; the organisation of a system arises through the dynamic interaction among the system’s elements and through its interaction with other systems.

It is, therefore, important that systems are not static and are constantly changing. An adaptive system can generate its own behaviour and react differently to the same inputs in unpredictable ways.

As systems are tightly linked any intervention or action within one element of the system will affect – positive or negative – on the other elements of the system. So, it’s important for the system to be governed by feedback, as each element of the system needs to be aware of the positive or negative impact (or expected effects) of intervention within other elements of the system.

Systems are controlled by feedback loops that provide information flows on the state of the system, moderating behaviour as elements react and ‘back-react’ on each other.

A very simple healthcare example of this is seen in the UK when community-based General Practice (GP) services are closed. When this occurs, more people attend emergency departments in hospitals, often for non-urgent health matters.

As GP services and hospital’s emergency departments are usually operated by different organisations, without a flow of information and feedback, it’s quite possible for these two elements of the system to operate in self-organising isolation of each other, which would be highly likely to have a negative impact on patient care.

Therefore, it’s important that hospital managers know when GP services are closed so that they can plan for the additional workload that will undoubtedly come their way.

However, in practice, the relationships between elements of a system cannot be arranged along a simple input-output line. That is, if one element of system undertakes action Y, this will produce outcome X within another element of the system.

The relationship between inputs and outputs across the system are typically non-linear and often unpredictable. Within complex systems like healthcare, often the effects can only be fully understood over time, as they are history dependent. Short-term or immediate effects may differ from the long-term effects of any intervention.

Applying this to our example of when a patient opted to go to the hospital’s emergency department because they are not able to see a GP – if the experience they received within the emergency department was positive, particularly compared to what they perceive they may have received from their GP, this patient may decide to bypass their GP permanently and always go to the hospital’s emergency department when they are unwell.

If this shift in patient behaviour is seen on a large scale this could destabilise the system as a whole, and therefore an intervention elsewhere in the system might be needed to mitigate against this change in patient behaviour.

De Savigny and Adam’s (2009) model concludes that across the system, some simple and effective interventions may function perfectly well in one area, but counter-intuitively in another. This, in part, may be an example of how parts of the system are resistant to change.

Applying this to our example, a logical action may be to extend the opening hours of GP practices. However, this may be resisted by staff who may feel they do not have the resources to do this, therefore this action would risk diluting the quality of care to other patients attending throughout the week.

Resources could be directed away from hospitals and into general practice to mitigate this, but this may be resisted by hospital management who may argue it would have a detrimental impact on services as they have to open their emergency department 24/7 no matter what.

Alternatively, resources could be spent on a public health campaign educating people only to use the emergency department in a genuine emergency, or funding could be given to community pharmacies to provide out-of-hours services when GPs are closed.

Whatever action is taken will probably be welcomed by one element of the system, but derided by another. Similarly, it may work in one geographical region but not another.

Within the UK, the healthcare system is operated by autonomous organisations under the NHS banner, together with a range of public and private organisations, and statutory and regulatory bodies.

Policymaking and interventions can occur anywhere within the system and therefore trying to predict the impact of any single policy or intervention on the overall output or the performance of the whole system is incredibly complex. After all, across the world, healthcare systems are funded and operated by an array of organisations from governments, insurances companies, private business, charities and religious organisations.

Your task

Share a situation from your experience where you have observed system characteristics play out – this could be in or out of a healthcare context/organisation.

References

_{Savigny, D., and Adam, T. (2009) Systems Thinking for Health Systems Strengthening. Alliance for Health Policy and Systems Research [online] available from https://www.who.int/alliance-hpsr/resources/9789241563895/en/ [21 April 2020]}