Complexity in public health
I went to an excellent meeting in the Spring at the Health Foundation led by Prof Rutter on complexity. It’s the new “thing” don’t you know. It made my brain hurt. A lot.
Much to reflect on. This blog covers the points I took from the meeting, and subsequent reflections
Part 1 – what’s the issue. some background, some definitions and the problem that is the starting premise
1. What do we mean by complexity
A complex system cannot be explained merely by breaking it down into its component parts because those parts are interdependent: elements interact with each other, share information and combine to produce systemic behaviour.
They exhibit ‘non-linear’ dynamics produced by feedback loops in which some forms of energy or action are dampened (negative feedback) while others are amplified (positive feedback).
It is impossible to precisely predict what changes might happen as a system is most likely highly context-dependent and dependant on starting conditions & the actions of all the actors in the system .
2. Braithwaite makes a set of excellent observations
The article is about health care, the applications well beyond health care.
1. Complex adaptive systems have multiple interacting agents with degrees of discretion to repel, ignore, modify, or selectively adopt top down mandates
2. Complexity makes it hard to impose order.
3. Complex systems are indeterministic – the future cannot be predicted by extrapolating from the past
4. The total of the negotiations, trade-offs, & positioning of stakeholders pulls strongly towards inertia.
5. No one person or group is to blame; but a complex system clearly does not change merely because someone devises and then mandates a purpose designed solution
1. Complex systems do not react predictably; they respond in different ways to the same inputs (staff, funding, presenting patients, buildings, and equipment).
2. The sheer number of variables and the unpredictability of their interactions
3. This is the essence of “non-linearity.”
Change, when it does occur, is always emergent.
The features of the system, and behaviours, appear unexpectedly, arising from the interactions of smaller or simpler entities; thus, unique team behaviours emerge from individuals and their interactions.
Selected attractors of change
Stimulated by medical progress
Incontrovertible evidence shows public benefit
New models of care emerge
practices alter by necessity or because of professional acceptance
Selected repellents of change. Systems can reject change when:
The primary or sole strategy is to mandate solutions
change is not supported by parties with power to resist or reject
initiative encounters entrenched bureaucracy,
More policies and procedures are issued on top of a multiplicity of existing policies and procedures
3. complexity theory provides four key policymaking insights also relevant to commissioning
1. law-like behaviour is difficult to identify because the policy process is ‘guided by a variety of forces’, suggesting that X will only have an effect on Y under particular conditions that are difficult to specify in advance. This makes a standard approach to commissioning a little tricky.
2. systems appear to have ‘self-organizing capacities’, making them difficult to control; the effect of an internal or external force may be large or small and this is impossible to predict from the force alone. This makes a standard approach to commissioning a little tricky, again.
3. Consider the metaphor of the ‘fitness landscape’ or ‘surroundings in which living beings exist and behave’. This landscape, which provides the context for the choices of agents, is unstable and often changes rapidly.
4. actors within complex systems can create ‘their own perception of what they want and how to behave in the landscape they are in’. However, policymakers (& some commissioners) often seek to concentrate more power at the centre rather than seek to understand their policymaking. (From Cairney 2012)
4. We often talk complexity and upstream, but act differently .
See for example this important quote from HSC evidence on obesity – “We really need a whole systems approach and parents are the key”
To spell it out – parents make decisions in a social and environmental context, till you change the context you can empower parents all you want.
5. But…… upstream stuff is in the stuff that really matters. Big picture shifts matter, and matter alot.
For eg – Carbon tax at £1k a tonne would completely transport our food and physical activity promoting environment, as would reform of the CAP. Or…..simpler….. we can focus on downstream interventions – bariatric surgery
6. But…..mostly strong pushback when you try
Industry driven push to shut down debate on upstream. Watch Harry Rutter’s timeline.
Russian trolling firms on twitter, paid for by industry (I get a little bit of this but nothing like what he gets), IEA, Adam Smith Inst etc
Makes a lot of noise and this makes big change politically difficult
However, nobody is going to get voted out for proposing more funding for NHS interventions, or downstream interventions in other sectors.
The whole debate on individual responsibility skews it more towards individuals and individual focused downstream responses. This debate is deliberately manipulated by those who stand to loose from upstream stuff.
The evidence base skews debate towards individuals. See my earlier blogs on evidence in public health.
7. “upstream approach” is not another word to describe “complexity” or “complex adaptive system”
And vice versa.
You can have complex adaptive system in a downstream way. Consider the NHS.
The upstream / downstream refers to the approach to the problem being solved, not the context in which the problem is considered.
8. Many paradigms are tending to push in the wrong direction
Research paradigms are pushing in the wrong space
Some, but not all, paradigms are pushing in the right space
Political paradigms ditto
Part of the solution is addressing these issues at upstream level.
9. The policy making process is fundamentally anti complex. Problems include:
Reductionist / command & control tendencies are common. There’s a lot of institutional inertia. The what is measured (usually simple stuff) vs what matters issue usually simplified policy further.
See Swinburn, 2011 for a good example around obesity – causes of the problem vs approaches to evidence, discourse and political mandate.
The way we conceptualise evidence, ask for evidence, generate evidence responses to policy questions sets up reductionist expectations
Furthermore , on account of constraints within a system (financial, political, other) we often find we are constantly pulled back to downstream and constantly pulled back to reductionism
10. Chapman set out some significant obstacles to adopting a system approach to policy-making.
• aversion to failure, exacerbated by the political process, which uses failures to score points rather than learn lessons
• the pressure for uniformity in public services shared assumptions between civil servants and ministers that command and control is the correct way to exercise power
• lack of evaluation of previous policies
• lack of time to do anything other than cope with events
• a tradition of secrecy used to stifle feedback and learning
• the dominance of turf wars and negotiations between departments, effectively making end-user performance secondary to other considerations
• the loss of professional integrity and autonomy under the knife of efficiency in policy-making,
• resistance and protection of vested interests by some professional and intermediary bodies.
Getting change towards systems approaches, esp those located far upstream of the problem, may require shift in power base
Blog 2 will cover what to do.
Thanks to John Soady for some thought in this space (and many other spaces)