How ARE we to think of healthcare systems? It has been fashionable to think of them as supertankers — the images conjured up of something big, slow and as the politicians and managers were wont to say, slow to turn, so (to cite Piet Hein’s TTT) things take time. But such thinking is wrong-headed and always has been — it reflected a top-down technocratic mind-set that saw healthcare as rational and plannable. I have never bought this argument, and argued that healthcare systems should be conceptualised as a school of fish, as they can turn on a dime! We have much to learn from a swam of bees, a colony of ants or a flock of birds. (and even a school of fish). The bigger and more complex a system becomes (like healthcare systems) the least likely it is to be amenable to notions of levers to push or strings to pull type thinking — but such thinking veritably oozes from academe where reductionist and linear analytical models are easier to research, but fail to take account of reality itself. (The academic group that seems to consistently get things wrong for similar reasons is economics, and surprise, surprise, many people think that health economics has something to tell us about health reform — but similar models and thinking are pervasive!)
Now, Peter Miller’s book, Smart Swarm has received laudable coverage in the Economist newspaper. The book and many articles in the popular press have highlighted the efficient design that comes from the apparently unplanned but linked behaviour of individual generally unintelligent ants or bees, which collectively bring order to complex natural environments.
For our cherished health system planners, it suggests that they have overstated their impact and relevance, if indeed they ever were really effective. For me, it suggests that health policy has become a bit too much like the old Soviet bread planners, thinking that since people needed the bread, planning for it would ensure is got to people’s table, but of course the planning was part of the problem, not the solution. (I’m trying not to make the bread an issue of markets but of coordinated behaviour of linked systems.)
The best way to understand complex systems is to embed intelligence within the behaviour of the bits that make it up, rather than impose it from above, or fruitlessly planned in. The key factor which makes these distributed systems work is the ability to exchange information — planners create funnels through which information flows and if you get the funnels wrong, the system fails to optimise, or indeed work at all! By allowing parts to exchange information easily, on an as-needed basis and act accordingly, coordinated behaviours emerge, which effectively bring the desired order without some remote planner deciding how it should work. It all comes down to information flow and exchange.
And so to health systems. We all want joined up, linked, coordinated healthcare; that patients seen in clinic A who go to clinic B can be seen by people who have information about you; that when you show up for your operation, they know you’re coming, and so on. Healthcare systems are really all about patients, but we plan them on the basis of the behaviour of health professionals, who actually communicate with each other quite a lot — and indeed, construct informal systems to make the healthcare system work better often despite formal planned structures. One might say they behave like the bees and ants by simply getting on with things. It does raise the question of what roles are needed within healthcare systems to ensure the flow of information — this is usually seen as a reason for managers, but managerial models frequently fail to understand the purposeful behaviour of interconnecting systems as management is a reductionist organisational notion.
The information that patients carry is critical, but generally not accessed — it is important to realise that only the patient has experience of the whole care pathway, not the health professionals within it. This is important information that is lost within formally planned systems, which focus on structuring care, rather than the flow of information that links the bits together. I call this information structure the “healthcare information value chain” and it is the most important, but generally least understood, aspect of healthcare systems, as embedded within this value chain is the information needed for the various components of a healthcare system to coordinate their activities, without the great planner in the sky. This information value chain is not some construction of an IT system, it is information used in the course of people going about their work — of the ant hill at work. It is worth noting that ants or bees manage complex systems without IT systems, but researchers have needed IT systems to understand them!
Want to know more?
Ants may have an edge when designing efficient systems, a commentary on US health system reform, by Joseph Reisert.
Emergence: The connected lives of ants, brains, cities, and software, a book by Steven Johnson.
It may also be helpful to understand how complex adaptive systems work: for instance,
The US National Academy of Medicine has thought about healthcare as a complex adaptive system in “Health Care as a Complex Adaptive System: Implications for Design and Management”. [here]
Implementation Science is an open source journal that has articles on this subject, including this example [here] on making change in healthcare settings.
Regretfully, much useful literature is not available to the informed or interested public, as it is squirrelled away in the academic journals for which the publishers require passwords, subscriptions etc. in order to access. Any research that has been funded from public sources should be available for public access in open source locations or journals. I will not cite reference material that is not generally available to the public. If authors have material on this subject that they would like to enable public access to, please send me the links to be added to this (very) selective list.