Complexity and Public Health

I’m just stretching the WordPress muscles a few times to get used to it, so I thought that it would be best for me to set the tone …

Philosophically Speaking!

We are taught that to make a decision we must gather all of the available evidence and then rationally and objectively calculate the correct answer. The more complicated the problem the more time and resources are needed to gather the evidence and ensure an accurate decision.

This is essentially a Newtonian approach to knowledge and science and it is a very good thing. Since the rebirth of scientific thinking during the Enlightenment, we have moved from pseudo-religious gods and monsters, through the mechanical mastery of the industrial revolution, to our present digitally imaged incarnation. Contemporary management is typically versed in this mechanical origin of classical science whereby, to understand a phenomenon, one need only reduce that phenomenon to its simplest individual components. Broken down into unequivocal observable evidence, science becomes the refutable aggregation of facts.

And in fact, many aspects of our society are underpinned by this reductionist model of science, even our education system itself. At the age of 10, someone selects on our behalf, a small number of subjects to learn about. At the age of 13 we choose a smaller selection to focus on. At 15 we choose an even smaller set of subjects that can be ranked. At 17 you choose one subject to define you. After 3 or more years being defined by your subject, you come out the other end only to find that your one subject can now be split into 25 even smaller subjects. Our society and organisations are set up to reward and promote people who become more and more adept at less and less of the world.

There are a few exceptions!

Medicine is one of them. An older science, pre-dating both medieval pseudo-religious social control and the Enlightenment that sought to overthrow it. Dating back beyond Hippocrates, practitioners in the art and science of medicine have acknowledged the essential empiricism of living systems. Despite the rational and objective scientific theories that are true; biological entities tend to adhere to some deeper, more ambiguous set of rules and indirect relationships between them.

One could argue that this deeper understanding persisted throughout the millennia of alternate dominant philosophies, in the writings and experiences of many notable commentators. In the popular histories however, this deeper biological model of the world reappeared with Darwin and Wallace. The concepts and sciences of evolution, of ecology, of non-linearity and the essential wholeness of living systems, have continued to emerge, grow and accelerate over the past 50 years. What we now know, is that in between the chaotic mysticism of gods and monsters and the orderly mechanics of Newton; there is a complex interacting living science that provides a much better explanation of the world we inhabit.

It’s not that complexity science is a new paradigm to replace the old ones; it was there, all along. When we look at events and activities of our present lives and try to explain the innumerable layers between the mundane and the extraordinary, complexity simply emerges when you know how to recognise it. Now this may sound slightly mad and it is inevitable that at the edges of popular understanding the idiots and conmen will peddle their snake oil. The sciences of complexity and medicine share the inevitable proximity of the shameless quack and must similarly protect curiosity with a liberal dose of critical thinking.

Applications in Practice!

In the UK, people are surviving childhood more often. Thanks to relatively comfortable lives, we are thriving despite an increasing range of challenges in adult life. And then we go and live longer, to the point where more people are dying with something, than from something. In our increasingly interdependent society we are becoming more complex. Typical of complexity, the underpinning rules remain simple eg feel safe, eat well, exercise, form relationships and a sense of achievement.

Trying to define what complex means, in terms of health need, is not easy. However, the closest approximation translated from the complexity lexicon suggests that; a person with complex needs will have a number of related factors that affect their typical life and those factors and the relationship between them, are sensitive to change over time. You cannot understand their whole life system from one perspective and their system will co-evolve as you interact with it.

It’s not entirely controversial to suggest that our contemporary structures and processes are increasingly less able to cope with this inherent ambiguity. Fortunately, people and groups of people are themselves, complex adaptive systems and we’re doing what we do best. To deal with the increasingly complex and diverse demands, our clinicians are forming increasingly complex relationships and diverse methods of responding. Recognising these new practices as legitimate and advocating their continued adaptation and development is becoming our biggest and most interesting challenge.

For example, research undertaken within the NHS has sought to identify how multidisciplinary teams organise themselves to best meet the needs of their patients. This basic observational work, which included filming multidisciplinary teams going about their daily activities, has highlighted the wide range of structures and relationships that are deployed under the umbrella term of ‘MDT’.

Furthermore, despite having different structures and processes these groups appeared to be making decisions in a very similar way. Based on an initial intuitive heuristic, the MDTs were gathering just enough evidence to validate their judgement and then retesting that judgement in a cycle best described as a ‘successive limited comparison’. This continuous testing of judgement appeared to synchronise with the relative complexity of each patient, in a measurable way.

Within NHS Wales understanding more about how people work together has led several teams to start measuring their impact on the Wellbeing of individuals and communities. We’ve developed a methodology that draws on complexity science to complement the structures used to provide care. I know it sounds freaky, but we behave like the spaces we inhabit. More on this later.