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Perturbing ongoing conversations about systems and complexity in health services and systems.

The term ‘unintended consequences’ [1] has become ubiquitous [2] in health policy and delivery circles. We argue that this is a sign of the growing unease arising from the realization of the limitations of the still dominant reductionist research approaches, ‘evidence’ and linear thinking in relation to health system and health services policy redesigning. Complexity theorists argue that many of the problems of health services and systems will not be solved through the application of more reductionism [3]. The most revered tool in reductionist research is the randomized controlled trial (RCT). However, as Cartwright has pointed out RCTs have very significant limitations for real world problems. ‘The claims of . . . RCTs to be the gold standard rest on the fact that the ideal RCT is a deductive method: if the assumptions of the test are met, a positive result implies the appropriate causal conclusion. . . . the benefit that the RCT conclusions follow deductively in the ideal case comes with a great cost: narrowness of scope. . . . (in order) to draw causal inferences about a target population, which method is best depends case-by-case on what background knowledge we have or can come to obtain’ [4]. Health services researchers, decision makers and practitioners are now faced with at least two challenges: how to respond to the limitations of current research and decision-making models that have taken us ‘just so far’; and how to integrate other sources of evidence into policy and practice in the real world [5]. What matters is making sense of what is relevant, i.e. how a particular intervention works in the dynamics of particular settings and contexts. It is not very useful to change a system based on deductive, in Cartwright’s words – average explanations. As Stengers [3] pointed out – the most useful questions addressing complex problems must imply an open situation: ‘What will the intervention be able to produce?’ and ‘What kind of behaviour will emerge? What are our frames of reference? What are our ideas and values in relation to success?’ In relation to policy development Glouberman, an applied philosopher adds: ‘Frameworks for understanding policy development do not merely describe the process. They invariably indicate what a “well-functioning” process is like. And so they place a value on certain structures and behaviour. As our theories change, so do our views of what is good’ [6]. Responses to the challenges to our contemporary frameworks are many and varied. They include the rise of translational research [7], narrative evidence-based medicine [8], the quest for utility in patient-reported outcome measures, together with new statements about trials and multifaceted interventions [9–12]. Acknowledging these challenges is not only a sign of understanding the crisis of scientific knowledge [13], but also evidence that new conversations have started [7,14,15]. Common to complex systems are two fundamental themes – the universal interconnectedness and interdependence of all phenomena, and the intrinsically dynamic nature of reality [16]. ‘At each level of complexity we encounter systems that are integrated, self-organizing wholes consisting of smaller parts and, at the same time, acting as parts of larger wholes’ [17]. Notable international examples of an emerging and evolving discourse about complex systems in health services research and quality improvement include the Institute of Medicine’s report ‘Crossing the Quality Chasm’ [18] with a resultant series of US quality initiatives, and Glouberman and Zimmerman’s report to the Romanow Commission in Canada [19]. Approaches to 1 A health system incorporates health services and broad social systems that influence human wellbeing and survival. 2 Health services are specific entities responsible for conducting activities to directly improve health. Examples include a doctor’s office, cancer care centres, emergency departments. Health services are subsystems of a broader health system. Journal of Evaluation in Clinical Practice ISSN 1356-1294