The interactions within a complex adaptive system are often more important than the discrete actions of the individual parts. As the examples below illustrate, a productive or generative relationship occurs when interactions among parts of a complex system produce valuable, new, and unpredictable capabilities that are not inherent in any of the parts acting alone.5
Although health care depends largely on productive interaction, the organisation and management of its delivery surprisingly does not always reflect this insight. In the United Kingdom, for example, having separate budgets and performance targets for primary care, secondary care, and social services promotes an internal focus on the operation of each of these parts, but not necessarily the good functioning of the system as a whole.
Consider the administration of thrombolytic drugs, which greatly increase survival when given to patients within 60 minutes of the onset of myocardial infarction.6
Following classic performance management thinking, the current national service framework for coronary heart disease in the NHS has established an immediate priority target for acute care trusts to ensure by April 2002 that 75% of eligible patients receive thrombolytic drugs within 30 minutes of arrival at the hospital, while health authorities and primary care trusts are asked to aim for patients to receive them within 60 minutes of calling for professional help.7
Each of these targets, along with others for ambulance response times, segments the timeline into intervals deemed controllable by the separate parts of the system. What if the patient delays for an hour or more hoping that the pain will go away before calling for help, and the ambulance journey requires an additional 25 minutes?8
The acute care, primary care, and ambulance service trusts could indeed be meeting their individual targets, but the patient may not be getting the full benefit intended and receiving treatment within 60 minutes of the onset of infarction.
Complexity based organisational thinking suggests that goals and resources are established with a view towards the whole system, rather than artificially allocating them to parts of the system. We might therefore set a single, whole system, target for thrombolysis within 60 minutes of the onset of myocardial infarction and establish a pooled budget that provides funds for changes intended to meet this target. The pooled budget would include funds from acute care, primary care, ambulance, community, education, and health promotion budgets.
Whole system targets and pooled budgets encourage generative relationships among the various stakeholders that may provoke more creative ideas. For example, thinking together might lead to ideas about symptom awareness campaigns or paramedic support. In widening the focus to the whole system, we might further work to assure that the patient receives aspirin on discharge from hospital and continues it when home. In the current situation, suggested enhancements typically focus only on changes within individual parts of the system and approaches that cross boundaries emerge less frequently. Attention to the overall aim—better patient care—can get lost.
Complexity thinking suggests that current organisational leaders in both policy and operations should begin looking more across the parts and at the system as a whole. The National Health Service might be better thought of as the National Health System.9