Editor—In his editorial Smith asks whether the NHS is getting better or worse.1 By falling into the reductionist trap of assuming that the healthcare system can be understood by dissecting it into its component parts, he succeeds in being precisely wrong rather than vaguely right.
Underpinning his argument is a belief that the transfer processes that relate inputs to outputs in each element of health care are well understood. Information is used as feedback that is compared with a desired state (performance assessment), allowing the system to be engineered towards the desired objectives by using incentive manipulation (performance management). He infers that all we need are enough data, and a “complete, validated, interpretable, and uncontested” picture will be revealed. The truth really is out there.
Figure 1.
How do we know if the patient is improving?
Credit: HULTON GETTY
His observation of muddling through against a background of improvement, stasis, and deterioration offers the metaphor of an ecosystem rather than a machine. All parts are adapting by learning to survive in a topography that is provided by co-existing and changing elements. This approach sees health care as a network of interrelated systems that interact in a non-linear fashion—small inputs can have large and unexpected consequences in any part of the system. The characteristics of the system are not represented by the sum of its parts; each element cannot be understood in isolation.2,3
Evidence is beginning to emerge that this model, underpinned by insights from chaos theory, may be a more accurate representation of the healthcare transfer process and why measures such as waiting times are a very poor indicator of system performance.4
An overemphasis on outcome measurement constrains us within a set of unreliable assumptions about the relations between cause and effect in health care and invariably numerous unhelpful conclusions.
Competing interests: None declared.
References
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- 3.Kernick D. Complexity and health care organisation. A view from the street. Abingdon: Radcliffe Medical Press (in press).
- 4.Papadopolous M, Hadjitheodossiou M, Chrysostomu C, et al. Is the national health service at the edge of chaos? J R Soc Med 2001;94(12): 613-6. [DOI] [PMC free article] [PubMed] [Google Scholar]