Understanding and Working with Complexity

Posted by: Diane Ketley - Posted on:

Healthcare is a complex adaptive system. This means it has multiple interacting elements which are dynamic and unpredictable. Having an understanding of complexity, and of such systems, is therefore fundamental to being able to lead and deliver innovation and improvement in our increasingly interconnected and complex health and care system. 

What do we mean by complexity and complex systems?

Complex systems are uncontrollable systems with no observed cause and effect relationships. Such systems are unpredictable in the detail – although patterns may be seen. Complex systems have the characteristics of uncertainty, unpredictability and emergence. This means there is the need to be flexible and adaptive in working with such systems. In contrast, complicated systems can operate in a planned, standardised way with observable cause and effect relationships.

A recent blog by Andrew Singfield describes ‘hard’ and ‘soft’ complexity and offers a way of understanding complexity. Andrew writes about ‘hard’ complexity which is the result of the interconnectedness and co-dependency of the system components and limits our ability to plan with confidence when compared to situations with fewer connections and dependencies. ‘Soft’ complexity is the result of differences in what people value producing different worldviews, and also limits our ability to plan when compared with situations with less emotional involvement.

These two dimensions help explain why change, especially large scale and complex change, is difficult.  As the scope of the change increases, more system components and more stakeholders need to be involved. As Andrew writes

 “With more components we typically get more ‘hard’ complexity as the multiple connections between these components becomes important. With more stakeholders we typically get more ‘soft’ complexity as we increase the number of potentially competing perceptions and misaligned actions”.

How can we work with complexity?

A common but unproductive approach is to treat a complex situation like a complicated one, taking a detailed planned approach that also does not consider the people aspects i.e. those aspects of soft complexity. Back to Andrew:

“Unfortunately, whilst this approach appears comforting (as we can plan) and seems to tick our governance boxes (as we can tell people our plan), it does not work. Conflicting worldviews and highly interconnected systems mean our plans and reality soon diverge”.

So what to do?

Trisha Greenhalgh in her 2018 paper on improving success of technology projects recommends the following:

  • seek to understand where complexities lie
  • reduce those complexities where possible
  • manage the remaining complexities adaptively and creatively

The paper includes some suggestions on how to do this:

  • don’t oversimplify the situation so don’t treat a complex situation as a complicated or simple one, as described above
  • review the change to try to reduce complexity wherever possible e.g. consider the trade-off between ‘nice to have’ features of the change and the impact on the system and added complexity
  • work with principles, or ‘simple rules’, to help the team respond adaptatively to the complexity, Greenhalgh lists 10 such rules in the paper

When considering ‘hard’ and ‘soft’ complexity, how can we reduce the complexity burden? An approach is to reduce the ‘soft’ complexity by identifying a shared purpose across all stakeholders. This is a key step in all change work including that of the spread and adoption of innovations and improvements. ‘Hard’ complexity may be circumvented in practice by localised adaptation.

Understanding complexity, its nature and implications, allows us to match our approach to change to fit the situation and increase the likelihood of success.

Further information

Andrew Singfield. ‘Why does scale matter in large scale change?’, blog available on NHS Futures platform (NHS sign in needed) or by contacting Andrew, Transformation Academy for Large Scale Change (TALSC) Faculty, andrew.singfield@nhs.net.

T. Greenhalgh. How to improve success of technology projects in health and social care. Public Health Res Pract. 2018;28(3):e2831815

D Ketley. COVID-19 – A Complexity Leadership Response Horizons blog 2020.

The topic of complexity is the focus of module 5 of The School for Change Agents. 

More information on complexity, system convening and the 7 spread and adoption principles is available on the NHS Horizons website.

If you’re interested to read more there are previous blogs and further blogs to follow. Please do subscribe to this blog and follow @DianeKetley @HorizonsNHS, #nhsspread.

“Understanding complexity, its nature and implications, allows us to match our approach to change to fit the situation and increase the likelihood of success”.