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Services Research & Policy

Entangled complexity: why complex interventions are just not complicated enough
Simon Cohn, Megan Clinch, Chris Bunn and Paul Stronge
J Health Serv Res Policy 2013 18: 40
DOI: 10.1258/jhsrp.2012.012036

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 Essay

Entangled complexity: why complex interventions

are just not complicated enough

Simon Cohn, Megan Clinch1, Chris Bunn2, Paul Stronge2

Primary Care Unit, Institute of Public Health, Cambridge University, UK; 1Faculty of Social Science, The Open University, UK;
2
Institute of Public Health, Cambridge University, UK

The shift of health care burden from acute to chronic conditions is strongly linked to lifestyle and behaviour. As a
consequence, health services are attempting to develop strategies and interventions that can attend to the
complex interactions of social and biological factors that shape both. In this paper we trace one of the most
influential incarnations of this ‘turn to the complex’: the Medical Research Council (MRC) guidance on
developing and evaluating complex interventions. Through an analysis of the key publications, and drawing
on social scientific approaches to what might constitute complexity in this context, we suggest that such
initiatives need to adjust their conceptualisation of ‘the complex’. We argue that complexity needs to be
understood as a dynamic, ecological system rather than a stable, albeit complicated, arrangement of
individual elements. Crucially, in contrast to the experimental logic embedded in the MRC guidance, we
question whether the Randomised Controlled Trial (RCT) is the most appropriate method through which to
engage with complexity and establish reliable evidence of the effectiveness of complex interventions.
Journal of Health Services Research & Policy Vol 18 No 1, 2013: 40 –43 # SAGE Publications Ltd 2013

Introduction: recognising complexity and elsewhere, where questions of the ‘essential’

In 2000 the (UK) Medical Research Council (MRC) pro-
duced a document1 which exemplified and pioneered
what has been called the ‘appropriation of complexity’2
within health care. The Council’s framework was
amongst the first to frame contemporary health inter-
ventions as inherently complex, involving overlapping
modes of operation, and hence challenging any straight-
forward measurement or evaluation of their impact.
Over the next few years, the framework was widely-
cited, yet also at times aroused critical comment.
Subsequently, in 2008 it was replaced by ‘New
Guidance’,3 which explicitly addressed a range of criti-
cisms, and has since become a central document for
those concerned with designing and testing health
interventions.
But what does this mobilisation of complexity signify?
Both the 2000 and 2008 documents largely avoid
directly confronting the specific question of what consti-
tutes ‘the complex’. The potential importance of this
omission has been raised in debates in this journal
Simon Cohn PhD, Medical Anthropologist Senior University
Lecturer, Primary Care Unit, Institute of Public Health, Cambridge
University Forvie Site, Cambridge CB2 0SR; Megan Clinch PhD,
Research Associate; Chris Bunn PhD, Research Associate;
Paul Stronge PhD, Research Associate
Correspondence to: megan.clinch@open.ac.uk
nature of the concept of complexity have begun to
surface.2,4,5,6,7 For example, whilst Paley approaches
the notion in terms of a narrow and austere ‘explanatory
category’, requiring rigorous policing,2 Greenhalgh and
colleagues treat complexity more as a ‘world view’ with
regard to the nature of change.4,6
Our own discussion similarly draws on broader
approaches to complexity within and beyond the
natural sciences. Yet, rather than attempting to define
what complexity is or is not in the abstract, we wish to
draw attention to the consequences of the ‘fit’, or lack
thereof, between the rhetoric of ‘the complex’ and
current research cultures of public health and public
policy more generally8 – specifically, the claims of evi-
dence embedded within the Randomised Controlled
Trial. Overall, our argument is quite simple: a richer
appreciation of complexity and the commitment to the
RCT as the ‘gold standard’ of evidence (to which the
MRC Framework is ultimately directed) are ultimately
incompatible.
After briefly reviewing the MRC’s guidance, we high-
light two interconnected issues that emerge from a
genuine engagement with complexity. The first con-
cerns confronting its ‘ecological’ character, while the
second shows how this inherently challenges the con-
ventional standards of reproducibility and fidelity that
govern the development and testing of health

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Entangled complexity
interventions. We argue that both these issues must be
taken seriously if the ‘challenge of complexity in
health care’4 can be engaged with meaningfully. Two
possible solutions arise from this. Either such interven-
tions should abandon the use of the term ‘complexity’
to more accurately reflect how studies pragmatically
reduce interactions to a restricted number of variables;
or, more radically, if there is to be meaningful engage-
ment with complexity, alternative means to test, evalu-
ate and represent interventions and their effects need
to be developed.
The emergence of complex interventions
The 2000 MRC publication was ground-breaking in its
acknowledgement that many novel health interventions
did not consist of singular elements. Consequently,
researchers were no longer being asked to isolate and
assess the efficacy of one component over another,
as in the case of a classic drug trial. Rather, they were
increasingly being forced to evaluate components
across a range of different domains – bio-medical,
organisational, psychological and social – all at work
simultaneously. This, the Framework argued, pre-
sented an analytical problem requiring fresh thought
from the research community. To make sense of the
implications of these interconnected components, it
proposed a ‘stepwise approach’ to intervention develop-
ment, improvement and testing, and suggested that
there should be space for a mixture of research
methods. It was asserted that qualitative research was
particularly useful for refining the nature of an inter-
vention and predicting its possible impact so that
insights generated could be used in the stages that fol-
lowed. The implicit assumption was that by adopting a
mixed methods approach, ‘the complex’ could be ade-
quately captured and understood to enable the final
design of the intervention and trial.
There can be no doubt that the MRC’s framework has
been influential and has contributed to the generation
of a wide range of innovative research approaches.
Subsequent studies conceptualised complex interven-
tions in a wide variety of ways. For example, a study
which followed the guidelines to develop a standardised
pathway for the treatment of heart failure conceptual-
ised complexity as a property arising from the multiple
components and trajectories of established clinical path-
ways.9 In contrast, another initiative piloting diabetes
education groups posited that the complexity emerged
from an array of factors acting in combination, and
that this variability should be accommodated rather
than be subject to any kind of standardisation.10 In
response to this variability, the 2008 revision of the
MRC document was designated ‘guidance’ rather than
a framework and dropped the titular reference to
RCTs. It also incorporated other important changes.
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Essay
In particular, it described less linear models of design
and data extraction in order to allow for greater input
and feedback at various stages. However, the revised
text largely continued to avoid the specific question of
what constituted a ‘complex’ intervention. Our general
point, therefore, is that while researchers increasingly
agreed that health interventions targeted on practices
and behaviours were inescapably complex, no consen-
sus on what ‘complex’ meant was forthcoming.11
Reconceptualising complexity: from
mechanical to ecological
The 2008 MRC guidance reproduced the assumption
that complex interventions are those that are comprised
of ‘several inter-acting components’. It is also implied
that such multiplicity can effectively be captured via
a process of identification and enumeration. Thus,
whilst this approach acknowledges the significance of
the interactions between elements, the term ‘com-
ponents’, coupled with an emphasis on measuring
them as discrete elements (whether behaviours, vari-
ables, or outcomes etc.), produces a depiction of
complexity that is essentially mechanical. Such an
approach simply cannot accommodate the idea that
together such elements form a dynamic and integrated
system.
In contrast, within a wide range of scientific fields
such as chaos theory and systems biology, it is now com-
monly emphasised how phenomena cannot be reduced
to constituent variables. Rather, key properties of the
interactions are emergent and contingent upon one
another, while there are also always significant elements
that remain uncertain and unknown.12,13 Similarly,
social theorists have explored complexity in terms
of links between the individual and society, or the
behaviour of groups versus individuals, arguing that
such relationships are inherently dynamic and dia-
logical, and, as a consequence, ultimately irreducible
to their parts.14,15 More recently, these enquiries
have expanded further to include the parts played
by material, nonhuman actors within networks of
complexity.16
The notion of ecology encapsulates much of this
current thinking on complexity in both the sciences
and social sciences. Integral to this perspective is the rec-
ognition that alteration in one part provokes change
throughout the system, and that the ‘system’ can never
be isolated from its ‘environment’. A classic example
was provided long ago with Charles Darwin’s celebrated
‘entangled bank’ account of the hedgerow.17 Darwin
describes how all of the life-forms that inhabit such a
setting rely on both ‘internal’ factors, such as the other
living things around them, and on ‘external’ factors,
for instance, climatic conditions or farming practices.
The introduction of a new element inevitably establishes
Essay
itself as part of the whole in multiple and varied ways.
The general point here is that engaging seriously with
complexity from this ecological standpoint is neither
simply a matter of attempting to develop more ‘sensitive’
or ‘accurate’ strategies to capture more and more data,
nor is it, as has sometimes been suggested in the
context of designing health interventions, to do with
pursuing ever more sophisticated causal models to
identify those ‘active ingredients’ which might ulti-
mately drive a complex problem.18 Rather, this appreci-
ation of complexity begins with recognition of the sheer
range of relevant factors and the significance of the
variability of local conditions.
Capturing ecological complexity
The ecological approach we describe conceptualises
complexity not as a closed system of identifiable con-
stituent parts, but rather as a dynamic and constantly
emerging set of processes and objects that not only
interact with each other, but come to be defined by
those interactions. In contrast, research toolkits such
as the MRC’s Guidelines, ostensibly designed to guide
researchers to deliver and assess an intervention
ideally through a RCT, require the isolation of measur-
able parts and hence the sacrifice of any genuine
commitment to complexity. If we genuinely want to
acknowledge complexity rather than merely note, in
a mechanistic way, that health-related issues are very
complicated, we must find a way of engaging with its
dynamic variability. In other words, the challenge is
how to go about studying complexity without fully un-
ravelling it.
We want to suggest that social scientific approaches,
beyond simply asserting the value of ‘qualitative
methods’, can aid the development and implementation
of intervention research that offers alternative, but
potentially complementary, forms of evidence and
scientific standards. In accordance with the notion of
ecological complexity, knowledge generated by the
social sciences concerns itself with more than just
the production of detailed and accurate accounts of
the social world. With a commitment to holism and
interconnectedness, the key strength derived through
research methods such as ethnography is the attention
paid to tracking and identifying the processes and
relationships through which ‘particular events, practices
and things’19 become meaningful and important. Thus,
these approaches can assist in the identification of
experiences and practices that are otherwise liable to
be left out of accounts, including those associated with
the research process itself.
Social scientists such as Lock acknowledge the impor-
tance of this holism in the study of health and medicine.
She adopts the term ‘local biologies’ to refer to ‘the way
in which biological and social processes are inseparably
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Entangled complexity
entangled’.20 Such particularistic visions are not just an
anthropological preserve: they are also increasingly
becoming standard in more traditional biomedical
circles.21 These approaches accept that studies of par-
ticular entanglements provide a partial account of how
elements emerge as meaningful and relevant in relation
to each other. But they nevertheless do some justice to
the complexity of complexity, and recognise the many
ways in which a complex world can at once be encoun-
tered and intervened upon.22
But crucially this also implies that a commitment
to the generalisablility and reproducibility of things
that are inherently complex is naı̈ve and misplaced.
Complex health interventions will always be highly vari-
able in both character and form due to the dynamic
nature of their constituent parts and the inevitable
adaptations that emerge from their implementation in
local contexts.
Conclusion
The ‘turn to the complex’ has clearly been a necessary
and productive response to the changing nature of
common health problems. However, drawing on theor-
etical approaches from beyond medicine, and in par-
ticular from the social sciences, we have argued that
genuinely acknowledging and addressing complexity
requires more than the simple adoption of an ever-
expanding number of variables or array of statistical
tests. Rather, we have suggested that the notion of eco-
logical complexity perhaps best captures the specific
dynamics of complexity in the domain of health and
illness. Such an approach emphasises not only how
different elements come together to produce a system,
but also how such elements become meaningful and
change as they travel through and interact in particular
contexts.
This view of complexity, however, also challenges
the extent to which RCT thinking and standards can
aid in the development of high quality, appropriate
and effective health interventions. We have argued
that rethinking complexity in these ways offers an
alternative and complementary account of how causal
relationships emerge and are made meaningful, but
such an account demands new methods through
which they can be assessed. Only when such evaluative
frameworks have been developed can the complex
nature of interventions fully emerge and be put to
work to improve health.
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