Can Complexity Theory
feature Provide Better Understanding
of Integrated Care?
ABSTRACT
The patterns of health and social care provision in
the community have always been complex. The
Government’s current call to integrate systems of care
can be seen as a search for greater simplicity and
predictability, but people in these systems know that
any new networks will be equally complex. This
article argues that our organisations and systems
should no longer be viewed and managed as
‘machines’ with inherent rationality, and suggests
that the new intellectual discipline of complexity
theory offers a more relevant model with which to
view the real world where we operate under the
constraints of limited time, knowledge and
processing power. The author is a general
practitioner with an interest in applying complexity
insights to health care organisation.
KEYWORDS: COMPLEXITY; ORGANISATIONAL
DEVELOPMENT; HEALTH AND SOCIAL CARE
INTEGRATION
Contact details: su1838@eclipse.co.uk
Introduction - from normal to post-normal
science
The period of the Enlightenment that began in the late
18th century was based on the confident assumption
that the application of reason would expand
knowledge and purge the residues of religion and
22 Journal of Integrated Care Volume 11 • Issue 5 • October 2003
David Kernick
GENERAL PRACTITIONER
mysticism. Human progress was to be achieved through
a programme that extended scientific knowledge and
technical control to all aspects of society. The
predominant model for modern science was to be the
machine, underpinned by three main assumptions:
• reductionism - a system can be understood by
breaking it down and understanding its
component parts and the behaviour of the system
can be inferred from the sum of its parts
• linearity - there is a simple and proportional
relationship between inputs (cause) and outputs
(effect) for any part of the machine
• determinism - a knowledge of the component
parts will predict the future.
Science, this view holds, sees areas of ignorance merely
as puzzles waiting to be solved. In this model of a
‘clockwork universe’, complicated systems need
complicated rules, and when these do not yield the
required results, even more rules must be created.
Approximations and statistical manipulations are used
to adjust for discrepancies while predictive limitations
are viewed as data or processing inadequacies,
omissions, bias or randomness. An impartial observer
can stand outside the system without being influenced
by it and engineer it towards defined objectives, and
problems can be formulated as the making of a rational
choice between alternative means of achieving a known
end.
In the 1920s Heizenberg’s uncertainty principle
defined the fundamental limits of our ability to
© Pavilion Publishing (Brighton) Ltd
Can Complexity Theory Provide Better Understanding of Integrated Care?
describe systems and predict events. Arising from
these concerns, post-modernism emphasised the
process of knowing and the importance of how our
minds form an integral part of that process. To the
post-modern eye, the truth is not out there waiting
to be revealed but something constructed by
people, always provisional and contingent on
context and power.
This ‘post-normal’ science does not replace
normal science or contest its claims to reliable
knowledge, but offers a complementary perspective.
It recognises that many systems comprise networks
of elements interacting constantly to give rise to
behaviour that is not predictable and which cannot
be understood by breaking down the system into
its component parts. This is surely recognisable to
any care professional or strategic manager these
days.
The central feature of this behaviour is the
presence of positive and negative feedback loops in
the system which are acting recursively (repetitively
and feeding back on themselves) and which give
rise to non-linear features, as summarised in Figure
1, below.
Figure 1: CHARACTERISTICS OF NON-LINEAR
INTERACTIONS
• Small changes can have large system effects
• Large effects can lead to small system changes
• Non-linear systems are sensitive to initial
conditions - the history of the system is
important
• Non-linear systems cannot be understood by
reduction into their component parts - the
whole is different from the sum of the parts
What is a complex system?
Complexus (Latin) - braided together
The following distinctions are a good starting point.
Journal of Integrated Care Volume 11 • Issue 5 • October 2003
A complicated system
A jumbo jet is complicated. Its action can be
determined by an analysis of its component parts and
its behaviour is predictable. Each part of the system will
behave in the same way wherever it is installed. The
intelligence of the designer resides in the system.
A complex system
A rose is complex. As it unfolds, its future has
boundaries that can be described but which cannot be
predicted in detail. There is no pre-defined geometric
plan and no one element in control. The shape that
emerges is the result of interaction between its elements
at a local level as they respond to the information they
are presented with.
A complex adaptive system
An example is a hospital. The outcome of the system is
boundable but uncertain in any detail. The history of
what has gone before is important, but all parties adapt
and learn from each other as they interact.
A complex system is a system of individual
elements (known as ‘agents’ in complexity
terminology) that have the freedom to act in ways
that are not always predictable, and whose actions
are interconnected such that one agent’s actions
changes the context for other agents. The
interaction between agents is invariably non-linear,
because of the existence of recursive or repetitive
feedback loops. Examples of complex systems
include the immune system, a patient-doctor
consultation and an entire care system.
As with all emerging disciplines, there is no
consensus about complexity definitions and
terminology. Because the subject is approached
from different perspectives within a number of
disciplines, there are a number of theories, concepts
and metaphors within the complexity framework,
many of which are contested. Some will be
mentioned in the rest of this article, in which an
attempt is made to apply these insights to the
organisational issues which surround the
development of integrated care.
© Pavilion Publishing (Brighton) 23
 Can Complexity Theory Provide Better Understanding of Integrated Care?
Applying complexity theory to
organisations: (1) some key concepts
Mental models
Agents respond to their environment using internalised
rules that direct action. In a simple complex system
such as a biochemical system, the rules could be a series
of chemical reactions. At human level, these rules form
the basis of our mental models or map of the world -
the way in which we respond to changes in our
environment. This accords with the difficulties in
collaborative working observed by many researchers
(Cameron & Lart, 2003).
There are a number of important features of
human complex adaptive systems.
• Our mental models change with time as we learn
and adapt.
• We can have some awareness of the whole system
and not just our local environment.
• Our ability to hold mental images and project
them into the future enables us to make sense of
our environment. We can identify goals and
purposes, develop strategies and choose among
several alternatives. We are able to formulate
values and social rules of behaviour.
• Our interactions take place within a network
influenced by language and other symbolic forms.
Through a shared context of meaning, we acquire
identities as members of social networks that
generate the boundary of an organisation.
Awareness of this seems fundamental to the capacity to
conceive a more integrated system of care in the
community.
An important insight is that the internal rules of
agents and their subsequent actions may not be
influenced predominately by an organisation’s
legitimate systems of hierarchy, rules and
communication patterns, but by the ‘shadow
organisation’ that lies behind the scenes, such as
hallway conversations (Stacey, 2000).
24 Journal of Integrated Care Volume 11 • Issue 5 • October 2003
Complex systems are dependent on their history
As non-linear systems are dependent on initial
conditions, the history of a system will be critical to an
understanding of it and its development. For example,
it would be inadvisable to consider the current
developments in integrated care without an
understanding of their historical context.
The ‘butterfly effect’
Although agents interact strongly with the elements
closest to them, information about such events may be
communicated across the whole system. Because of
non-linear characteristics, small changes in one area
can occasionally have large effects across the whole
system. This has been called the ‘butterfly effect’ (a
butterfly in New York can flap its wings and cause a
hurricane in Tokyo). For example, the riding accident
of the actor Christopher Reeves had a large but
probably inappropriate impact on the redistribution of
research funding into spinal injuries in the US
(Greenberg, 1997). Conversely, large influences may
only have a negligible impact. The Health of the Nation
initiative was a major strategic UK government
initiative designed to influence the health of the public,
but it had little impact on the targets it sought to
influence (Hunter et al, 1998).
Because of this distributed non-linearity,
detailed planning and prediction are never
possible. This insight has been interpreted as ‘good
enough vision’ (Zimmerman et al, 1998). For
example, rather than spend time on detailed
planning and striving to calculate a solution by the
continuous addition of rules, planners should be
content to set minimum specifications and
establish boundaries, and let the system settle into
a condition that satisfies the constraints placed on
it. Given the known barriers to integrated care, local
approaches based on these ideas might deliver
better results.
Simple rules underpin complex systems
An important but contested insight is that the capacity
of systems to evolve to new patterns of order can arise
© Pavilion Publishing (Brighton) Ltd
Can Complexity Theory Provide Better Understanding of Integrated Care?
from the recursive application of a relatively small
number of simple rules. For example, the complex
phenomenon of a flock of birds in flight emerges from
the recursive application of three simple rules: move to
the centre of the crowd, maintain a minimum distance
from your neighbour and move at the speed of the
element in front of you.
The suggestion is that underpinning complex
behaviour are a small number of simple rules or
guiding principles. Identifying the rules of a system
through the use of observation or analysis of
narrative and experimentation on a small scale can
instigate change and re-configure complex systems
(Plsek, 2001). For example, Plamping (1998) has
identified three simple rules that have traditionally
underpinned the NHS, and offers an alternative set
(in italics) which may be more applicable
nowadays.
I am responsible I am responsible in partnership
Can do, should do Maximise the health gain
for the population
within the available
resources
Doing means treatment Doing takes place within a
broader social action
Self-organisation
Although unpredictable, the behaviour of complex
systems evolves from the interaction of agents at a local
level, without external direction or the presence of
internal control. This property is known as ‘emergence’
and gives systems the flexibility to adapt and self-
organise in response to external challenge. (The NHS
Plan and the National Service Frameworks are
examples of external challenges.) Emergence is a
pattern of system behaviour that could not have been
predicted by analysis of the component parts of that
system. A balance of co-operation and competition
drives change in such a way as to maintain system
stability.
A self-organising system will attempt to balance
itself at a point known as ‘self-organised criticality’,
where it is able to adapt with the least effort. The
Journal of Integrated Care Volume 11 • Issue 5 • October 2003
system will seek out and maintain an optimum
state in response to a wide variety of external
challenges.
In human systems, preconditions for self-
organisation are:
• shared principles - systems align themselves
around core values even if system goals are not
articulated
• connectivity and feedback - self-organisation
emerges from non-linear processes arising from
feedback at a local level
• dialogue - this involves sensitivity to other
perspectives and willingness to change our mental
models and paradigms
• memory - without memory the system can do no
better than mirror the environment; as any system
has a finite memory capacity, there must also be
some form of selective forgetting
• interdependence - self-organisation is driven by
both competition and co-operation among
system elements but against a background of
interdependence.
There are parallels here in the literature on effective
joint working (Cameron & Lart, 2003). Complexity
gives some theoretical underpinning.
Applying complexity theory to
organisations: (2) the ‘edge of chaos’
The ‘edge of chaos’ metaphor, used originally in
mathematics, has been interpreted diagrammatically by
Stacey (1996), who applies it to organisational
understanding and decision making. He identifies three
areas of organisational life depending on the certainty
about the relationship between cause and effect
between system variables, and the agreement between
agents on this relationship. This interpretation is shown
in Figure 2, overleaf.
When there is a high degree of certainty as to
outcomes from actions and a high degree of
agreement among the people involved in the
actions about the relationship between actions and
outcomes, machine-systems thinking with detailed
planning and control may be appropriate. The
© Pavilion Publishing (Brighton) 25
 Can Complexity Theory Provide Better Understanding of Integrated Care?

Figure 2: THREE ZONES IN NETWORKS - THE ‘STACEY DIAGRAM’

LOW

Chaos
Agreement by
people taking the
action about
outcome certainty
Zone of Complexity or
edge of chaos

Stable
Linear
zone
LOW
HIGH Certainty about how outcomes relate to inputs

instinct of reductionist science is to resolve
ambiguity and paradox and move into this linear,
rational zone on the underlying assumption that
there is a correct answer to any problem. It seems
unlikely that there will ever be high certainty/high
agreement in the field of integrated care.
The upper right-hand segment of Figure 2
represents a system of anarchy where chaos reigns,
and is to be avoided. However, most issues in
organisations are in the ‘zone of complexity’, where
there are only modest levels of certainty and
agreement and where it would be most appropriate
to use the paradigm of complex adaptive systems.
This perspective would accommodate paradox and
value the inherent tension that arises from it. The
attention focuses on things that seem to be working
best and learning incrementally.
Applying complexity theory to
organisations: (3) an ecological perspective
Organisations have been studied using the model of an
interacting network before complexity theory was
developed. For example, it has been recognised that
network forms of organisation are most effective under
conditions of diversity, autonomy and uncertainty, and
where knowledge and competencies are important
drivers of success (Scott, 1992). From a sociological
perspective, social networks have been seen as
providing efficient systems for processing, interpreting
and storing information, shaping identity and
mobilising resources for joint action. The concept of
community implies that people’s behaviour is
embedded in ongoing systems of social relations and
their well-being is influenced by interactions with
others. The economic perspective sees the co-
ordination of productive activities through a network of
informal mechanisms rather than the bureaucratic
directives of an organisational hierarchy or contractual
regulations negotiated within a market. In this way, the
costs of undertaking transactions (costs related to the
exchange of goods and services rather than their
production) are reduced.
However, these discourses see organisations as
complicated systems, where what each of the parts

26 Journal of Integrated Care Volume 11 • Issue 5 • October 2003 © Pavilion Publishing (Brighton) Ltd
Can Complexity Theory Provide Better Understanding of Integrated Care?
will do in response to a given stimulus can be
predicted. The contribution of complexity theory is
the appreciation of network features that arise from
the non-linear interaction between component
parts.
Viewing organisations using the metaphor of an
ecosystem (Royston & Dick, 1998) can offer useful
insights into organisational delivery. Each agent
cannot be understood in isolation. All parts are
adapting by learning to survive in a topography
that is provided by co-existing and changing parts.
Figure 3: TRADITIONAL AND COMPLEXITY APPROACHES TO ORGANISATION
Traditional thinking
(machine metaphor)
Decision made by logical, analytical processes with
emphasis on managers controlling and driving strategy
Focus on experts and charismatic leaders
Importance of future, goal-setting and strategic
plans
Organisation understood by analysis of
component parts
Emphasis is on measurement and system
quantification
Attempt to rationalise decision-making even
when problems are ‘messy’, reducing uncertainty
and ambiguity
Teams are permanent and part of a hierarchical
reporting structure; managers decide who
participates and what the boundaries are
Organisation is based on strong shared culture
Adapted from Stacey, 1992
Journal of Integrated Care Volume 11 • Issue 5 • October 2003
Ecosystems cannot be engineered - there are no
causal links that promise sophisticated tools for
analysing and predicting system behaviour. But
they can be nurtured. Figure 3, below, outlines
some main differences between traditional and
complexity approaches to organisation.
Applying complexity theory to
organisations: (4) leadership and change
Viewing organisations as complex adaptive systems has
important implications for organisational leadership.
Complexity thinking
(ecosystem metaphor)
Decisions made by exploratory and experimental
processes; intuition and reasoning by analogy
encouraged
Focus on the group; managers create favourable
conditions for learning
Emphasis is on the here and now
Holistic perspective; the organisation is different from
the sum of its parts
Qualitative aspects of measurement important; the
importance of process factors is emphasised as part of a
learning process
Recognising the creative potential of ambiguity and the
importance of resolution through dialogue
Teams are informal, spontaneous and temporary;
participants decide who takes part and what the bounds
of their activities are; the focus is on self-organising
networks with an appreciation of the importance of both
co-operation and competition
Organisation is provoked and constrained by culture
© Pavilion Publishing (Brighton) 27
 Can Complexity Theory Provide Better Understanding of Integrated Care?
The traditional ‘transactional leader’ has a strong sense
of direction and comes to an agreement with
subordinates about what each will do to make a reality
of a given vision. Specific goals are articulated and
quantified within a linear, bureaucratic framework.
These are the formal structures, rules and regulations
that define relationships of power, boundaries
established by contractual agreements that delineate
departments, budgets and strategic plans. However,
instructions will always be modified and reinterpreted,
ignored in parts and added to in others. A system
survives by not working to rule. All this was originally
demonstrated by Lipsky in a classic text (1980).
A ‘transformational leader’ drawing upon
complexity insights recognises the importance of
the organisation’s socially constructed network
where meaning often remains implicit, and
understands the interplay between the
organisation’s formal design structures and its
informal self-generating networks. Change is rarely
initiated by top-down instructions or force and
there may be dysfunctional consequences of doing
so. The inherent non-linearity of the system is
recognised, as is the fact that power does not exist
in agencies or structures but resides in the
relationships that people have with each other as
they try to understand who they are and construct
their identities with each other. The emphasis is on
understanding what creates patterns of order and
behaviour and how these patterns evolve, setting
boundaries and removing obstacles to
development, facilitating communication through
increasing organisation connectivity and feedback,
amplifying the voices of employees who would not
otherwise be heard, working with the informal
networks of relationships and incorporating their
innovations into the organisation. Experiments and
marginal activities are tolerated in the hope that
they will lead to innovation.
Conclusion
Some principles for managing complex adaptive
systems, many of which are already finding acceptance
within the NHS, are shown in Figure 4, below.
28 Journal of Integrated Care Volume 11 • Issue 5 • October 2003
Figure 4: SOME PRINCIPLES FOR MANAGING COMPLEX
ADAPTIVE SYSTEMS
• Good-enough vision - build a good-enough
vision of the future rather than plan out every
little detail
• Tune the system to the edge of chaos; foster the
right degree of information flow, diversity and
difference, connections inside and outside the
organisation, power differential and anxiety
• Uncover and work with paradox rather than
trying to avoid it and manage it
• Listen to the shadow system; informal
relationships, gossip and rumour contribute
significantly to mental models and subsequent
actions
• Grow complex systems by ‘chunking’ - ie allow
them to emerge out of links among simple
systems that work well and are capable of
operating independently
• Balance co-operation and competition
Taking as its starting point a model of a non-
linear network, complexity theory offers an
alternative perspective on organisational life where
we operate under the constraints of limited time,
knowledge and processing power, where the bulk
of our activity is to establish and modify
relationships rather than seeking an endless series
of goals, each of which disappears on attainment.
The focus is on the patterns of relationships within
organisations, how they are sustained, how they
self-organise and how outcomes emerge.
Kuhn (1962) argued that the time to rethink the
appropriateness of a framework is when it becomes
less able to answer the questions asked of it. The
complexity approach is not without its detractors,
who see it as little more that intuition already
contained in popular wisdom (Marshall, 1999).
Invariably, these commentators lack the insight of
practitioners who are in contact with the
contingencies of the real world and for whom
modern medicine has been unable to provide a
© Pavilion Publishing (Brighton) Ltd
Can Complexity Theory Provide Better Understanding of Integrated Care?
model to describe the physical, psychological and
social elements of illness and the complex
interactions between health care and health.
If nothing else, complexity theory alerts us to
the fact that there are no quick policy fixes or any
easy way to integrate analytical techniques with
policy making and participatory processes, and
challenges the dominant ways of thinking about
organisational change. If it only sensitises us to the
interplay of patterns that perpetually transforms the
system against all attempts to the contrary, it may
just help us to do things a little better.
References
Cameron A & Lart R (2003) Factors promoting and
obstacles hindering joint working: a systematic review
of the research evidence. Journal of Integrated Care 11
(2).
Greenberg D (1997) NIH resists research funding
linked to patient load. Lancet 349 1,229.
Hunter D, Warner M, Beddow T et al (1998) The Health
of the Nation - A Policy Assessed. London: HMSO.
Kuhn T (1962) The Structure of Scientific Revolutions.
Chicago: University of Chicago Press.
Lipsky M (1980) Street-Level Bureaucracy. New York:
Russell Sage Foundation.
Marshall T (1999) Chaos and complexity. British Journal
of General Practice 49 234.
Plamping D (1998) Change in resistance to change in
the NHS. British Medical Journal 317 69-71.
Plsek P (2001) Re-designing health care with insights
from the science of complex adaptive systems. In:
Institute of Health Improvement Crossing the Quality
Chasm: A New Health System for the 21st Century.
Washington DC: National Academy Press.
Journal of Integrated Care Volume 11 • Issue 5 • October 2003
Royston G & Dick P (1998) Healthcare ecology. British
Journal of Healthcare Management 4 (5) 238-41.
Scott WR (1992) Organisation, Rational, Natural and
Open Systems. Englewood Cliffs: Prentice Hall.
Stacey R (1992) Managing the Unknowable: Strategic
Boundaries between Order and Chaos in Organisations. San
Francisco: Jossey-Bass Publishers.
Stacey R (1996) Strategic Management and
Organisational Dynamics. London: Pitman Publishing.
Stacey R (2000) Strategic Management and
Organisational Dynamics - The Challenge of Complexity.
London: Pearson Education.
Zimmerman B, Lindberg C & Plsek P (1998) Edgware:
Insights from Complexity Science for Health Care Leaders.
Irving, TX: VHA Publishing.
Background reading
Cilliers P (1998) Complexity and Postmodernism.
London: Routledge Press.
Sweeney K & Griffiths F (Eds) (2002) Complexity and
Medicine. Abingdon: Radcliffe Press.
Kernick D (in press) Complexity and Health Care
Organisation. Abingdon: Radcliffe Press.
Useful resources
The Plexus institute -
www.plexusinstitute.com/edgeware
The Complexity in Primary Care Group -
www.complexityprimarycare.org (see this site for details
of this year’s conference held jointly with the NHS
Modernisation Agency: ‘Improving the NHS through
the lens of complexity’)
© Pavilion Publishing (Brighton) 29