Response to ‘The Appropriation of Complexity Theory in Health Care’

John Paley's article ¹ is good teaching material because it illustrates some classic rhetorical moves used in the ancient sport of argumentation. ² These include the ‘post hoc ergo propter hoc’ fallacy (assuming that if B occurred after A then A must have caused B); the ‘slippery slope’ fallacy (suggesting that the opponent is guilty of A, then taking the audience through a series of small steps in which A becomes B, B becomes C etc, and concluding that the opponent is guilty of Z); the ‘ad hominem’ fallacy (depicting the opponent as ignorant or foolish, and then concluding that everything s/he says is weak and superficial); and the ‘ad populum’ fallacy (appealing to some positive but ill-defined quality to which the audience is assumed to aspire – such as ‘rigour’ or ‘depth of understanding’).

It is ironic, for example, that in the very first sentence of a paper which purports to explain complexity theory, Paley draws a direct and linear link between a series of introductory articles which we published back in 2001^3–6 and alleged misunderstandings and misapplications of complexity theory by others in the health care field. ⁷

Paley claims that in our 2001 series, we ‘partially understood’ what he chose to define as the second principle of complexity – that ‘successive states of the system, globally defined, are determined by previous states, locally defined’. We apparently ‘failed to recognize’ what Paley decided was complexity theory's first principle – that complexity is an explanatory concept. It is presumably coincidental, then, that Paley chose to use the same example (a termite colony) to illustrate this principle as we ourselves used to illustrate it in the first article in our series. ³

Paley's third principle of complexity is expressed thus: ‘Complexity explanations account for global order by specifying the local behaviour of units which have no awareness of the order thereby being produced, and which have no intention to produce it'’. If, as he claims, we ‘failed to recognize’ this, why did we say in our first article ‘Order, innovation, and progress can emerge naturally from the interactions within a complex system; they do not need to be imposed centrally or from outside. For example, termite colonies construct the highest structures on the planet relative to the size of the builders. Yet there is no chief executive termite, no architect termite, and no blueprint. Each individual termite acts locally, seemingly following only a few simple shared rules of behaviour, within a context of other termites also acting locally. The termite mound emerges from a process of self organization'’? ³

Paley suggests that in our article on complexity, leadership and management, ⁴ we misinterpreted the notion of the self-organizing system to mean that bottom-up approaches to organizational strategy and development should replace top-down ones. Had this been true, it would have been a grievous fault. What Plsek and Wilson actually said was ‘Complexity based organizational 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'’. The article, written at a time when National Service Frameworks and other rigid, nationally imposed performance targets were stifling local initiative and flexibility, was arguing that tight central control can be counterproductive, not that organizations work better with nobody in charge.

The analysis of an argument is incomplete without a consideration of the audience for which it was constructed and the context in which it was presented. ⁷ An argument that is seen as robust and evidence-based by an audience of academics may be rejected as ethereal and out of touch by an audience of policymakers. ⁸ The intended audience for our original series on complexity consisted of doctors and other BMJ readers who were entirely naïve to the notion of a complex adaptive system (it was, after all, early days). The articles as originally drafted were misunderstood by the BMJ's reviewers and rejected by its editors for being implausible and containing too much jargon (contrast the quote from Paley in paragraph five above with the quote from our own paper, which says essentially the same thing in plain English). The final version of our series contained numerous simplifications and some rather populist examples and metaphors, though we did manage to avoid the one about the butterfly's wings. Algebra, as offered by Paley in his article, would undoubtedly have been edited out, and rightly.

We have published a number of subsequent papers and a book, all of which Paley chose to ignore, which offer a more sophisticated analysis of complex adaptive systems.^9–19 For example, in her opening keynote lecture to the 2009 World Family Doctors' Conference in Basel, Switzerland, Greenhalgh argued that what is widely referred to as ‘complexity theory' is little more than a general world view at a high level of abstraction; it needs to be refined, adapted and applied in different ways for different research questions. ¹⁶ Family medicine research typically involves the study of how individuals behave and relationships develop, contextualized in particular social, institutional and technological settings. Within our over-arching world view (‘complexity’), and with specific questions in mind, we can make eclectic use of middle-range theories to illuminate how micro-level phenomena (such as human agency, identity, capability, morality and physiology, and the affordances and constraints of particular technologies) interact in complex ways with macro-level phenomena such as economic, political, legal and professional structures to produce outcomes that can never be fully predicted or controlled. A detailed theoretical paper applying this approach to the study of the adoption and nonadoption of technologies in the UK National Programme for IT is in press. ²⁰

Other authors have applied this same principle of combining the general world view of ‘complexity’ with a more specific and detailed middle-range theory for undertaking (for example) organizational case studies, ²¹ designing information systems,^22;23 developing clinical microsystems ²⁴ and preparing for bioterrorism. ²⁵

Our original BMJ series on complexity in health care has been cited by some 900 publications. These include many scholarly papers which recognized the introductory focus of that series and offered nuanced corrections, extensions and adaptations. Numerous other authors over the years have misinterpreted, misrepresented or misapplied our arguments, but we cannot be held responsible for this.