Why is it becoming harder to address complex health problems?

Note the perspectives and arguments in this article have been superceded in my later work. This can be found in my 2021 book Interactional Creation of Health: Experience Ecosystem Ontology, Task and Method.

Most healthcare systems continue to suffer from poor outcomes, growing costs and high patient burden. With increasingly scarce resources, the sustainability of the structures, institutions and practices created to prevent and treat illness is under mounting threat from multiple pressures and numerous complex and persistent system problems.

They are all too familiar and easy to recall: Rising incidence of chronic, lifestyle conditions and diseases; an increasingly vulnerable very elderly population; high levels of unnecessary care and the related over-prescribing of medicines, sometimes leading to addiction or drug resistance; inequalities in patient access and the quality of care; enduring risk of infection and sickness in hospitals; a lack of preventive focus on the social determinants and risk factors of disease; mismatched provider incentives and payment systems together with misaligned pharmaceutical and industry practices and pricing, and too many cases of avoidable patient harm, amongst many others. Despite ongoing improvement and intervention efforts, and high rates of treatment and technology innovation, there remains a great struggle to improve health outcomes significantly, widely and at scale. Frustration continues to build whilst underlying forces and factors of disease origination become more hidden from view and more distant from action

The challenge of complex health system problems

Complex health system problems contain several forming forces and sedimented tendencies that are typically hard to identify and difficult to separate from their effects. This means that attempts to address one cause can sometimes worsen another; they simply push it onto another stakeholder or into a different part of the system. Similarly, like squeezing one end of a balloon, cost savings made in one care setting or disease area can lead to bigger cost increases elsewhere. Often, problem owners and stakeholders disagree over the nature or even existence of a problem; they assign different meaning and interpretation, they give them varying priorities, and they experience conflict over how to address them. Intervening to improve or more boldly, transform complex health system problems is a challenge itself, with high failure rates. Typical causes include limited problem understanding, a lack of system-wide vision, an absence of common language, entrenched behaviour and assumptions, and misaligned innovation, strategy and change management plans and action.

In the last decade, greater onus has been placed on technology, especially digital technologies, as the panacea that will drive transformation and cure complex health system problems. Yet to date, such technologies have experienced only slow adoption and have not been deployed at scale. Great effort is required to gain the commitment of patients, clinicians, regulators and payers to use or approve them. Despite more upfront collaboration with stakeholders, it seems that resistance rather than acceptance is the norm upon implementation. Too often, health technologists and entrepreneurs are learning the painful lesson that complex health problems cannot be addressed through forces of push and technology alone.Design thinking and systems

Design thinking and complex systems

When making interventions in complex health systems, it is necessary to identify, engage with and satisfy the needs of multiple stakeholders. A health designer seeking to create new value must understand how complex systems adapt and evolve in response to the direct and indirect interactions of all stakeholders, the different goals they have, the diversity of resources they use, the outcomes they prioritise and often, the widely different (and sometimes in conflict) values they possess. Learning about a problem from only one or two stakeholder groups risks leaving important gaps in understanding, leading to the design of partial interventions and piecemeal solutions based on incomplete evidence. Rather like the parable of the learned blind men touching an elephant, focusing on just one part of a complex system problem only ever produces limited insight (especially if you are at the tail end). Such a narrow perspective is one of the main reasons why technologies and solutions fail to become adopted, or do not achieve the hoped-for scale of implementation.

In recent years, the emergence of solution-, product- and experience-oriented design thinking as the dominant problem-solving approach adopted by companies and taught in business schools, has struggled to deploy an appropriate systems perspective. It has a tendency to frame complex system problems too narrowly in exactly the way I describe above. With only a subset of problem insight, it then launches too quickly into a solution generation mode with just a handful of core stakeholders. From a complex systems viewpoint, this form of design thinking suffers from what I call the 5S Syndrome. It has a tendency to address symptoms over causes; within narrow silos over systems; aimed at the superficial over scale; the short-term over sustainability and at its core, with a preference for leaping into solution mode over first acquiring deep objective, multi-stakeholder and wide context problem understanding. Whilst prototyping and iterating ideas, improving the patient experience and redesigning processes within a frame of current health system structures, pathways, journeys and institutions can deliver some impact, the current paradigm of design thinking lacks scale and wide perspective, and involves high risk. More fundamentally, it is simply not always possible to learn by doingin a design-like way due to safety, regulatory and ethical restrictions when prototyping with patients

What can be done?

How can health designers enjoy more effective and sustained impact when seeking to address complex health system problems? How can they adopt a more strategic mindset to design multi-stakeholder interventions? How can they widen their frame of problem search to look into new adjacent spaces, contexts and possibilities beyond the status quo? What does value even mean from a systems perspective, and how should it be designed and delivered; is it enough to think in terms of technology, products and experiences alone? Can design thinking approaches rely solely on interpretive, divergent thinking? Or is there a need for them to embrace analytical methods too, and find an appropriate blend of right and left-brain process? Most of all, how is it possible to build and deploy an advanced systemic design capability, one that delivers much greater potential to address complex health system problems and in doing so, not only improves but also transforms outcomes for patients, clinicians, payers, government, industry and society overall?

The ecosystems lens offers much more

Increasingly, health planners and innovators think of health systems as ecosystems, consisting of a mix of interacting stakeholders — patients, practitioners, payers, providers, institutions and government bodies — each with varying goals, needs and desired outcomes.

Whilst the ecosystem concept is largely understood in respect of how it helps identify multiple actors and stakeholders, our understanding of how they health systems function, evolve and adapt is less well articulated. Critically, knowing why they do not function well has clear practical application for complex health problem solving. Indeed, the ecosystems metaphor provides several uses for rethinking and redesigning health innovation and design thinking. It helps innovators to:

• Understand better how health systems are structured, function, evolve, adapt and sometimes, fail
• Determine the multiple factors and properties that lead to, and define, complex health problems
• Reveal new opportunities for addressing complex health problems
• Reveal a wider set of possibilities or frames for new value propositions (from functional and clinical, to experience, adaptation and transformation); as well as evaluate existing ones for their ecosystem fitness
• Design a portfolio of health system interventions ranging from the incremental to transformative
• Create adaptive ecosystem growth and evolution strategies
• Co-create superior solutions with stakeholders aligned with all the above

Last but not least, an ecosystem lens shows us how to build a dynamic complex health problem solving capability. It tells what we can do to build design thinking and innovation leadership within organisations that wish to continuously address complex health problems.