Exploring Health Services With the Help of a Work Systems Lens

Introduction

The challenges of providing universal health care in modern society is a subject of concern among people in all walks of life - citizens, patients and health professionals alike. It is discussed in the Press, in patient groups and among politicians of every persuasion. While there may be little agreement on the way forward, there is at least agreement that this is a ‘wicked’ problem that defies a simple solution. People may call for more money for the health service (whether from taxation or from private investment) but, at the same time, it is widely recognized that money alone will not tackle all the challenges or produce optimal solutions.

Ackoff (2004) discussed the nature of problem situations, pointing out that in social settings, no problem ever exists in complete isolation:

He goes on to point out that an analytical approach to problem-solving, seeking to identify and solve each problem in a system of problems separately, not only often fails to achieve a satisfactory solution but also serves to intensify the mess. Problems within human systems are difficult to define because they are usually open to interpretations and differences of opinion, as well as interrelationship with other problems – forming a mess. Pidd refers to this when he suggests:

Why do we make this mistake? Aspects of a mess may appear temptingly simple – we want to move forward. Management Science and Operations Research have developed sophisticated methods for analysis to generate optimal solutions to defined problems. However, optimal solutions to many separate problematic situations will probably not result in a satisfactory dissolution of a ‘wicked’ problem (or mess). Sub-optimality arises because what makes things better for one part of a system could be making them worse for another, or indeed create new problems at their boundary.

When parts of a mess are critical (as is the case in health services) sub-optimal outcomes from decision-making may be catastrophic. Any or all interventions made in efforts to move forward towards achieving a solution actually create new challenges, tightening the mess still further. Part of the difficulty for would-be improvers is that it is not possible to say ‘Wait a moment while we make some useful changes’. The problem situation will have moved on in the meantime and real people may suffer in consequence. Time scales are not the only difficulty, of course.

As Checkland and Poulter (2010) point out: “…the (social) world is taken to be very complex, problematical, mysterious, characterized by clashes of worldview…” (2010, p. 198).

Interconnected problems cross many social, political and financial boundaries. Every involved actor will have a particular perspective on the nature of challenges faced, the priorities that should be applied in finding a solution and which interventions are likely to be most efficacious. Different stakeholder groups may desire change but hope that the fiscal challenges will fall on someone else.

In a problematic situation such as that faced by health services in England, it is vital that differences of perspective surfaced and strands of messy problems teased out. Those seeking to make changes to balance effectiveness and efficiency need to draw upon both explicit data and tacit knowledge embedded in practice within the service. Exploration using Systems approaches, creating multiple learning spirals, could inform such change.