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Changing how we think about healthcare improvement

BMJ 2018; 361 doi: (Published 17 May 2018) Cite this as: BMJ 2018;361:k2014

Is it time to think big – and design a “real health system”?

Changing how we think about healthcare improvement [1], while alluding to complexity, does not really address the complex issues facing the “healthcare system” as a “socially designed complex adaptive system” [2].

Prerequisites for real change

(1) Generally speaking, how many people require healthcare, and where is that care provided?
It may be surprising but most of us are healthy or healthy enough not to require health professional services. Kerr White’s 1961 ground-breaking study has since been repeated in many contexts showing that health and the need for healthcare services follow a Pareto (or 80:20) distribution [3], i.e. 80% of the community is healthy or healthy enough not to require health professional input, of the 20% that seek health care, 80% (or 16% of the community) require primary care services, of the 20% that require additional care, 80% (or 3.2% of the community) require secondary care services, and the remaining 20% (or 0.8% of the community) receives tertiary hospital care [4].

(2) Does the healthcare system actually provide care for health?
Current health systems, for all intense and purposes, are focused on non-health. Health professionals at large concern themselves with – if possible fixing – but mostly managing the diseases of their patients. In other words, the system more accurately is a “disease management system”, and as far as it goes, it is doing a good job under that label [5, 6].

(3) Why is improvement no longer a viable option?
Improvement and reform assume that the current system is fundamentally sound and that tweaking it at the edges will achieve the desired outcomes. Tweaking entails that the fundamentals of the system, or its current paradigm, are fine! If it is true, as many now believe, that the health system is failing, we need a different mindset, or paradigm, with which to look at the problem. We need a shift from thinking about disease and disease alleviation/management to health and well-being, accepting that the emergence of disease over the lifetime is a biologically inevitable fact – and most notably that most elderly people regard their health as good or better despite their increasing number of morbidities [7]. Focusing on health as a “personal experiential state” [8, 9] is paramount as self-rated health is the strongest predictor of health service use and mortality [10, 11].

Designing a “real health system”

Health systems are organisations, they are socially constructed complex adaptive systems. Organisations function based on 4 key principles – its “a-priori definition” of its purpose, goals and values which provides the foundations for delineating its key operational principles (aka “simple rules”). In a complex adaptive organisation “control and decision making” are dispersed and decentralised, allowing the organisation to rapidly adapt to changing demands and environmental circumstances [12-16].

Understanding that the prevailing health systems can only deliver – and indeed does deliver – what it is designed for based on the 4 principles that drive any organisation also guides the necessary steps forward to solve the prevailing problems. What we need is a rethink and redefinition of the purpose, goals and values for a “health-focused” health system, and what our key operational principles (or ”simple rules”) should be.

These are the key components for health system redesign [2]. If you want to engage in this – very slowly emerging discourse – you may want to join discussion at “Health System Redesign” (

1. Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018;361.
2. Sturmberg JP. Health System Redesign. How to Make Health Care Person-Centered, Equitable, and Sustainable. Cham, Switzerland: Springer; 2018.
3. White K, Williams F, Greenberg B. The Ecology of Medical Care. N Engl J Med. 1961;265(18):885-92.
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15. Chen DT, Werhane PH, Mills AE. Role of organization ethics in critical care medicine. Critical Care Medicine Organizational and Management Ethics in the Intensive Care Unit. 2007;35(2):S11-S7.
16. Rouse WB. Health Care as a Complex Adaptive System: Implications for Design and Management. The Bridge 2008;38(1):17-25.

Competing interests: No competing interests

22 May 2018
Joachim Sturmberg
School of Medicine and Public Health Faculty of Health and Medicine University of Newcastle – Australia, Foundation President - International Society for Systems and Complexity Sciences for Health
PO Box 3010