The meaning of integrated care: a systems approach

INTRODUCTION: In all well developed societies, such as those that we live in, there tend to be strong borders or barriers between different organisations and different professions. People with different kinds of knowledge are kept well apart. So how can we—should we—manage health and social services that are located in different organisations? If we are to improve the capability of a health care organisation to function as an integrated part of a locally driven health and social service system, we need a new model. Traditional models view systems as machines. Instead, we perhaps should approach them as constantly changing living organisms. This is the importance of Complexity science. It helps us understand what happens in dynamic living systems, where many agents are interconnected. COMPLEX ADAPTIVE SYSTEMS (CASS): The term ‘complex system’ emphasizes that the necessary competence to perform a task is not owned by any one part, but comes as a result of co-operation within the system. ‘Adaptive’ means that system change occurs through successive adaptations. A CAS consists of several subsystems called agents, which act in dependence of one another. They are interdependent. They may either compete or co-operate according to their sense of their interests and what will bring them an advantage. Complex Adaptive Systems are distinguished by self-organisation. Self-organisation is about creating order or increasing the regularity of the system without help from the outside. Good examples would be the ant-hill, the human immune defence, the financial market and the surgical operating theatre team. When we study a CAS, the focus is on the interaction and communication between agents. Contrary to the old cliché, that the whole is greater than the sum of the parts, the whole is the relations between the parts. Order, innovation and progress arise naturally from interactions within a CAS. They do not need to be prescribed from ‘higher’ levels or from the environment. It has been found that for purposes of fostering connectivity among diverse agents, effective coupling of structures, ideas and innovations, and ensuring that they are neither too loose nor too tightly interdependent, complex systems are better led by indirect than by direct leadership behaviours. CONCLUSIONS: The CAS approach helps the management to understand why the traditional top down way of managing may meet with problems in organisations with complex tasks. An important discussion is about how the top management in fact executes its steering function. As a leader in a CAS you will accept complexity instead of trying to reduce it, formulate few simple and concrete goals, communicate and give feedback and measure on performance. As we begin to see health care organisations as CASs we should gain more insight into the processes that go on within and between organisations. But best of all, this organic mental model opens up for greater success in implementing strategies.