General practice — chaos, complexity and innovation

Ervin Laszlo1

In a recent editorial, Piterman2 depicted the death of general practice, as we know it, and the emergence of a new system of primary health care (PHC). PHC is undergoing major transformation, with a focus on shifting general practitioners’ work patterns and remuneration towards integration with multidisciplinary teams and the wider system. The change is challenging the traditional role of the GP, and we need to evaluate and debate the reforms that are currently taking place. In this complex and potentially chaotic environment, we need long-term goals for PHC and general practice in Australia.

Keleher3 has defined PHC and primary care in the following terms:

In the past, primary care has been principally provided by GPs, who have demonstrated an ability to adapt to the many scientific medical developments and related changing community needs.4 Nurses, allied health workers and other groups are now playing an increasingly expanded role in primary care. While better access to comprehensive integrated community-based care should improve population health and reduce health disparities,5 primary care is not yet integrated nor coordinated within PHC,3 having been shaped by fragmented bureaucratic and funding environments.

How can GPs and other primary care providers reshape their roles and goals in the emerging PHC environment? The Australian Government intends to fund Divisions of General Practice to “support GPs and general practices with a changing primary care environment; improve access; encourage integration and multidisciplinary care; focus on prevention and early intervention; better manage chronic conditions; support quality and evidence based care; and ensure a growing consumer focus”.6 What approaches should inform divisional activities in transforming general practice?

Reforms are typically based on scant evidence from the most accessible and easily known PHC domains and activities, yet most PHC is complex and poorly understood.7 A recent editorial8 challenged GPs to get more evidence about practice and shift their attention from “theoretical” (inward-looking) activities. However, most practice activities occur in the context of human relationships, which is outside the typical evidence-based domain.9

Adapted from Joanna Macy10

According to Glouberman and Zimmerman,11 systems can be understood as being simple, complicated, complex, or chaotic (Box 1). Simple and complicated systems or processes are related to separate entities or discrete activities. Complex systems are based on relationships, and their properties of self-organisation, interconnectedness and evolution are clear and constant.

However, research into complex systems demonstrates that they cannot be understood solely by simple or complicated approaches to evidence, policy, planning and management.12

Approaches to understanding complex systems developed by Kurtz and Snowden13 for IBM international e-business management have been successfully applied with frontline health care providers.14 They categorise activities on four levels of knowledge and organisation — described as the known, the knowable, the complex and the chaotic (Box 2). Each is governed by a particular evidence and decision-making mode: the known (analytical/reductionist evidence-based care); the knowable (potentially ascertainable by application of evidence-based methods) and the complex (non-predictable, but potentially understandable by pattern observation) knowledge domains. The known and knowable refer mainly to simple and complicated knowledge, while complex knowledge is based on understanding dynamic system patterns in which the whole is greater than the sum of the known and knowable parts. True chaos represents a major system failure and requires charisma or dictatorship to stabilise. Yet there may be emergent patterns in chaos that replace old patterns and allow innovation to arise.

We argue that GPs’ generalist role in the PHC setting is more often than not dealing with decision-making in a complex systems environment. In contrast, specialisation typically involves simple or complicated evidence-based decision-making around defined diagnoses with discrete interventions.

General practices are locally run complex systems interconnected with communities, bureaucracies and other practices.16 The complexity of activities will increase with greater networking and interdependencies within the PHC system.

The preoccupation with evidence-based medicine and evidence-based policy is a predictable response of policy-makers, funders and administrators to shift PHC from a knowable to a known domain, thus gaining control over the activities under their jurisdiction.17 As a corollary, they look much more favourably at efforts that lead to additional simple evidence or complicated evaluations.

Complicated approaches frame questions such as: What reforms and behavioural change mechanisms do we put in place to integrate multiple guidelines and multiple provider inputs for best practice approaches to comorbidity in patient care?; What general practice and team structures do we need to ensure guideline adherence and better outcomes?. Complex questions ask: How do patients and providers perceive PHC knowledge models and best practices?; Are PHC system goals congruent with the “real world” as experienced by patients and providers?; How can we help GPs to self-organise in practices, teams and communities?; How can GPs and other PHC pro-fessionals build on their simple, complicated and complex knowledge, historical strengths and relationships to improve quality by innovation?

Improving chronic disease care integration, promoting timely availability of services and reducing sociocultural barriers to health care access18 are PHC goals that are not only or even best addressed with simple evidence from the known and knowable domain. Financial incentives, especially when associated with bureaucratic “red tape” — such as the Enhanced Primary Care and Practice Improvement Payments19 — have limited impact on the integration of general practice care into the broader sphere of PHC.20 Highly trained and experienced GPs work with complex patterns of patient and disease knowledge, referral systems and multifaceted roles and responsibilities in chronic illness care. Complex multifaceted system interventions that support incentives such as Enhanced Primary Care would seem most appropriate.

We argue that identifying underlying patterns of functioning systems allows simple and complicated evidence to be more effectively applied. Applying simple or even complicated solutions to complex general practice problems creates unintended negative consequences.21 Ignoring the historical highly developed roles of GPs, for example, could lead to the irreversible decline of the unique contribution of general practice. GP non-participation may result in chaos — boycotts by medical graduates, GP strikes and crisis management and emergency solutions would destabilise PHC.

Current reform movements may precipitate a state of confusion for some of the medical profession. Nonetheless, they offer the unique opportunity to redefine the GP’s role. It is clearly advantageous to stay in the realms of a complex system solution to address challenges associated with moves to new models of PHC. However, all is not lost if chaos ensues, as radical new solutions may emerge. Unfortunately, such solutions may not include general practice in its current central role (Box 2).

Two challenges in the evolving new PHC environment can be broadly grouped as (i) knowledge7 (how to develop complex knowledge, how to increase still scant knowledge in known and knowable domains,20 how to translate complex and other evidence into daily practice and systems interventions and maintenance); and (ii) self-organising leadership (how to reconstruct our roles and responsibilities around patient needs and new knowledge, how to truly engage with key stakeholders in our practices and communities, how to engage with policy- and decision-makers, how to lead and sustain innovations in health service delivery and organisation).

New complex knowledge solutions include “meta-narrative” systematic literature reviews in contrast to simple and complicated systematic meta-analyses.22 “Meta-narrative” is the overarching scientific storyline that drives research within each research tradition: What are the main theories and explanations? What are the main methods of study? What is the “storyline” of unfolding research?

Whether the small business general practice model will eventually disappear is open to debate, but one thing is certain — it will change. How it will adapt depends to a considerable extent on general practice self-organisation. The risk of imposed non-complex solutions has been demonstrated in Ontario, Canada, where the provincial government promoted a voluntary Family Health Network model featuring blended payment/capitation, extended hours and funding of nurse practitioners in accordance with best evidence. It proved bureaucratic and slow to take on.23 Subsequently, a different method of practice payments was introduced to extend practice hours and improve care for patients, while maintaining historical practice patterns, relationships and fee-for-service remuneration. This model, called Family Health Groups, had much less “red tape” and proved very popular.20 More recently, family health teams with GPs, nurse practitioners, nurses and other providers (not necessarily GP-led) are being funded to provide extended primary care services.24 While proving popular, there is an ongoing focus on the job redefinition of roles and responsibilities in primary care and primary health care.

Albert-László Barabási25

Understanding the complex and chaotic phases of PHC and the role of general practice in PHC renewal requires further development. Before research and policy are implemented, it is critical to understand health system patterns and take advantage of adaptive opportunities in the disruption of change.

The 2003 WONCA Conference in Kingston, Ontario, defined the focus of general practice as primary care morbidity, individual and community values and the health care system,26 and called on general practice internationally to redefine itself in response to new demands and challenges and to shape its own research and clinical future. Complexity approaches provide an organising framework to create new roles, knowledge and possibilities for general practice with long-term goals and strategies for PHC in Australia.