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Healthcare Reform: The Need for a Complex Adaptive Systems Approach


The notion of health care, and in particular primary health care, being a public good was strongly expressed in the Declaration of Alma-Ata in 1978 [ 1 ] .


  • Health System
  • Simple Rule
  • Health Workforce
  • Complex Adaptive System
  • Health Experience

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  1. 1.

    Bhutan seems to be the only exception; the country follows the Buddhist ideals that development of human society should benefit from the side-by-side development of material and spiritual growth, and that both aspects reinforce each other. Development is measured in “growth in national happiness” based on the principles of promotion of sustainable development, preservation and promotion of cultural values, conservation of the natural environment, and the establishment of good governance.

  2. 2.

    George Annas re-emphasised this: The “economic perspective” ignores the inability of the market to distribute goods and services whose supply and demand are unrelated to price.

  3. 3.

    For a detailed discussion of these notions, see Chaps.  1417.

  4. 4.

    See Chap.  39 by Seltman and Berry.

  5. 5.

    For more detail see, e.g. the training guides of the National Park Service (, especially.

    What are core values?

    How Will Core Values be Used?

    National Leadership Council on Core Values.

  6. 6.

    These insights are not new as such, e.g. Dent & Holt described the application of complex adaptive systems thinking in the context of the US Air Force in the following terms: Its most powerful “attractors of meaning” are its core values: “integrity first,” “service before self,” and “excellence in all we do.” …

    Successful organizations of the future will maximize its members’ understanding of the mission and vision, optimize the connections inside and outside the organization, and then seek to remove barriers to formal structural change. They will be identifiable by their core values, beliefs, and culture. An organization’s values will be the source of its self-referential stability and order. They will provide the organization with a strong anchor that will enable self-renewal without experiencing chaos. The emergence of informal structures within the organization will be encouraged and supported but not prescribed. Senior leadership will not insulate organizational members from the realities of the environment. Organizational change will be governed only by a few guiding principles or core values that are central to the identity of the organization [13].

  7. 7.

    See Chap.  15 by Sturmberg for more details.

  8. 8.

    With a growing total population, a steady proportion of the population requiring hospitalisation will still result in an increase in the absolute number requiring hospitalisation, significantly impacting on workloads and costs.

  9. 9.

    For more details, see Sturmberg, Chap.  15.

  10. 10.

    The therapeutic relationship—sometimes also referred to as the ‘doctor as a drug’—as a source of healing has been downgraded as a placebo effect, e.g. see Benson [33 35]. However the field of psychoneuroimmunology has provided the “scientific” explanations of the workings of the therapeutic relationship: the dampening of the pituitary–adrenal axis.

  11. 11.

    For somato-psycho-socio-semiotic nature of health, refer to Sturmberg, Chap.  15.

  12. 12.

    The importance of the patient experience, and the impact of harnessing this experience, has been demonstrated by Ben Heywood and colleagues from PatientsLikeMe(

    PatientsLikeMe was inspired by the personal experiences with an ultimately fatal condition in the co-founders family. PatientsLikeMe conceptualized and built a health data-sharing platform that … can transform the way patients manage their own conditions, change the way industry conducts research and improve patient care.

    PatientsLikeMe followsfour core values: putting patients first, promoting transparency (“no surprises”), fostering openness and creating “wow.” We’re guided by these values as we continually enhance our platform, where patients can share and learn from real-world, outcome-based health data.

    For a detailed discussion on PatientsLikeMe, see e.g. TEDxCambridge—Ben Heywood tells the story of PatientsLikeMe (

    For its impact, see e.g. Paul Wicks, Timothy E Vaughan, Michael P Massagli & James Heywood. Accelerated clinical discovery using self-reported patient data collected online and a patient-matching algorithm. Nat Biotechnol 2011;29(5):411–14.

  13. 13.

    For more details on this, refer to Chap.  4

  14. 14.

    The likelihood of death for patients treated in New York than those treated in Texas showed a hazard ratio of 0.87 (CI 0.78–0.98), the likelihood of suffering from angina amongst patients in Texas than New York was significantly higher (OR 1.41; CI 1.13–1.76), and the ability to NOT perform instrumental activities of daily living requiring  ≥  5 METs was significantly greater (OR 1.62; CI 1.26–2.07)

  15. 15.

    For a more detailed consideration of this aspect, see Stewart Mennin, Chap.  43

  16. 16.

    Suggested points 4 and 5 relate to the system dynamic behaviours, the one-to-many relationship of each agent, and the time delay common to inputs into a system.

  17. 17.

    A key lesson, summarised by Peter Allen, Prof of Management at the Cranfield University School of Management, is: No learning if agents cannot read the feedback!, Centralised organizations will stop Local learning, and theNeed to design Organizations that allow learning.

  18. 18.

  19. 19.

  20. 20.

  21. 21.

  22. 22.

  23. 23.

  24. 24.

  25. 25.

  26. 26.

  27. 27.,_purpose_and_priority.aspx

  28. 28.

  29. 29.

  30. 30.

  31. 31.

  32. 32.


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47.6 Appendix 1: Core Value Statements of Government Health Departments

1.1 47.6.1 Secretary of State for Health, UK, July 2010

Our values

  1. 1.

    It is our privilege to be custodians of the NHS, its values and principles. We believe that the NHS is an integral part of a Big Society, reflecting the social solidarity of shared access to collective healthcare, and a shared responsibility to use resources effectively to deliver better health.

  2. 2.

    We are committed to an NHS that is available to all, free at the point of use, and based on need, not the ability to pay. We will increase health spending in real terms in each year of this Parliament.

  3. 3.

    The NHS is about fairness for everyone in our society. It is about this country doing the right thing for those who need help. We are committed to promoting equality and will implement the ban on age discrimination in NHS services and social care to take effect from 2012. The NHS Commissioning Board will have an explicit duty to address inequalities in outcomes from healthcare services.

  4. 4.

    We will uphold the NHS Constitution, the development of which enjoyed cross-party support. By 2012, the Government will publish the first statement of how well organisations are living by its letter and spirit. The NHS Constitution codifies NHS principles and values, and the rights and responsibilities of patients and staff. It is about mutuality; and our proposals in Chap.  2 for shared decision-making by patients, their carers, and clinicians will give better effect to this principle. It is also about NHS-funded organisations being good employers; and our plans in Chap.  4 will give organisations and professionals greater freedoms, leading to better staff engagement and better patient care.

  5. 5.

    Current statutory arrangements allow the Secretary of State a large amount of discretion to micromanage parts of the NHS. We will be clear about what the NHS should achieve; we will not prescribe how it should be achieved. We will legislate to establish more autonomous NHS institutions, with greater freedoms, clear duties, and transparency in their responsibilities to patients and their accountabilities. We will use our powers in order to devolve them.

1.2 Health Canada, Canada, October 2011

Core Values—Our Values in Action

The Dialogue on Values and Ethics resulted in the identification and description of the following core values for Health Canada. In pursuing and fulfilling our vision and mission, we achieve personal, organizational and public good by:

Taking Pride in What We Do

We are motivated and guided by our personal integrity.

  1. (a)

    We recognise our potential

  2. (b)

    We take the initiative to improve ourselves and the way we do things

  3. (c)

    We act with sound judgment

Building a Workplace Community

We respect each other and work together in a healthy environment.

  1. (a)

    We embrace diversity and nurture empowering relationships

  2. (b)

    We communicate honestly and effectively

  3. (c)

    We create an environment that promotes learning and innovation

Caring for the People of Canada

We advance the public good with purpose and passion while honouring democratic values.

  1. (a)

    We provide credible information, reliable advice and quality services

  2. (b)

    We establish and maintain good working relationships with our stakeholders

  3. (c)

    We responsibly and wisely manage resources entrusted to us

By being accountable for our values and their integration in our work, we lay the foundation for excellence at Health Canada.

1.3 Department of Health and Ageing, Annual Report 2010–2011, Australia

Our Values

We value:

  • An apolitical, impartial and professional environment.

  • The importance of achieving results for the Government and the community.

  • Delivering services to the public fairly, ­effectively and impartially.

  • Transparency, accountability and responsiveness.

  • A workplace that is fair and free of discrimination.

  • Diversity and equity in employment.

  • The highest ethical standards.

  • Innovation.

  • Respect.

These principles reflect the Australian Public Service Values in the Public Service Act 1999 (Section 10) and the department’s People Strategy.

1.4 Office of Public Health and Science, 2011, USA


The OPHS has identified and defined five core values, which are listed below.

Put People First

  • Honor the public’s trust and confidence

  • Respect for colleagues and the public health professions

  • Recognise the invaluable contributions of OPHS staff


  • Adhere to the highest ethical standards

  • Ensure products and services are truthful, accurate, and comprehensive

  • Assure health research conforms to scientific norms

  • Recognise that privacy and safety of human participants is paramount


  • Conduct programs and activities guided by science and driven by results

  • Delineate clear and enforce consistent accountability for program outcomes

  • Design programs and activities so that rigorous program evaluations can and will be performed

  • Promote public health that is effective, efficient, and community-delivered


  • Embrace the richness of OPHS’ diversity and seek to strengthen it

  • Value the diversity of our Nation and the perspectives brought by differences in race

  • Ethnicity, gender, age, and socio-economic status

  • Believe that all Americans should benefit from advances in health promotion

Leadership through collaboration

  • Commit to disease prevention and health promotion

  • Believe that collaboration and coordination builds effective, efficient, responsive

  • Sustainable public health systems

  • Foster input from all relevant partners and stakeholders in program operations

Appendix 2: Core Value Statements of Health Institutions

2.1 Institute of Health Improvement, USA

Our Values

These operating values are core principles for work in IHI. They guide the behaviour and choices of all staff, faculty, and the Board of Directors.

Without Boundaries: The people of the IHI compose a single organization, with common systems, common knowledge, and unconditional teamwork.

Speed and Agility: We change our own work and respond as quickly as the health care systems we serve need us to. Our past work need not ever be our future work. We are always willing to change.

Focus on Subject Matter: Our concerns are health and health care; we are not wedded to specific methodologies. We remain always open to new approaches to the continual improvement of care. Results for patients and communities define our success.

Valuing Volunteers: We network together ­people who have expertise and knowledge, so that they can teach each other, help others, and improve the work of IHI. These people are our “faculty.” Their work is the lifeblood of the IHI. We will make their experience with IHI the most satisfying of their professional lives.

Customer Focus: To achieve our mission, we must serve and delight those who shape and deliver health care. Their satisfaction—100% satisfaction—is our uncompromising aim, in everything that we do.

Honesty: To achieve our mission, we must earn and preserve the trust of those we attempt to help. To do so, we must tell the absolute truth about ourselves and our work, reporting both failures and successes with equal discipline, and seeking the views and opinions of people outside our organization.

Transparency: We are an institute without walls. Those who work with us, no matter where or when, should feel informed and welcomed. We work always in daylight.

Orderliness: Disorder is waste, which neither we nor health care can afford. We will be lean in our work, and continually reduce waste and disorder. We practice what we teach.

Celebration and Thankfulness: Our mission is long, and our work is not easy. We take time to look back, as well as forward, to thank each other, and to take pride in what we do.

2.2 Centre for Disease Control, Atlanta, USA

CDC Core Values

  • Accountability—As diligent stewards of public trust and public funds, we act decisively and compassionately in service to the people’s health. We ensure that our research and our services are based on sound science and meet real public needs to achieve our public health goals.

  • Respect—We respect and understand our interdependence with all people, both inside the agency and throughout the world, treating them and their contributions with dignity and valuing individual and cultural diversity. We are ­committed to achieving a diverse workforce at all levels of the organization.

  • Integrity—We are honest and ethical in all we do. We will do what we say. We prize scientific integrity and professional excellence.

2.3 Cancer Council Western Australia

Our Values

  • We will serve the people of Western Australia to reduce the impact of cancer.

  • We will improve our services to the people of Western Australia based on the best available evidence and practice.

  • We will respect and value the community, volunteers and our staff.

  • We will work toward our vision and mission through teamwork and collaboration.

  • We will act with integrity and honesty.

  • We will strive to achieve equity in the provision of programs and services.

  • We will manage and apply funds entrusted to us by the community in the most effective way.

Appendix 3: Core Value Statements of Professional Associations

3.1 American Medical Association, USA

Core values

  1. 1.


  2. 2.


  3. 3.

    Integrity and ethical behaviour

3.2 Canadian Medical Association, Canada

CMA Values

Our values describe what is important to us and outline the behaviours required to make us successful.

  • Excellence: We strive to be the best in everything we do for physicians and their patients and we are committed to continuous learning and improvement.

  • Professionalism: We strive to unite physicians around the fundamental tenets of high quality standards, patient safety, professional autonomy, accountability, responsiveness and physician health and well-being.

  • Integrity: We uncompromisingly adhere to the highest ethical standards and honesty in representing our members and conducting our business.

  • Compassion: We foster an individual and corporate culture of caring for physicians, their patients and each other.

  • Rassembleur: We strive to bring together diverse communities of interest in the pursuit of common goals.

3.3 Royal College of General Practitioners (RCGP), UK

Our Values

The RCGP is the heart and voice of General Practice and as such:

  • We protect the principle of holistic generalist care which is integrated around the needs of and partnership with patients.

  • We are committed to equitable access to, and delivery of, high quality and effective primary healthcare for all.

  • We are committed to the theoretical and practical development of general practice.

3.4 American Association of Family Physicians (AAFP), USA


AAFP and its Members are Committed to Care that is…

  • Equitable for all people

  • Centered on the whole person within the context of family and community

  • Based on science, technology, and best available evidence

  • Supported by lifelong professional learning

  • Grounded in respect and compassion for the individual

3.5 Royal Australian College of General Practitioners (RACGP), Australia

RACGP values statement

“we serve with integrity, strive for excellence, foster GP unity, advocate for health equity and embrace the diversity of our profession”

Appendix 4: Core Value Statements of Clinical Institutions

4.1 Mayo Clinic, Rochester, USA

Primary value

The needs of the patient come first.

Value statements

  • These values, which guide Mayo Clinic’s mission to this day, are an expression of the vision and intent of our founders, the original Mayo physicians and the Sisters of Saint Francis.


  • Treat everyone in our diverse community, including patients, their families and colleagues, with dignity.


  • Provide the best care, treating patients and family members with sensitivity and empathy.


  • Adhere to the highest standards of professionalism, ethics and personal responsibility, worthy of the trust our patients place in us.


  • Inspire hope and nurture the well-being of the whole person, respecting physical, emotional and spiritual needs.


  • Value the contributions of all, blending the skills of individual staff members in unsurpassed collaboration.


  • Deliver the best outcomes and highest quality service through the dedicated effort of every team member.


  • Infuse and energise the organization, enhancing the lives of those we serve, through the creative ideas and unique talents of each employee.


  • Sustain and reinvest in our mission and extended communities by wisely managing our human, natural and material resources.

4.2 Central Coast Health, July 2008, Australia


Integrity  ×  Teamwork  ×  Best Practice

Accountability  ×  Social Justice

4.3 Brigham and Women’s Hospital, Boston, USA


  • Quality Patient Care: Delivering quality patient care is the center of everything we do.

  • Teaching Excellence: We seek to uphold the highest standards in training health care professionals.

  • Research Leadership: We continuously seek new ways to demonstrate our leadership role in research.

  • Customer Focus: Our focus is to serve our customers.

  • Respect for the Individual: We recognise and value the contributions of every individual.

  • Teamwork: We work toward a unified approach to developing health care solutions.

  • Embracing Change: Embracing change will help us to be successful.

  • Operational Efficiency: We strive for efficient and effective delivery of services.

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Sturmberg, J.P., O’Halloran, D.M., Martin, C.M. (2013). Healthcare Reform: The Need for a Complex Adaptive Systems Approach. In: Sturmberg, J., Martin, C. (eds) Handbook of Systems and Complexity in Health. Springer, New York, NY.

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