The practice of complexity: review, change and service improvement in an NHS department.

PURPOSE: In the last five years more and more scholars have drawn on insights from the complexity sciences as a way of understanding the process of managing and organising in the NHS differently. This paper aims to describe working methods derived from the theory of complex responsive processes, a more radical interpretation of these insights, used by a consultancy team in one NHS setting. DESIGN/METHODOLOGY/APPROACH: The authors were invited to undertake this intervention over a two year period to bring about service improvement. The paper sets out a critique of systems theory, which underpins most management literature, as well as offering a critique of some of the ways that complexity theory gets taken up in the health literature. As an alternative it explores the theoretical underpinnings of complex responsive processes and gives practical examples of methods that the authors believe are more suitable for understanding the complex environment NHS staff work within. FINDINGS: Working with ideas of ambiguity, paradox and complexity are not easy for staff educated in a Western tradition of linear cause and effect. However, as a result of this intervention managers and staff pointed to a much greater confidence and skill in dealing with the complex daily process of organising, which they attribute to the methods used. Although the authors make no claim that service improvement arose as a direct consequence of the methods employed, significant, observable improvements in service provision did occur during and after the consultancy intervention. ORIGINALITY/VALUE: The description of working methods based on reflective and reflexive group processes, alongside more empirical data-gathering methods, is offered as a radical alternative to more orthodox ways of understanding, and attempting to work with change in the NHS.

Planning to innovate. Designing change or caught up in a game?

In this article I engage with some orthodox theories of the management of innovation and change, which take for granted the idea that they can be predicted and controlled. Organizations are thought to be systems with boundaries, which managers acting as engineers, or doctors, can 'diagnose' and restore to 'health', or order differently. As an alternative, and by drawing on an experience of working with health service managers, I argue instead that change and innovation arise as a result of the interweaving of everyone's intentions. Organizations are sites of intense political interaction and contestation, and exactly what emerges is unpredictable and unplannable, even by the most powerful individuals and groups.

Therapy and support services for people with long-term stroke and aphasia and their relatives: a six-month follow-up study.

OBJECTIVE: To evaluate the impact of attending an aphasia therapy centre on quality of life and communication skills in people with stroke and aphasia and their relatives. DESIGN: Before and after study, six months duration. SETTING: Community-based aphasia therapy centre in the United Kingdom. PARTICIPANTS: Thirty-eight men and women with aphasia following a stroke, and 22 of their relatives. Mean time since stroke was 33 months (SD 24.1). INTERVENTIONS: A range of group therapies for people with aphasia and their relatives and counselling for individuals and couples. OUTCOME MEASURES: Quantitative outcome measures were ratings of quality of life and communication for people with aphasia, and relatives' independent ratings of communication and coping with caring. Qualitative outcomes were perceptions of quality of life and communication skills using semi-structured interviews. RESULTS: Improvement was detected on all outcomes at six months. There were significant changes from baseline on the quality of life measure, mean difference 0.14 (95% confidence interval 0.02, 0.26); and the communication measure assessed by people with aphasia and their relatives, mean difference 12.8 (4.0, 21.5) and 9.7 (3.6, 15.7) respectively. The changes on the coping with caring measure were not significant, though the direction of change was positive. Qualitative interviews revealed a similar pattern of benefit in terms of increased levels of self-confidence and changes in lifestyle and levels of independence. CONCLUSIONS: The results suggest that this therapeutic approach has an impact on quality of life and communication for people with aphasia and their relatives.