'Complexity-compatible' policy for integrated care? Lessons from the implementation of Ontario's Health Links.

Complex adaptive systems (CAS) theory views healthcare as numerous sub-systems characterized by diverse agents that interact, self-organize, and continuously adapt. We apply this complexity science perspective to examine the extent to which CAS theory is a useful lens for designing and implementing health policies. We present the case of Health Links, a "low rules" policy intervention in Ontario, Canada aimed at stimulating the development of voluntary networks of health and social organizations to improve care coordination for the most frequent users of the healthcare system. Our sample consisted of stakeholders from regional governance bodies and organizations partnering in Health Links. Qualitative interview data were coded using the key complexity concepts of sensemaking, self-organization, interconnections, coevolution, and emergence. We found that the complexity-compatible policy design successfully stimulated local dynamics of flexibility, experimentation, and learning and that important mediating factors include leadership, readiness, relationship-building, role clarity, communication, and resources. However, we saw tensions between preferences for flexibility and standardization. Desirable developments occurred only in some settings and failed to flow upward to higher levels, resulting in a piecemeal and patchy landscape. Attention needs to be paid not only to local dynamics and processes, but also to regional and provincial levels to ensure that learning flows to the top and informs decision-making. We conclude that implementation of complexity-compatible policies needs a balance between flexibility and consistency and the right leadership to coordinate the two. Complexity-compatible policy for integrated healthcare is more than simply 'letting a thousand flowers bloom'.