Stasis and adaptation

Many of our most pressing societal challenges arise from our inability to move on from present practices and structures and do what is needed. Healthcare struggles to improve safety and quality. It resists adoption of best practices and persists in high levels of unwarranted variation in care delivery, and clings to financially unsustainable models of care. One explanation for this state of affairs is not a lack of will, but that we are experiencing system inertia--a consequence of the increasing complexity of our human systems. In this paper I explore three possible system level interventions that may help design systems that are less likely to approach inertia, as well as help change our current systems so that they again become adaptive, and move to the outcomes we desire. Firstly, I question our religious belief in the power of standards, an intervention designed to minimise adaptation and almost from first principles designed to lead to inertia. Next I explore the power of apoptosis, a process that sees existing structures and practices programmatically removed to free up resource for adaptation. Finally I explore a flexible but controversial approach to system management called market-based control. Whether any of these, together or in tandem, are a way out of inertia is an open question. However, it is time for us to engage with the challenge of system inertia, and find a way out.