The way the NHS envisages change is at odds with the new online world. It needs new ‘change stories’ – the metaphors and rationales that we tell each other about how and why change should happen.

Currently these change stories – especially in the NHS – revolve around 20th century understandings derived from the needs of hierarchical, command and control organisations. Typical stories include a strong emphasis on KPIs, financial incentives, quasi-markets, the judicious use of sticks and carrots and ‘governance’.

The emergence of the ‘social age’ of horizontal, peer-to-peer relationships makes these changes stories largely irrelevant because freely-given, citizen-volunteered actions by definition fall outside the control exerted by hierarchical organisations. In addition, the knee jerk reactions of hierarchical organisations to try and gain control, as we have seen, infuriates the online world.

So health systems are faced with complex, adaptive, co-equal and rapidly evolving systems that lie out with their control. The toolbox that has driven change across public services for the last 30 years is uncomfortably empty. Are there any new change stories on the horizon that might help tightly-coupled, vertical health services interact with the horizontal and chaotic online?

We came across three possible opportunities in our interviews and readings (There are probably many others).

Embrace Entanglement

The first is ‘entanglement’: For those seeking change between complex organisations, citizens, and the environment one way forward is to seek and promote ‘entanglement’. This narrative arises out of actor-network theories and sees assemblages of systems working together and loosely co-evolving as the way forward. By accepting the reality that it is systems that deliver outcomes, and not individuals or single organisations, we can begin to build approaches that foster and reward the relationality and processes needed to tackle complex issues. (For more on this read Toby Lowe and Rob Wilson at Newcastle University –

Understand Precarity

The second way of understanding change in these complex co-equal worlds is to see the world and the organisations within it as in a state of ‘precarity’ – i.e. we are always and everywhere vulnerable to the actions of others. As a result, whatever we aim for, whatever policy we choose, the result will be contaminated diversity, a term coined by the academic Anna Tsing that describes it as “collaborative adaptation to human-disturbed ecosystems”. Contaminated diversity is what happens whenever we try to actively change an organisation, pathway, policy or ecosystem. It contains both the success and the detritus of effort, both the intended and the unintended consequences, both serendipity and Sod’s Law. As Tsing says “contaminated diversity is not always pretty. But it is who we are and what we have as available working partners for a liveable earth”.

Get Eco-Devo-Revo

The final and perhaps most exciting set of metaphors about how to ‘manage’[1] complex adaptive systems comes out of hard science. The very rapid development of our understanding of development biology, ecology and evolution has created the ‘eco-devo-evo’ [i]revolution. As a result, it is now clear that symbiosis and collaboration are widespread and at least as important as competition; that the environment routinely affects how genes are expressed; that species including mammals frequently exchange genetic material via viruses; that everywhere things ‘become together’. These provide a rich source of metaphors and since they are already transforming biomedical-sciences may be relatively easy to assimilate into healthcare.

So how might these new change stories help in practice?

Firstly, like all myths they can provide comfort to confused participants (i.e. us!) by saying look, this is how the world really is, the older understandings aren’t useless but the confusion that surrounds you is not pointless. The new world which is no longer so much about ends and means but about living the means and discovering the ends as and when we arrive (which if you think about is actually what happens 90% of the time anyway).

Second, online health communities are an ideal way for organisations to develop their ways of being in this new world – they are not mission critical, they give instant feedback, and one way or another they have to be dealt with.

Thirdly here, as elsewhere, scale is a bug not a feature. The local environment, the local heritage of custom and practice, all matter. ‘Best practice’ is not something others give you to roll out with a cookie cutter steam roller. Best practice can only be defined for you, within your environment.

So you matter, not just as an agent of others, but in your own particularities which taken together with those of everyone around you is all you’ve got. You have to think, take responsibility, to act responsively. And whatever happens it is a co-creation. You are neither the sole source of success nor the fountainhead of failure. These stories put professionalism – ‘the exercise of discretion on behalf of another in the face of uncertainty[ii] – back centre stage.

Finally, these stories of change proclaim that since the participation of everyone is inevitable, so everyone needs to be considered. Power, real and imagined, may distort behaviours and shape ultimate solutions but the truth is that fundamentally we ‘become together’. There is no escape from being entangled with others, not matter what your role, because others are as much linked to the becoming that you need to midwife, as you are.

These new change stories represent a significant shift from received wisdom. They will not be grasped easily – perhaps not until they become part of the standard medical model. However, they represent a real opportunity – and one perhaps best grasped by exploring any of the next steps outlined at the end of the executive summary.



[1] The whole concept of ‘management’ presupposes a degree of control by one set of actors over another. It is precisely this control that is largely lacking in these complex environments. Hence the quotation marks.

[i] Ecological Developmental Biology. The environmental regulation of development, health and evolution. Gilbert S, Epel D 2nd Edition Sinauer Associates 2015

[ii] Mintzberg H

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