Talking it Better: Conversations and Normative Complexity in Healthcare Improvement

Article Summary by Alan Cribb

No doubt everyone would agree that conversations are valuable. Amongst other things they are one of the ways we can attend to, appreciate and learn from one another. This, of course, is relevant to practical activities like healthcare improvement. Healthcare improvement typically involves technical or formally specified processes working alongside various social processes. Conversations might be said to both make up a sub-set of these processes and to ‘oil the wheels’ that enable others. In this article we acknowledge this general account of the relevance of conversations to improvement but, in addition, focus in on a specific contribution which, we suggest, makes them especially valuable.

In a nutshell our argument is that conversations play a crucial role in managing what we call the ‘normative complexity’ of healthcare improvement. Improvement, we argue, involves managing more than one kind of complexity and some forms of complexity have had more attention in the improvement literature than others. Notably there has been quite a lot of explicit attention given to the complexity of deciding what to do or ‘what works’ in improvement—which, in this paper, we describe using the shorthand ‘explanatory complexity’. In this context authors tend to write about healthcare being bound up in ‘complex systems’ such that it is difficult to draw clear and tidy lines between ‘Intervention A’ and ‘Desired Result B’. This crude summary reflects an important set of challenges but the challenges we are most interested are different from (although overlap with) them.

We suggest that it is equally important to recognise the complexities that attach to answering the question “what should count as working?’ or, more plainly, ‘what is an improvement?’ or ‘what is better?’. Aspects of normative complexity do feature in the improvement literature, and some quite prominently, but the theoretical and epistemic problems generated by normative complexity are rarely the focus of sustained attention. For example, there is prominent practical consideration given to the notion that good quality healthcare has different ‘dimensions’, that there are different perspectives on what counts as ‘good’ from different stakeholders and also to some issues in the ‘ethics of improvement’ that invite the question of whether the ‘improvement cure’ is always worth taking. These concerns, alongside other complexities—such as, for example, the question of how responsibility for improvement can and should best be ‘divided up’—considerably complicate the process of deciding what improvers should be doing. In short there is no clear and tidy story to tell either about ‘what works ‘or about ‘what should count as working’ and these two sets of problems intersect.

By definition there are no simple answers here. But our suggestion is that conversations can and do contribute significantly to negotiating normative complexity. This is because conversations are suited to keeping open a range of normative possibilities whilst bringing separate voices together, because they both enable and respond to the emergence of new possibilities and, most fundamentally, because they can help to create the organisational conditions for empathy and moral imagination.

Read the full article on the Medical Humanities journal website.


Alan Cribb co-directs the Centre for Public Policy, King’s College London, a group focussed on strengthening the way applied philosophy, sociology and inter-disciplinary scholarship can contribute to understanding experiences of, and engage in contestations about, policy enactments. The Centre takes an approach to the analysis of policy that is both critical and practically oriented and has a particular interest in questions of social justice and ethics. Alan is currently working with Vikki Entwistle and Polly Mitchellalong with collaborators from healthcare improvement research, policy and practice—on a Wellcome Trust funded project on philosophy and healthcare quality improvement.

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