title: Embedding research in health systems: lessons from complexity theory.
abstract: BACKGROUND
  Internationally, there has been increasing focus on creating health research systems. This article aims to investigate the challenges of implementing apparently simple strategies to support the development of a health research system. We focus on a case study of an English National Health Service Hospital Trust that sought to implement the national recommendation that health organisations should introduce a statement about research on all patient admission letters.
  
  
  METHODS
  We apply core concepts from complexity theory to the case study and undertake a documentary analysis of the email dialogue between staff involved in implementing this initiative.
  
  
  RESULTS
  The process of implementing a research statement in patient admission letters in one clinical service took 1 year and 21 days. The length of time needed was influenced firstly by adaptive self-organisation, underpinned by competing interests. Secondly, it was influenced by the relationship between systems, rather than simply being a product of issues within those systems. The relationship between the health system and the research system was weaker than might have been expected. Responsibilities were unclear, leading to confusion and delayed action.
  
  
  CONCLUSIONS
  Conventional ways of thinking about organisations suggest that change happens when leaders and managers change the strategic vision, structure or procedures in an organisation and then persuade others to rationally implement the strategy. However, health research systems are complex adaptive systems characterised by high levels of unpredictability due to self-organisation and systemic interactions, which give rise to 'emergent' properties. We argue for the need to study how micro-processes of organisational dynamics may give rise to macro patterns of behaviour and strategic organisational direction and for the use of systems approaches to investigate the emergent properties of health research systems.
authors.affiliation: King's College London, Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, London, United Kingdom. louise.caffrey@kcl.ac.uk.|NIHR Biomedical Research Centre at King's College London and Guy's & St. Thomas' NHS Trust, London, United Kingdom. louise.caffrey@kcl.ac.uk.
authors.forename: Louise
authors.initials: L
authors.lastname: Caffrey
authors.affiliation: King's College London, Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, London, United Kingdom.|Guy's and St Thomas' NHS Trust, London, United Kingdom.
authors.forename: Charles
authors.initials: C
authors.lastname: Wolfe
authors.affiliation: King's College London, Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, London, United Kingdom.
authors.forename: Christopher
authors.initials: C
authors.lastname: McKevitt
mesh_terms: D035843:Biomedical Research; D003142:Communication; D003695:Delivery of Health Care; D004739:England; D006282:Health Personnel; D006761:Hospitals; D006801:Humans; D007857:Leadership; D010343:Patient Admission; D018579:Patient Selection; D013222:State Medicine
keywords: Complexity theory; Health research systems; Implementation; Organisational change; Systems approaches