Appraising the implementation of complexity approaches within the public health sector in Scotland. An assessment framework for pre-implementation policy evaluation

Complexity approaches have gained international attention as potentially effective strategies to address population health challenges. In light of this, the Scottish government (Scot. Gov.) set the implementation of these approaches as the recommended practice for its public health sector organizations. This study evaluates the opportunity and feasibility of implementing complexity approaches in public health Scotland employees' everyday routine by employing a qualitative study that involves 20 stakeholders, representative of different organizations and roles. We made use of an assessment framework based on Soft Systems Methodology (SSm) and Normalization Process Theory (NPT) comprised of five phases: Phase One defines the boundaries, aims, and goals of the issue under study; Phase Two consists of data collection, drawing on the e-Health Implementation Toolkit (e-HIT); Phase Three involves short presentations and breakout group activities to provide information on the new policy; Phase Four employs system thinking tasks to structure debate and builds shared understanding among participants; Phase Five applies NPT to appraise the organizational position around complexity based on information from the preceding steps. We found two main obstacles to implementing complexity approaches: (1) a lack of a shared understanding of the key concepts in complexity and their practical implications; (2) stakeholders' fear of significant disruption to work routines and power relationships. We recommend addressing these issues with appropriate training and customization of goals and tools that may enable complexity approaches to succeed within the Scottish public health context. Our assessment framework allows the recognition of key mechanisms to support how Scotland's Public Health body can enhance the implementation of complexity approaches. The appraisal framework could be used to study early-stage policy implementation in other contexts.