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The inclusion of user representatives in committees and groups alongside health professionals is one of several ways of involving users in the planning and monitoring of health services. However, there have been reports of barriers to the involvement of users in such groups and very little is understood about the processes that take place and the factors which promote effectiveness. This study addresses this shortfall in relation to a specific type of user involvement forum in maternity services - the Maternity Services Liaison Committee (MSLC). MSLCs are attached to hospital trusts or health authorities and bring together health professionals and local users to plan and monitor local maternity services. The study is a qualitative assessment of a sample of eight MSLCs using a combination of observation and interview methods. It investigates the structure and work of MSLCs, the way members participate, and the meaning and value of MSLCs to members, in order to establish the effectiveness of MSLCs and potential for improvement. The committees were found to have a limited direct impact on maternity services. Arguably their greatest influence was in promoting collaboration between constituent groups and the accountability of health professionals. The impact of MSLCs and the extent to which users were involved were limited by factors to do with the structure and processes of the committees. MSLCs could be improved to some extent through changes to these, but improvement beyond a certain point would be difficult to achieve because the problems reflect fundamental issues to do with the structure of the health service and the way MSLCs were set up, the high degree of professional control over MSLC activity and health care in general, and characteristics of users. These findings have implications for the effectiveness of other forums for user involvement presently being implemented in the health service.

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The purpose of this study is to explore performance measurement systems in the healthcare services in Malaysia. This study postulates a framework based on an analysis of the existing literature in the field and on the empirical evidence collected during fieldwork. This framework provides a useful perspective for studying performance measurement in developing countries such as Malaysia. Moreover, identification of gaps in the field enables both academics as well as practitioners to improve the existing systems, thereby creating more robust and better surveillance in the healthcare industry. The findings show that in order for systems to operate efficiently, three major components must work together, namely strategy formulation and deployment, internal control systems, and managing processes. The empirical framework developed in the study represents an amalgamation of approaches used in organisations. One of the findings is that top management commitments, people involvement, and structure to accommodate change process are the catalyst for measurement systems to work. Further analysis reveals (survey) that 80% of users are not satisfied with their measurement system. This means that there is a need for further research in the future. Performance measurement is in its embryonic stage in Malaysia as the survey reveals domains accomplishment of less than 50%. The healthcare industry is inevitably growing and the Malaysian government needs to address the importance of measuring performance in the long run. Learning from another country's experience is the best way forward. The thesis also provides a context in which performance measurement works. There are two contexts applied: healthcare industries and Malaysia. Both contextual elements are important; healthcare has special attributes that make it different from other industries, while Malaysia has unique properties that provide a fresh look at healthcare. The key to successful performance measurement is to ensure congruence in all elements of the systems: context (Malaysia and healthcare) and content (organisations where systems exist). Then integration can be accomplished.

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This thesis explores reactions to changing occupational roles and identities precipitated by a Business Process Re-engineering management change programme within a National Health Service setting. The thesis offers further understanding of the changing nature of professional roles and occupational identities within health care. Taking a qualitative approach, through the use of interviews and focus groups, the empirical core of the PhD examines professional employees' responses to changes in their own working practices. The main thrust of the argument is that work reorganisation that changes the role and scope of practice impacts on occupational identities. The empirical work demonstrates how the effects of change in working practice create a situation whereby there are clearly defined winners and losers within and between professions. This thesis links such a recognition with the multiplicity of interests and the complexities of professional occupational identities within health care. An added dimension is the extent to which disciplinary knowledge creates these professional roles and occupational identities. If health care professionalism is to be redefined there is a requirement for an agenda which addresses the issue of how knowledge and expertise are acquired.

The aim of this thesis was to observe appointment negotiations in general practice, and investigate patients' and receptionists' experiences of appointment making. Improving access to health care is a National Health Service priority. These priorities are manifest when patients' request an appointment to see their GP. This study was conducted in three general practices on Tyneside: a singlehanded practice; a three doctor practice; and a seven-doctor practice. Two methods were used, participant observation, consisting of observing and recording practice activities and observations with informal interviews, and long interviews with patients and professionals. Activity recordings and observations were conducted in waiting rooms, behind reception counters, and in other settings. There were 35 activity recordings and 34 periods of observation. Thirty-eight patients and 15 professionals were interviewed. Participants were selected by theoretical sampling. These included 12 short interviews with patients attending an 'open access'surgery. Six groups of patients (23) and 15 professionals were selected for long interview. These included patients who complained about appointment making or who complimented the receptionists. Transcripts of observations and interviews were analysed by theoretical coding and data display to identify concepts and categories of data. Several methods were used to enhance the research's quality. Outcomes from appointment negotiations are influenced by patient's illness behaviour, the process of negotiation, and appointment availability. Appointment requests are legitimised by receptionists enforcing practice rules and requesting clinical information. Receptionists also work outside 'official' practice rules to manage limited appointment availability. These strategies include 'fitting patients in, ' reserving appointments, referring to other professionals and using advocates to support their actions. Patients volunteer information to provide evidence that their complaint is appropriate, and employ strategies, such as assertiveness, and threats, to try and obtain appointments. Receptionists have a crucial role in managing patient access that remains unacknowledged by policy makers.