Introduction: Health website quality assessment tools are designed to guide patients to high quality websites and away from those of poor quality. However, the ability of such tools to do this successfully is unclear. Aim: To assess the applicability of three recognised generic health website quality assessment tools (LIDA, DISCERN and HWAT 3.0) to a specific health topic by ascertaining whether they can identify the highest quality orthognathic websites. Method: A cross-sectional study was carried out to assess the correlation between the quality scorings of 100 orthognathic websites produced from a Google search, when the websites were examined using these three tools. The rankings of the 100 websites produced with each tool were also compared with quality scores from a newly developed (AM) checklist which had been specifically developed for the assessment of orthognathic context. The AM checklist was used as a standard to assess if orthognathic websites contained all of the information perceived by clinicians as necessary for their patients. Results: DISCERN was the only tool to identify correctly the highest quality orthognathic websites. A strong correlation was found between DISCERN and the AM checklist (r = 0.816 p < 0.01) but no other correlations were found. The AM checklist and LIDA both had good inter- and intra-examiner reliability. However, the reliability of the HWAT 3.0 and DISCERN tools was moderate. The AM checklist and DISCERN indicated that UK websites were of significantly better quality than US websites. No significant differences were found between the quality of websites according to the Google ranking and suffix. Blogs had the highest overall scores and were comparable to websites of hospitals and professional organisations. Conclusions: Generic health website quality assessment tools require further development to increase their reliability and ability to identify high quality websites. UK orthognathic websites can be used as a marker of high quality compared with US websites but the Google ranking and suffix are poor quality markers. Blogs should be investigated further as a possible useful resource of information for orthognathic patients.

The strategy of Government to improve translational clinical research in England is being driven through a policy framework that aligns investment to the requirement for collaborative NHS Trust-University arrangements. This has resulted in the creation of new partnerships that in theory should better facilitate the effective delivery of translational clinical research. The study presents new knowledge into how these macro level policy interventions are being translated at the meso (organisational) and micro (individual) levels, utilising Huxham and Vangen's theory of collaborative advantage as the lens through which to view the perspectives of clinical academics from two case study NHS-University partnerships. A comprehensive analysis of the policy environment from the launch of 'Improving National Health: Improving National Wealth' in 2003 through to 2015, provides an insight to Government's ambition to increase the volume and quality of translational clinical research. The study contrasts this ambition with data gathered from qualitative, semi-structured interviews of senior clinical academics working in two case study NHS-University partnerships. A detailed analysis of how policy levers are being translated in the two case study settings is provided, revealing data that has a wider application to other similar partnerships in the Health and University sectors. The study also presents data which demonstrate that whilst funding for translational clinical research has increased at a national level, the majority of this is focussed upon partnerships operating mainly in London and the Southeast. The study's two case study partnerships have been purposively selected to sit outside of these areas, such that the national policy decisions could be tested in regions that historically receive less funding for translational clinical research. This was aligned to the central hypothesis that that the national policy developments will not be sufficient to increase the volumes and quality of translational clinical research across England. The data analysis revealed that both of the NHS-University partnerships displayed individualistic attributes that are not necessarily in-step with, or conducive to, the new national policy environment. These included a lack of clarity with respect to joint performance measures, made more challenging by virtue of the different cultures and priorities that exist within the NHS and University sectors, and a lack of joint leadership to provide the necessary impetus and vision with regards to a strategy for translational clinical research. At an individual level, these pressures were translating into a frustration around the high volume of Government initiatives to which clinical academics are expected to contribute, with the suggestion that a move towards devolved regional approaches would allow partnerships a degree of necessary flexibility. The research also found that the national shortage of clinical academics is a particular issue for NHS-University partnerships based outside of London and the Southeast. Without the necessary numbers of clinical academic staff, the objectives of the new national policy environment for translational clinical research will not be realised, and this is therefore an important finding. The study brings new knowledge and perspectives to an area which has been under researched within the literature, by focussing on two non-accredited NHS-University partnerships, operating outside of London and the SouthEast that have been formed in response to the national policy environment. Its conclusions and recommendations therefore provide a useful insight into how this macro level framework is translated at a local level. As a piece of practitioner research, the study utilises the data analysis to support a series of recommendations that could be applied within the two case study environments or within similar NHS-University settings. It also presents a proposed suite of joint performance measures, suggesting that these might be a useful stimulus at the early stage of NHS-University partnership formation.

The purpose of this thesis is to evaluate unfair inequality in healthcare use in Brazil, between 1998 and 2013, allowing for multiple social dimensions of inequality. The thesis innovates methodologically by proposing the Health Care Advantage (HCA) approach, which takes into consideration multiple social dimensions of inequality using a metric that is directly comparable to traditional bivariate measures that focus on a single dimension of inequality such as income. The thesis also has three other contributions. Firstly, it provides new empirical evidence about unfair inequality in health care in a developing country, where inequalities are particularly large and important. Secondly, it provides up-to-date national evidence about equity in the use of health care by analyzing a new wave of survey data in Brazil not previously analyzed. Thirdly, it provides the first national evidence about health care equity trends in mammography and cervical screening in Brazil, during a period of substantial health care reform. The data for the analysis comes from four large, repeated cross section sample surveys, the Health Supplement of the Brazilian National Household Sample Survey for the year 1998, 2003, 2008 and the first National Health Survey, conducted in 2013, with an average sample size of 371,000 over the four waves. After controlling for age, sex and self-assessed health, unfair inequality – or “inequity” – is observed in three different forms of care: physician visits, mammography screening and cervical screening. Overall inequity is substantially larger than income-related inequity. Over time, inequity has decreased for physician visits and cervical screening in Brazil, although for mammography there is no clear trend. Decomposition analysis shows that the main component of unfair inequality in all cases is health insurance, and its relevance increased between 1998 and 2013. For mammography and cervical screening, though not for physician visits, other key components of inequality ( > 5% contribution) were region, urban status, education and income. Having children in the household was an important component of inequality in 1998, but this reduced substantially over time, as did the contribution of living in rural areas. The contribution of income to overall inequity decreased during the study period for physician visits and mammography screening, yet for cervical screening it doubled between 2003 and 2013. The methods developed in this thesis can yield useful new insights into unfair inequality in health care, and may help shift research attention away from income-related inequities that are not always the largest or most important inequities from a policy perspective.

BACKGROUND: In the context of the progressive movement towards patientcentred care, patient-specific decision support is an important focus of interest. Many diagnostic and treatment patient decision aids (PDAs) are now available to help patients make informed choice decisions. An increasing number of these are software-based, with some available online. Multi-Criteria Decision Analysis (MCDA) is a potentially useful technique on which to base a software-assisted PDA, especially when the decision is complex - as is the case in choosing the best treatment for non-small cell lung cancer – but it has so far been relatively little exploited in this area. The use of any from a number of existing MCDA-based software applications in the development and delivery of a MCDA-based interactive PDA can be an effective way of achieving “best-practice” or normative standards of decision making, such as 1) a well-constructed set of decision criteria or 2) logically consistent patient preferences. However, it also involves the use of resources such as the time and cognitive effort involved in decision-making. The comparative evaluation of alternative MCDA-based software applications in developing and delivering a PDA therefore involves trade-offs between decision effectiveness and decision resource criteria moving from the normative to the prescriptive. MCDA is an ideal tool for this meta-evaluation task as well as for the adoption decision itself. AIM: To analyse, as proof of concept, the use of MCDA for the development, implementation and evaluation of interactive PDAs in routine clinical practice. OBJECTIVES: 1. To assess the use with clinicians in the Spanish NHS of two alternative MCDA software applications which implement dissimilar MCDA techniques in the development of a PDA in routine clinical practice; 2. To assess the use with clinicians in the Spanish NHS of the same two alternative MCDA software applications in the implementation of a PDA in an environment replicating actual clinical consultations; 3. To build a meta-multi-criteria decision model based on the Decision Resources Decision Effectiveness Analysis (DRDEA) framework and assess the use of this model by clinicians in the Spanish NHS to make the choice between the two MCDA applications as the basis for a PDA. METHODS: 1) Two dissimilar MCDA software applications served as a basis for the development of a lung cancer clinical management PDA in close collaboration with two different groups of three clinicians from two different Spanish NHS hospitals (H1 and H2): 1) Expert Choice, which implements the Analytic Hierarchy Process (AHP) MCDA approach; 2) Annalisa in Elicia (ALEL), which implements the Simple Attribute Weighting (SAW) MCDA approach. The process of codevelopment of the PDA in hospitals H1 and H2 was documented; 2) Expert Choice was used to implement (i.e. deliver) the lung cancer clinical management PDA in three hypothetical consultations in hospital H1. In each consultation, one of the three clinicians involved in the development of the tool, with support by this researcher, guided a proxy patient (a non-clinical member of hospital staff) through the PDA. The same process was repeated with the MCDA software ALEL in hospital H2. The process of delivery of the PDA in hospitals H1 and H2 was documented; 3) This researcher built a meta-multi-criteria decision model based on the DRDEA framework to help clinicians choose between different MCDA software applications as the basis of a PDA. The MCDA approach used for this meta-model was Multi- Attribute Value Theory (MAVT). The model was implemented, using the software HiView 3, with three clinicians from hospital H3 for the choice between Expert Choice and ALEL as the basis of a lung cancer clinical management PDA. RESULTS: The thesis makes a three-fold contribution to research in patient-centred decision support. First, it presents two new MCDA software-based approaches to clinical decision support, based on joint work with clinicians in the Spanish NHS, for developing an interactive PDA for the clinical management of non-small cell lung cancer. Second, it describes the use of these decision support tools in the delivery of 5 an interactive PDA for the clinical management of non-small cell lung cancer in a hospital environment via simulated consultations between actual clinicians, with support from this researcher, and proxy lung cancer patients. Third, it presents and applies a new MCDA-based methodology for evaluating the use of alternative MCDA software applications in the development and delivery of interactive PDAs.

In recent years, private foundations have gained considerable relevance in global health due to their increasing presence in both financing and policy-making. Despite this, the question of how these actors make decisions on their funding priorities is under researched. The aim of this study is to understand and assess the relative importance of different factors in foundations’ decision-making. This question is important not only for actors in the global health arena, but for foundations that are under increasing pressure to be legitimate, effective and accountable players. This is a qualitative research study on the decision-making of foundations investing in global health. It applies a multiple case study methodology in the study of three foundations: the Bill & Melinda Gates Foundation, the Rockefeller Foundation and the Wellcome Trust. In-depth interviews with forty-six informants represented the main method for data collection. A qualitative thematic content analysis has been applied to both documentary sources and interviewees’ accounts. A strategic management approach has been used to de-construct the decision-making process into strategic planning and grant-making. As a first area of inquiry, this study sought to understand how foundations’ origins, governance structure and funding ethos are relevant in influencing their decision-making behavior. Second, this study sought to assess the relative importance of different factors (e.g., private partnerships or foundations’ networks) in influencing foundations’ decisions. Findings suggest influence is an overt objective of foundations' strategies. Leaders and networks are extremely important in both strategic planning and grant-making. By discussing findings through the perspective of major strategic management schools of thought, the study provides an in-depth understanding of foundations’ strategic planning and grant-making processes and recommendations to increase accountability, legitimacy and effectiveness. The analysis also introduces a re-conceptualization of foundations’ decision-making, and offers implications on the role of philanthropy in global health.

Every day around the globe, patients are harmed within healthcare organisations. Attempts to improve the quality and safety of healthcare traditionally focus on past errors and harm, yet there is little evidence of widespread improvement. In contrast, the positive deviance approach seeks to identify and learn from those who demonstrate exceptional performance despite facing the same constraints as others. Bradley et al. (2009) have proposed a four stage process to apply positive deviance within healthcare organisations: 1) positive deviants are identified using routinely collected data; 2) hypotheses are generated about how they succeed; 3) these are tested within representative samples; and 4)the successful strategies are disseminated. Despite this, limited guidance exists to support applications. This thesis sought to test a robust and pragmatic method for applying the positive deviance approach within multidisciplinary healthcare teams. Study 1 systematically reviewed the methods used to apply positive deviance within healthcare. Previous applications identified positively deviant organisations or individuals and focused on narrow outcomes or processes of care. Applications lacked quality and used extensive resources. Study 2 analysed NHS Safety Thermometer data to identify five positively deviant and five matched comparison elderly medical wards. In the main, staff and patient perceptions of safety on these wards supported their identification. During study 3, multidisciplinary staff focus groups were conducted to explore how these wards delivered exceptionally safe care. In total, 14 behaviours and cultures were hypothesised to facilitate positive deviance at ward level. Study 4 assessed the feasibility of applying positive deviance within a general practice setting. Findings highlighted challenges of selecting data to identify positive deviants, recruiting general practices to participate, and generating hypotheses about success strategies that were unique to positive deviants yet common among them. In combination, these studies generated guidance to support rigorous applications of the positive deviance approach within healthcare organisations. The evidence suggested that, in the future, it may be possible to improve the quality and safety of care by focusing on those that demonstrate exceptional rather than poor outcomes of care.

General medical wards deliver the majority of inpatient care. Despite technological and therapeutic advances, these wards expose 10% of patients to preventable adverse events, and disproportionately contribute to preventable hospital deaths. Improving ward team performance is often proposed as a mechanism to improve patient outcomes. The overarching goal of this thesis is to identify effective strategies to improve interdisciplinary team care on the medical ward. Chapter 1 introduces key concepts in healthcare quality, and specific issues in the delivery and measurement of interdisciplinary ward care. The existing literature for ward improvement strategies is then described. A narrative review identifies common targets for ward interventions [chapter 2], and a systematic review evaluates interdisciplinary team care interventions, finding little evidence of significant impact on objective patient outcomes [chapter 3]. The development and evaluation of prospective clinical team surveillance (PCTS) is then reported. PCTS is a novel interdisciplinary team care intervention, engaging staff to identify barriers to care delivery, with facilitation and feedback. A programme theory and mixed methods evaluation are presented, using a stepped wedge, cluster controlled trial [chapter 4]. Mixed-effects models show a significant reduction in excess length of stay with high fidelity PCTS [chapter 5]. Surveys, focus groups and auto-ethnography identify PCTS' mechanisms of action, and its impact on incident reporting, safety and teamwork climates [chapter 6]. Implementation outcomes, facilitators and barriers are described in chapter 7. Other perspectives on improvement are also explored. A model of organisational alignment is developed [chapter 8], and an interview study with patients and carers elicits their priorities [chapter 9]. Finally, chapter 10 summarises the findings, highlighting opportunities to develop medical ward outcome sets and construct a model of interdisciplinary team effectiveness. These can be used to support improvements in interdisciplinary care, through changes in policy and practice.

Whilst there is growing awareness of the case for children and young people’s participation across the public sector, there is limited evidence on how this apparent commitment to participation and children’s rights translates into professional practice and young people’s experience of participation in health services and research. Participation in health tends to be driven by a public involvement and engagement agenda rather than discourses of participatory practice. Young people’s views are still not consistently sought or acknowledged within healthcare settings; they are rarely involved in decision-making processes and often occupy a marginalized position in healthcare encounters. In addition to the piecemeal approach to participation in health services there have also been disparities in the characteristics of young people likely to participate, the types of decisions they are involved in making, and the extent to which this participation is meaningful and effective. This study drew on theories of participation and childhood, and considered how these were informed by debates around children’s rights, citizenship and agency in relation to young people’s participation in health services and research. Using a participative research approach informed by an action research methodology, the study sought to explore how participation was understood and operationalised in two case studies: a community children’s health partnership and a randomised controlled feasibility trial. Through working collaboratively with adults and young people in these case studies, and informed by a wider process of collaborative inquiry, the study sought to build capacity through learning to inform the embedding of participation. This study found that participation in health services and research was still conceptualised primarily as adult-initiated, context-specific collective participation in formal settings which potentially excludes some of the young people most likely to use health services and limits the potential for fundamental change. The learning from the study identified the potential for new approaches which would do more to transfer power to young people, and informed a rights-based framework for embedding participation in practice.

Remote monitoring is an essential part of future mHealth systems for the delivery of personal and pervasive healthcare, especially to allow the collection of personal bio-data outside clinical environments. mHealth involves the use of mobile technologies including sensors and smart phones with Internet connectivity to collect personal bio-data. Yet, by its very nature, it presents considerable challenges: (1) it will be a highly distributed task, (2) requiring collection of bio-data from a myriad of sources, (3) to be gathered at the clinical site, (4) and via secure communication channels. To address these challenges, we propose the use of an online social network (OSN) based on the quantified-self, i.e. the use of wearable sensors to monitor, collect and distribute personal bio-data, as a key component of a near-future remote health monitoring system. Additionally, the use of a social media context allows existing social interactions within the healthcare regime to be modeled within a carer network, working in harmony with, and providing support for, existing relationships and interactions between patients and healthcare professionals. We focus on the use of an online social media platform (OSMP) to enable two primitive functions of quantified-self which we consider essential for mHealth, and on which larger personal healthcare services could be built: remote health monitoring of personal bio-data, and an alert system for asynchronous notifications. We analyse the general requirements in a carer network for these two primitive functions, in terms of four different viewpoints within the carer network: the patient, the doctor in charge, a professional carer, and a family member (or friend) of the patient. We propose that a wellbeing remote monitoring scenario can act as a suitable proxy for mHealth monitoring by the use of an OSN. To allow rapid design, experimentation and evaluation of mHealth systems, we describe our experience of creating an mHealth system based on a wellbeing scenario, exploiting the quantified-self approach of measurement and monitoring. The use of wellbeing data in this manner is particularly valuable to researchers and systems developers, as key development work can be completed within a realistic scenario, but without risk to sensitive patient medical data. We discuss the suitability of using wellbeing monitoring as a proxy for mHealth monitoring with OSMPs in terms of functionality, performance and the key challenge in ensuring appropriate levels of security and privacy. We find that OSMPs based on quantified-self offer great potential for enabling personal and pervasive healthcare in an mHealth scenario.

It is argued that the consultation is central to general practice and that the patient's agenda is of prime importance within it. A written list of patient's concerns is proposed as an aid to communication. However, some doctors have prejudices about patients and their lists.;Pilot work:.;1. This involved the development of a form to be completed by patients prior to consultations (the 'list form').;2. A new form (the PtAF) was designed in order to help patients to express more of their ideas.;3. An educational workshop, using a simulated patient, was designed. The aim was to increase the doctor's efficiency in using the PtAF.;RESULTS: After the workshop there was an increase in one item of the doctor's satisfaction scale - perceived understanding (100% of 89.2%; P = 0.034). There were strong trends towards reduced time per problem, more problems identified and less time perceived by patients, but no other significant differences.;Subsequently, the workshop was amplified from two to six hours and GPs recruited from practices in Nottinghamshire and Leicestershire for a larger study, the power calculation having been based on the reduction in time per problem.;There appears to be little basis for the prejudices which some doctors have about patients and written lists. Use of the PtAF and attendance at an educational workshop are each associated with the identification of more problems and a tendency for longer consultations. The reasons for the lack of change in patient's and doctor's satisfaction, and BTWS are not clear. The patient's problems may be associated with complex agendas which include ideas and reasoning. It is suggested that medical education should focus on the patient's agenda and that consultation time should be sufficient to address this agenda.