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Evidence exists that the NHS has had, over many years, persistent problems of negative and intimidating behaviour towards staff from other employees in the NHS. The evidence also suggests the responses to this behaviour can be inadequate. Pope and Burnes (2013) model of organisational dysfunction is used to investigate and explain these findings. A qualitative approach was taken to research the organisational responses to negative behaviour, and the reasons and motivations for those responses. Forty three interviews and six focus groups were conducted. The Framework Method of thematic analysis was chosen for the main analysis and fourteen Framework Themes were identified. ‘3 word summaries’ of the culture were analysed. Further analysis was undertaken of words relating to fear, rationalisations/justifications, what people don’t want to do, the culture, and assumptions/beliefs. The model of organisational dysfunction has been extended. The findings show that participants consider the NHS to be a politically driven, “top down”, “command and control”, hierarchical organisation; a vast, enclosed, bureaucratic machine/system under great pressure. They believe there is a culture of elitism, fear, blame, bullying and a lack of accountability; a culture where power, self-interest and status matters. There is constant change. Saving money and achieving targets are seen to be the priority. A lack of care and humanity is described and negative behaviour seems to have become tolerated and normalised. Bullying is mentioned many times, and viewed as “rife” and “endemic”. Good practice/behaviour can be punished, and bad rewarded, as can failure. Corrupt and unethical behaviour is identified as are totalitarian and Kafkaesque characteristics. Participants describe resistance to voicing concerns and any information which puts individuals or organisations into a ‘negative light’. Employees who raise concerns can be victimised. The “top-down bullying culture ... suppresses constructive dissent”. There can be rhetoric, “empty words” and “spin”, rather than reality. A desire for “good news” and the rejection and hiding of “bad news” is described. There seem to be “islands” and “pockets” with a positive culture, however, the generalised evidence suggests the NHS is systemically and institutionally deaf, bullying, defensive and dishonest, exhibiting a resistance to ‘knowing’, denial and “wilful blindness”; a dysfunctional, perverse and troubled organisation. The NHS could also be described as a coercive bureaucracy and under certain definitions, a corrupt entity. The NHS appears to be an organisation with a heart of darkness; a “self perpetuating dysfunctional system”. There may be widespread “learned helplessness”. Overall, the needs of the NHS and the protection of image appear more important than the welfare of staff or patients. It does seem to be a “good news factory”. The NHS appears to have “lost its way” and its focus/purpose as an institution. The dysfunctional organisational behaviours manifest in the NHS need to be addressed urgently as there is a detrimental, sometimes devastating, impact on the wellbeing of both staff and patients. The NHS needs to embrace an identity of being a listening, learning and honest organisation, with a culture of respect.

Introduction: The aim was: “To document the process of policy development to prevent interpersonal violence in England, and explore the implications and potential role of public health”. Research gaps addressed include: an insider perspective of the policy process in general, and on the formulation process in particular. Violence and abuse are complex and challenging public health issues and wider lessons were drawn for public health. Methods: Qualitative research methods of documentary review, mapping and observation were used in the context of a case study of development of policy for violence prevention at regional and national levels in England from 2005- 2010. The research was based upon participatory observation methods as a public health advisor contributing to the policy process. In total 44 documents were reviewed and 157 meetings attended. Content and thematic analysis was conducted with violence, public health and policy frameworks followed by triangulation. Results: From initiation to publication, the policy process took ten years to complete (2003- 2012). Regional policy implementation contributed partially to national policy development. Networks and embedding within wider policy maintained the agenda. Evidence-based public health contributed to the policy, whilst, collaborative working, persistence and communication skills influenced uptake. Internal actors had the most power, especially the Prime-Ministers Office and the Home Office, whilst the Department of Health ensured development of the final policy. Senior leadership and champions drove the policy process and media reporting created windows of opportunity. Policy formulation revealed the importance of consensus and cyclical decision-making. Conclusions: Lessons include strengthening the art of public health: with clear leadership, communications and collaborative relationships, contributing to the uptake of evidence. Taking advantage of windows of opportunity and creating consensus is important for external actors. An integrated model of policy and the formulation process are presented to enhance understanding between policy and public health.

In industrialised societies Black and Minority Ethnic (BME) populations continue to battle against a rising tide of health inequalities that disproportionally affect their communities. To succeed, academics, policy-makers and public health providers need to fully understand the deep-seeded roots of health inequalities; to put into context the barriers facing people with varying heritage and cultural backgrounds. This research recognises information is a privileged commodity and a vital part in the fight to overcome health inequalities. Essentially this PhD presents a unique window into the health information activities of African and Chinese populations by exploring the varying routes through which ethnic identity continually shapes health information seeking and sharing. To achieve this, a pragmatic mixed methods approach was employed. Data was collected from 117 self-completion questionnaires, while ethnographic material was gathered from 36 semi-structured interviews and participant observation exercises spread over 7 months. The works of Sociologist Goffman (1959; 1963) and Information Scientist Chatman (1996) provide theoretical frameworks for data analysis and comparison in this research. Key findings recognise that for both BME communities health information seeking and sharing activities occur within cultural systems and social networks. Participants' perceptions of health ownership, stigma, privacy, and trust reinforce constraints around health information disclosure as well as seeking and sharing activities. Yet, findings also suggest that certain obstacles could be overcome with the assistance of information technology. eHealth (electronic healthcare delivery) offers settings whereby users could temporarily lift themselves out of information poverty and attain culturally sensitive health information. However, in order to achieve greater eHealth uptake developers need to work in conjunction with BME community organisations to raise awareness, build trust and relevance whilst encouraging the development of eHealth literacy skills.

Sustainable development (SDEV) aspects are increasingly becoming an integral part of managerial discourse in different industries. Stakeholders realise that long-term success is profoundly dependent on a balanced treatment of the Economic, Social and Environmental responsibilities through the lenses of the “Triple Bottom Line” (TBL) framework. As SDEV is becoming more vital for organisations, dealing with its challenges is also becoming more complex and costly. Modelling and Simulation (M&S) techniques could be valuable in providing understanding and insight for coping with systems that have high levels of complexity and uncertainty; However, findings of this research show that the empirical research in this area is still in its infancy; particularly, within the context of healthcare sector. The majority of existing studies are predominately focused on the productivity factors, while social and environmental elements are ignored in system modelling. Systems with SDEV characteristics (defined in this thesis as TBL-based systems) can be very complex and uncertain, particularly in healthcare, as they combine various subsystems comprising numerous elements and stakeholders with diverse interests. Thus, this research shows that developing models to respond to these complexities requires insight into the characteristics of SDEV and sustainable systems, alongside a major rethink of studying sustainability beyond existing modelling disciplines. To address these issues, this research has developed a comprehensive M&S framework for TBL modelling, to guide modellers in developing models for SDEV analysis of healthcare systems. It is argued that this framework could cater for all requirements and characteristics of TBL-based systems, thereby attempting to reduce the gap between TBL-based systems and the current capabilities of M&S methods. The framework is evaluated through existing case studies in a healthcare context, which are then extended to incorporate SDEV characteristics using the TBL framework. The lessons learned from the evaluations were used to make further amendments and revisions, leading to the final framework.

The thesis presents a participatory action research (PAR) study focusing on improving physical health assessment at a Crisis Resolution Home Treatment (CRHT) service. The aim of the study was to develop a robust and consistent approach in addressing an issue that had not previously been researched. It had been reported via clinical audit that physical health interventions were being missed and by means of an action research group (ARG) an inter-professional approach was used through which co-researchers were facilitated to discuss and explore the issue. The origins and key elements of PAR are illuminated and justification is given for its choice to answer the research questions by means of a problem-focused and context-specific approach within an emergent design. Five action research cycles included exploring the perspectives of professionals', service user experiences and a regional survey to capture current practice. Among a number of findings serviceusers described their physical well-being as extremely important and appreciated having this aspect of care assessed. Professionals viewed physical and mental health as inextricable and the regional survey revealed variable practice across the Northwest of England CRHT services. The study findings were used to generate actionable knowledge to improve clinical practice in physical health care which ultimately led to the embedding of physical health interventions within care pathways and the development of a service-user physical health questionnaire entitled Brief Overview of Physical health (BOP). Physical health strategies were absent in CRHT services within the region, and although physical assessment was taking place in many services, practice was inconsistent. This research developed an evidence based best practice framework that has wider national applicability and potentially offers clarity for existing vague Department of Health guidance. The challenges of utilising a PAR approach are examined including obtaining NHS ethical approval, staff turnaround and length of time to complete the project. The findings were augmented by substantive critical reflections focusing on salient aspects of the research process. Finally, the strength of the research is the sustained change to clinical practice within the CRHT service commensurate with the cultural and behavioural changes that colleagues made in the process of developing practice. It is argued that the research empowered colleagues with critical and research awareness, to continue in the process of transforming care.

This thesis follows a variety of practices in the field of social and health protection in Bijeljina, a border town in Bosnia and Herzegovina, where I completed a year of fieldwork during 2009 and 2010. I explored how people gained access to public services and provisions, and also considered how they pursued social and healthcare protection beyond state-funded institutions. Throughout the thesis, I treat these practices as a form of navigation through what I refer to as social and political space. I argue that navigating one‘s way through the fields of social and health protection in Bijeljina encompassed the pursuit of personalised relations as well as attempts to fit into institutionalised rules and categories. Instead of assuming what the proper 'state‘ roles were, and consequently approaching the ethnographic material in terms of how well it fits in to a certain model, I explore in what way the boundary between the 'state‘ and 'that which is not the state‘ was constituted through these practices of navigation. In several examples I demonstrate that the boundary between domains was movable and not very neat. These examples include an analysis of an organisation which was sometimes more like an NGO and sometimes more like a state-run centre for children with developmental needs; the way in which the state border was sometimes irrelevant, and at other times very important; the way in which the pursuit of various kinds of personalised relations was hard to separate from the pursuit of institutionalised ones; a charity practice (humanitarne akcije) which consisted of raising money for a single person‘s health protection from numerous charitable donors – municipalities, high school pupils, neighbours, and pop singers being counted among them. I also argue that this mode of navigating one‘s way through social and health protection, or this way of reconstituting the boundary between the 'state‘ and 'that which is not the state‘, enabled certain people to build up a very personalised mode of power which also worked through various institutions. Ethnographically situating this argument in the discussion of the social position and the life of one woman politician in Bijeljina, I suggest that a combination of the concepts of biopolitics and the Melanesian concept of 'Big Man‘ is useful for thinking about this personalised modality of power which works through institutions.

Quantifying uncertainty in environmental health impact assessment models is important, particularly if the models are to be used for decision support. This thesis develops a new non-probabilistic framework to quantify uncertainty in environmental health impact assessment models. The framework takes into account two different perspectives of uncertainty: conceptual and analytical in terms of where uncertainty occurs in the model. The first perspective is concerned with uncertainty in the framing assumptions of health impact assessment, whereas the second perspective is concerned with uncertainty in the parameters of a model. The construction of the framework was achieved by focusing on five specific objectives: (i) to describe the complexity of how uncertainty arises in environmental health impact assessment and classify the uncertainty to be amenable for quantitative modelling;(ii) to critically appraise the strengths and limitations of current methods used to handle the uncertainty in environmental health impact assessment; (iii) to develop a novel quantitative framework for quantifying uncertainty from the conceptual and analytical perspectives; (iv) to formulate two detailed case-study examples on health impact assessment of indoor housing interventions; (v) to apply the framework to the two case-studies. After critiquing the uncertainty quantification methods that are currently applied in environmental health impact assessment, the thesis develops the framework for quantifying uncertainty, starting with the conceptual uncertainty (uncertainty associated with the framing assumptions or formulation of the model), then quantifying the analytical uncertainty (uncertainty associated with the input parameters and outputs of the model). The first case-study was concerned with the health impact assessment of improving housing insulation. Using fuzzy cognitive maps, the thesis identifies key indoor factors and their pathways highly sensitive to the framing assumptions of the health impact assessment. The second case-study was concerned with estimating the uncertainty in the health burdens in England, associated with three ventilation exposure scenarios using fuzzy sets and interval analysis. The thesis presents a wider uncertainty framework as a first step forward in quantifying conceptual and analytical uncertainty in environmental health impact assessment when dealing with limited information.

Previous studies in the UK have established that minority ethnic groups as a whole experience more ill-health and onset of morbidity at younger ages or at lower levels of risk than the ‘White British’ population. Since the Race Relations Act of 1968, the official collection of ethnic group statistics by all government bodies has been mandated as a pre-requisite for identifying and tackling ethnic inequalities. The capture of ethnicity data in routine health records across the UK National Health Service forms part of this initiative. Although the facility to record ethnicity has been available in primary care since 1991 and in secondary care since 1995, until recently, unsystematic recording resulted in poor quality of the initial data, limiting the usefulness of these data for clinical care, commissioning and research. The incentivisation of ethnicity recording in 2006 as part of the Quality and Outcomes Framework has resulted in an improvement of the quality of these data, though their suitability for use in UK-wide population-based research, at the commencement of this PhD, had not yet been explored. The studies reported in this thesis investigated the utility of electronic health records for research into ethnic differences in health and comprised three sub-studies. Firstly, the completeness, usability and generalisability of ethnicity data captured in primary and secondary care databases were assessed. Results showed that in 2012, valid ethnicity was recorded for 78.3% of patients in the Clinical Practice Research Datalink (CPRD), 79.4% of inpatients, and 50% of A&E patients and outpatients in the Hospital Episode Statistics for England (HES). Over 80% of patients with multiple ethnicities recorded had codes which either were identical or fell into the same five high-level ethnic group categorisation. The ethnic breakdown of the CPRD was found to be comparable to that of the combined censuses for England, Wales, Scotland and Northern Ireland, suggesting that studies of ethnic populations within the CPRD can be generalised to the UK population, particularly when using data from 2006 onwards, where completeness and consistency are highest. Secondly, in collaboration with the UK Biobank study, a pragmatic and comprehensive definition of diabetes mellitus for use in electronic health databases was developed. Once applied to the CPRD, the algorithms identified 34,530 individuals with type 1 diabetes and 355,717 individuals with type 2 diabetes. The incidence of type 2 diabetes was almost doubled in South Asian compared with White groups (70.7 vs 42.0 events per 10,000 person years). After adjustment for gender and age group, the risk of type 2 diabetes was over three times higher in the South Asian group compared with White the group (Hazard Ratio 3.27 95%CI 3.19, 3.35). Finally, a prospective cohort study of 860,000 patients registered with the CPRD was undertaken to quantify ethnic differences in the risk of incident coronary heart disease (CHD) and the extent to which this relationship is modified by the presence of type 2 diabetes. The presence of diabetes increased the risk of CHD by 40%, although this reduced to 22% after accounting for age, gender and deprivation (Hazard Ratio 1.22 CI95 1.20, 1.25). The excess risk associated with diabetes was markedly higher for ethnic minority groups, with an adjusted increase of 60% and 75% in South Asian and Black African/Caribbean groups respectively, compared with 28% in the White groups. Adjusted rates of CHD were consistently higher in South Asian groups and lower in Black African/Caribbean groups, with differences more pronounced amongst men than women. Ethnic differences in CHD risk were consistently more pronounced amongst patients without type 2 diabetes than in those with type 2 diabetes. The studies have generated novel results which provide valuable information about the usability and generalisability of ethnicity data available in UK electronic health records. They have replicated findings from non-database studies of the prevalence and incidence of diabetes and extended our knowledge of the patterning of ethnic differences in heart disease outcomes. They represent the first ever use of UK routine electronic health records to answer these questions in relation to ethnicity. Together, the findings reported in this thesis provide a unique insight into the ways in which routinely recorded ethnicity data can be maximised for the purposes of epidemiological research into health inequalities across the UK.

In the UK since the early 1990s there has been a growing trend for certain hospital initiated specialist drugs to be prescribed by GPs within primary care. GPs have been encouraged to undertake this activity supported by the use of so-called “shared care protocols.” Despite these arrangements this has proven difficult with concerns over the quality and availability of shared care protocols and reported safety related incidents including fatalities linked to the use of certain specialist drugs. GPs have benefited from the complete computerisation of general practice unlike their hospital based colleagues who on the whole continue to work and prescribe within paper-based systems. These benefits have included the use of electronic prescribing and the introduction of computerised decision support systems (CDSS) in the form of reminders and drug related warnings and alerts. Scoping reviews are an established way of assessing the evidence base of a subject area which can then be summarised to reflect the broad nature of the field. For this thesis a scoping review of CDSS was used to evaluate how this intervention has been used within primary care and to identify areas where it can be further developed. Although the use of information technology has been suggested as a possible solution to some of the problems at the primary and secondary care interface, no published studies have evaluated the potential for a CDSS to support the prescribing of specialist drugs by GPs. In order to explore this concept further and gain additional knowledge of current CDSS usage, key informants were identified and interviewed. The key informants described the current availability and characteristics of CDSS within UK general practice. The concept of developing a CDSS to support GPs in the use of specialist drugs to include prescribing was acknowledged as beneficial and was widely supported. Enablers and barriers to development and implementation were identified including a number of potential operating models. Key enablers included data quality and functionality features, joint development and implementation and to make use of existing systems and frameworks. Key barriers included addressing the needs of end users, security, regulation and funding. Human ergonomics was used to further investigate GPs and the actual level and use of computers and software programs including CDSS at the point of prescribing both during and outside of patient consultations. The application of an analytical approach to these processes through a task analysis framework identified failings in existing arrangements for GPs to safely prescribe specialist drugs.