In the UK the National Health Service (NHS) faces the challenge of securing £20 billion in savings by 2014. Improving healthcare productivity is identified by the state as essential to this endeavour, and critical to the long-term future of the NHS. However, healthcare productivity remains a contentious issue, with some criticizing the level of professional engagement. This thesis explores how contemporary UK policy discourse constructs rights and responsibilities of healthcare professionals (HCPs) in terms of productive healthcare, how this is made manifest in practice, and the implications for professional autonomy/identity. Using analytical lenses from the sociology of professions, identity formation and the Foucauldian concept of governmentality, it is proposed that policy discourse calls for a new flavour of professionalism, one that recognises improving healthcare productivity as an individualised professional duty, not just for an elite cadre but for all healthcare professionals. Adopting an ethnographic approach (participant observation, semi-structured interviews, focus group and document analysis), data is presented from a large UK Emergency Department (ED), exploring the extent to which this notion of self-governance is evident. The study elucidates the ways in which: professional notions of productivity are constructed; productive work is enacted within the confines of the organisational setting; and tensions between modes of governance are negotiated. The findings of this study suggest that HCPs perform identity work via their construction of a multidimensional notion of healthcare productivity that incorporates both occupational and organisational values. Whilst responsibility for productivity is accepted as a ‘new’ professional duty, certain ethical tensions are seen to arise once the lived reality of ‘productive’ work is explored within the organisational field. The complex interplay of identity work and identity regulation, influenced by the co-existence of two differing modes of governance, results in a professional identity which cannot be represented by a static occupational/organisational hybrid, but rather one that is characterised by continual change and reconstitution. Understanding healthcare productivity from this perspective has implications for professional education, patient care, service improvement design and the academic field of the sociology of professions.

This study addresses creativity and innovation literatures and explores the necessity for creativity in the implementation of service innovations in the English National Health Service. In doing so, it examines whether the standard definition of creativity (Stein 1953; Runco and Jaeger, 2012) is sufficient to explain the workplace creative practices associated with the implementation of a service innovation through the replication of best practice. Based on a qualitative research design, and using a critical realist approach (Bhaskar, 1975/2008, 1998), this research unearths a rich seam of empirical data through observations and semi-structured interviews in an English National Health Service primary care organisation, known as a NHS Clinical Commissioning Group (NHS CCG). Although human creativity is an essential ingredient of any successful innovation, characterised by individuals and teams having ‘good ideas’ (Amabile et al, 1996), creativity has a crucial role in the development of new services (Zeng, Proctor and Salvendy, 2009). However, it is noted that there have been relatively few recent empirical studies of creativity in service innovation (Giannopoulou, Gryszkiewicz and Barlatier, 2014), and in particular in the public sector. Thus models of organisational innovation remain virtually unchanged over the last three decades (Anderson, Potočnik and Zhou, 2014), and have not attempted to account for creativity and service innovation in the English NHS. The thesis makes a number of contributions to creativity and innovation literatures. It also provides some understanding of creativity and service innovation in a public sector health service context. First, the study provides empirical evidence for human creativity when new services are introduced through the replication of workplace practice from another geographical location or organisation. This means that the current understandings of creativity, which are focused on creativity as a teleological outcome, driving the production of novelty, for example a creative product, need to be modified to account for novelty in a new context. Accordingly, a definition of creativity which accounts for contextual novelty is presented. Second, the research study also contributes to existing knowledge by illuminating the creative practices of workers tasked with implementing service innovations. Hitherto, creativity research has focused attention on the importance of creativity in the earlier ideation stage of the innovation process (for example, West, 2002a). The empirical evidence presented in this thesis demonstrates that creative practices are also necessary at the back end of the service innovation process, and may be driven by human reflexivity, rather than more formal organisational structures, such as ideation workshops. Third, there is a contribution to both creativity and service innovation literatures. These literatures are influenced by stage-gate models of innovation, with an ideation stage followed by an implementation stage. This research study suggests that future approaches to service innovation should embrace the innovation process as a whole social process rather than be separated into discrete segments. A final contribution relates directly to the context of the research study. The English NHS is one of the world’s largest employers, with strategic guidance provided by the Department of Health, and operational training and developmental needs met by NHS England. However, this top-down approach has not stifled the capacity of its workforce to problematise issues arising during the implementation of service innovations, even though there is a lack of purposeful guidance on how to do this. Instead, with the support of the local clinical and managerial leadership, front-line staff are able to address difficulties requiring creativity as they arose, drawing, primarily, on their reflexivity. Further, while the workforce is being creative, it is not associating their practices with creativity. Consequently, people lack a discourse of creativity, which would otherwise make further calls on their reflexivity, and positively impact on their productivity.

This research examines how front line managers (FLMs) in a NHS Mental Health Trust responded when Electronic Rostering technology was introduced into their wards, with intentions of improving efficiency, transparency, fairness, skill matching, and safety, and potentially increasing control from above. The study applied a theoretical framework developed from previous research to investigate relationships between the organisational context and FLMs’ characteristics, change management processes and technology efficacy, and analyse their impact upon FLMs’ responses to E-Rostering adoption and consequent outcomes. The research questions focused upon the influences of organisational background and the change management process. The research strategy was an in-depth case study with data collection through semi-structured interviews with managers at ward, service/general, project and senior levels, observation of meetings and training, examination of system records and Trust documents. The theoretical framework was used to design interview guides to help researcher and subjects investigate perceptions of salient factors and FLMs’ responses, and help structure analysis. Cross referencing of data supported reliability and validity of interpretations. The FLMs were ward managers perceiving themselves as professional clinical leaders and operational managers, running wards semi-autonomously. Control of deployment was vital to their authority. They showed power to resist pressures to adopt technology which threatened their control and to resist changes not congruent with their priorities. They negotiated with the project team and adapted practices to produce locally acceptable rosters. Although electronic staff records helped administration, automatic rostering was not efficacious. Rosters needed considerable manual adjustment, meaning ward managers recovered control of deployment and maintained local customs. The study confirms the importance of organisational structure and culture and of political and change management processes, in explaining responses to IT innovation. Change leaders should investigate operational practices, unit cultures and contexts to prepare for technology adoption because these factors will strongly influence FLMs’ responses.

This thesis draws on the analysis of data from interviews, observations, documents and archival records to examine the conditions of possibility for PFI procurements by three English National Health Service (NHS) Trusts and the extent to which these projects are affordable and delivering Value for Money (VfM). Drawing from Bourdieu’s Theory of Practice and his social praxeology, the thesis problematizes the critical explanations for the adoption of PFI by NHS Trusts and the VfM evaluations in operational projects. It contributes to the literature by theorising and empirically examining the operational conditions that have made NHS PFI a viable possibility, and the affordability and VfM issues arising from choosing and implementing PFI. On the conditions of possibility, the thesis finds that the state, through a statecraft of modernisation, structured local dispositions for PFI programmes using multi-layered and multi-directed reforms. Reforms restructuring the bureaucracy and financing of healthcare delivery, together with state-wide neoliberal practices, made Trusts more receptive to the use of the PFI. In addition, the increasingly evolving demands from national healthcare delivery frameworks in their applications to insufficiently resourced Trusts, defined the spatio-temporal adoption of the PFI. The thesis also finds that the projects are relatively unaffordable, but the reasons for their unaffordability are complex and multi-layered. In addition, VfM in operational projects is polysemous; has largely become symbolic and inconsequential, with its pursuit and constitution taken for granted. Ex-post evaluation programmes are not executed as procurers hold the costs of such exercises to outweigh the benefits. Furthermore, HM Treasury’s regime for VfM determination, in application, constructs a VfM reality removed from the ‘lived’ experiences of the procurers; and accounts for the apathetic inertia in PFI procurements. However, this same regime works to the benefit of stakeholders vested with financial and ideological interests in the functioning of the PFI.

This PhD research started from an interest in how organisational and professional antecedents affect knowledge transfer in the professionalised context of the National Health Service. It was further motivated by findings from previous studies (Currie, Finn, & Martin, 2008a; Currie, Finn, & Martin, 2008b; Currie, Martin, & Finn, 2009; Currie & Suhomlinova, 2006a; Currie, Waring, & Finn, 2008c; Martin, Currie, & Finn, 2009; Martin, Finn, & Currie, 2007; Waring & Currie, 2009) which highlighted both the need for more contextual studies in the area of knowledge management and interesting issues around the role of professional boundaries in knowledge transfer. This research investigates and evaluates organisational and professional antecedents to knowledge transfer in the professionalised context of the UK National Health Service, to create empirical and useful results to researchers, practitioners and policy-makers. To achieve this goal, a range of literatures were evaluated, focusing primarily on knowledge management. The review of these literatures revealed a number of research gaps from within the Knowledge Management theory to which this study responds. The two most significant gaps for this are a) a need for empirically based studies on the influence of organisational antecedents on knowledge transfer in professionalised contexts at both organisational and individuals levels and b) a need for empirically based studies on the influence of professional antecedents on knowledge transfer in professionalised contexts at the level of the organisation and the individual. This research is underpinned by a subjectivist ontology, an interpretive epistemology and a multi-method research design. It is exploratory, evaluative, longitidunal, comparative and inductive research with two primary data sets gathered from nurses who participated in a knowledge transfer initiative in the NHS (19 semi-structured interviews) and from key informants of the nursing profession giving their opinion on the dissemination of knowledge in the nursing profession (10 semi-structured interviews). Each data set is used to better understand the impact of organisational and professional antecedents on knowledge transfer in a professionalised context. This research project also contributed to a larger research project led by Professor Graeme Currie from the University of Nottingham aimed at evaluating NHS genetics service investments on a national scale (Martin et al., 2007). This larger research project was based on a comparative analysis of organisational and professional antecedents affecting the implementation of genetic service investments. In total, 85 interviews, including that of the researcher, were conducted over a two-year period with key members of the projects such as General Practitioners, hospital consultants, scientists and nurses. The main finding of the current study is that knowledge transfer initiatives are difficult to implement into practice when taking into the impact of a professional hierarchy on organisational mechanisms of the National Health Service. As a result, the data provide empirical evidence to suggest that KM theories are not necessarily relevant enough to a professionalised context such as the NHS. Essentially, the study finds that existing power relationships between the medical profession and the nursing profession inhibit knowledge transfer and, as a result, poses problems for mainstreaming specialist knowledge such as genetics into generalist care settings of the NHS. In such context, knowledge transfer is influenced by professional institutions that regulate the transfer of knowledge in a profession. Therefore, the research contributes to organisation studies research by providing conceptual and empirical understanding into how organisational and professional antecedents become boundaries to knowledge transfer in a professionalised context. The study also contributes to the medical sociology literature by providing a refreshing look at the ubiquitous theme of medical dominance in healthcare systems (Armstrong, 2002; Dingwall, 1987; Dopson, 2005; Ferlie, Fitzgerald, Wood, & Hawkins, 2005; Larkin, 1978). The study finally contributes to management practice and government policy-making by providing an evaluation of knowledge management programmes in the NHS, and by making some strategic recommendations to respond to these issues.

This thesis describes an action research study that took place in the context of increasing intervention by UK central government in the shaping and delivery of health services, and broadening expectations about who could deliver services. The study was aimed at exploring the issues arising from the development of the interprofessional care co-ordinator (IPCC) role in an acute in-patient setting. The role was new, introduced with an inherent flexibility that enabled IPCCs to speed patients through their in-patient stays as fast as clinically possible. None of the four IPCCs appointed held a registrable qualification in health or social care. A review of the literature identified that very little is known about care co-ordinator roles in practice, particularly those held by non-registered workers. The study reported in this thesis began two years after the IPCCs took up post. The study’s objectives were to describe the characteristics, impact, issues and influences on the role. A wide range of qualitative and quantitative data were gathered and analysed between October 1998 and July 2000 within the framework of an action research approach. The findings identified that the IPCC role had informally shifted over time to take up the complex discharge planning work previously carried out by nurses. This shift was not reflected in Trust policy and had not been accompanied by a review of training, regulation or supervision. This had led to situations of risk for some patients. The findings threw light on contextual factors that enabled the role shift and disrupted the reflective leadership and long-term overview needed to monitor and respond to the shift. These factors included nursing staff shortages and a turbulent environment for managers characterised by multiple pressures, top-down targets particularly for acute efficiency, and high managerial turnover. In addition, nurses did not perceive that they had an influence on the ongoing development of the IPCC role. The findings support Abbott’s (1988) theory that an occupational group can take up the discarded work of a higher status occupational group, but challenge the theory that the work discarded is always more routine than the work retained. They support theories of a growing challenge to the primacy of professional knowledge and the existence of an organisational culture in the NHS in which there are broader expectations of who can deliver which health services. They also indicate that role substitution can lead to the routinisation and marginalisation of aspects of patient care. The findings also illustrate how an innovation can continue to be re-invented following its establishment into routine practice, and how the journey of an innovation can be influenced by its context. The findings throw light on a role in practice that is a cameo of current policy on new roles and have a number of implications for practice, policy, education and research.

The impact of line manager (supervisor) behaviour on employee well-being, work attitudes, performance and perceptions of organizational culture are assessed using a sample of specialist unit (S-Unit) ambulance personnel. Underpinning line manager behaviour was a 10 item, two-factor structure: supportive (six items) and unsupportive (four items) manager behaviour (see chapter 3). Analysis of manager behaviour on outcome variables was performed using cross-sectional (n = 473) and longitudinal, matched-cases, analysis (n = 242). Cross-sectional analysis (see chapter 5) revealed that supportive manager behaviour was significantly related to increased proximal and distal collective capability, individual capability (efficacy; see chapter 4), work engagement, attitudes towards patient care, organizational commitment, perceived organizational support and job satisfaction; and negatively related to symptoms of ill-health, burnout and intentions to quit. Unsupportive manager behaviour was observed to be significantly related to increased symptoms of ill-health and burnout. It was also found to be marginally related to symptoms of post-traumatic stress disorder. Longitudinal analysis (see chapter 6) revealed that supportive manger behaviour was linked to greater proximal collective capability and reduced intentions to quit. Unsupportive manager behaviour was found to be significantly related to increased reporting of symptoms of post-traumatic stress disorder and ill-health. Reverse causality testing was employed on the longitudinal data and results showed that symptoms of ill-health may influence perceptions of unsupportive manager behaviour. The factor structure of manager behaviour is discussed and relationships (significant and non significant) are assessed against other research.

Background This PhD study was an examination of the mechanism adopted by a change agent during an organisational change in healthcare. The context for the study was the secondary analysis of action research in a Child and Adolescent Mental Health Service (CAMHS) that had developed practice at an organisational level to address the excessive waiting list impacting upon that service. Aims and Objectives The research question addressed in the thesis was How does a change agent facilitate organisational change in a health setting? The objectives of this study were to i. explore the current literature available discussing the role of the change agent, thus identifying what is already known about this mechanism ii. through a secondary analysis of the data generated through the aforementioned action research in CAMHS examine the relationship between the change agent and the change participants iii. formulate an understanding of the mechanism of the change agent during organisational change. iv. use these findings to make recommendations for practice and further research. Methods The impact of the change agent during this organisational change was investigated using a triangulation of three methods: interviews with change participants, observations in the field and a reflexive diary. Findings The data were thematically analysed looking at the interaction between the change agent and participants. The way that the change agent used anxiety through the change process was presented in three themes: introducing anxiety into the system to initiate change; tolerating anxiety through the change process; sustaining the change. Analysis if the data generated through this study illustrated the change agent acknowledged the anxiety expressed by change participants and used this in a functional way to lever, maintain momentum and sustain the change process in the field. Conclusion This builds on the available literature that discusses how change agents might hold or contain anxiety during change processes. This thesis presents evidence that the change agent introduces and then uses anxiety functionally to initiate organisational change in a way similar to that described by Mason (1993) in his safe uncertainty theory. Mason had developed that theory to explain the work a family therapist does with families. Mason suggested that a family therapist invites a family into a position of ‘safe uncertainty’ in order to facilitate behavioural change within that family. From this study, there is evidence to suggest that a change agent working with health organisations works in a similar way, by inviting participants in an organisation to move into a position of safe uncertainty in order for change to be effected.

This research investigates whether the introduction of Payment By Results (PbR) into the National Health Service aligned clinical and managerial incentives and improved output, quality, quantity and productivity. The methodology applies three data collection techniques; in-depth interviews; documentary data; and numerical data for each of four foundation trust (FT) case studies. The results indicate that the case studies had not produced consistent and sustained improvements in productivity and did not appear particularly engaged with productivity improvement, or cost control or in the relationship between these factors and tariff under PbR. Boards of directors did not appear to focus on productivity; and the use of service line reporting, to allow clinicians and managers of hospitals to drive productivity improvement, was not widely available at board or clinical level. The results also demonstrated the dominance of Monitor, the FT regulator, in influencing the agenda of FT boards. It suggests that, without central direction and/or external pressure, FTs will not focus on productivity and quality issues. The policy significance of these results are that (a) with the lack of alignment of clinical and managerial incentives, it is unlikely that FTs will be able to produce a sophisticated and targeted review of clinical care pathways to target productivity improvement at areas where there is real opportunity for efficiency improvement; and (b) if, as the research results suggest, NHS management, and the organisations they lead, respond more effectively to central direction and control then, as the NHS enters one of the most financially challenged periods of its history, alternative policy options to the development of quasi markets need to be considered. The research explores several of these options, including: the roll-back of the FT movement, management franchising, creating conditions for increased pressure on hospital performance, a more radical introduction of competition, and options for the use of social enterprises.

Introduction The International Monetary Fund (IMF) is an international financial institution that acts as a lender of the last resort for countries experiencing balance of payments problems. Its loans to national authorities come with conditions, which typically include tighter control of public spending, though the nature and extent of conditions as well as the emphasis on social protection may vary according to the type of lending agreement. A subject of intense debate has been the effects of these loans on the capacity of health systems to meet health need. This study investigates the effects of IMF agreements on one crucial determinant of that capacity: government health expenditure (GHE). To do so, it evaluates: (i) the effects of IMF agreements on GHE across low- and middle-income countries; (ii) how these effects vary across different country income groups; and (iii) how these effects vary according to the type of agreement. Methods The study employs a dataset that includes GHE for 127 countries for the years 1995-2012, estimates the effects of IMF agreements using the Fixed Effects estimator, controls for determinants of GHE and accounts for endogeneity using a Heckman-style selection model. Results When controlling for endogeneity and important determinants of government health expenditure, the results suggest that, across all countries, agreements do not have a statistically significant effect on GHE. However, the effect differs according to country income group, with low-income countries experiencing increases in spending during agreement, lower-middle income countries seeing decreases in expenditure, for upper-middle income countries no effect on spending are observed. In addition, the effect differs according to agreement type: agreements with a social protection component are associated with increases in spending in low-income countries but have no statistically significant effects among middle-income countries. Agreement types with no social protection component are associated with decreases in spending among lower-middle income countries; and there is no statistically significant effect among low-income and upper-middle income countries. Conclusions The results indicate that, contrary to claims in the existing literature, IMF agreements do not have a statistically significant effect on GHE (positive or negative). However, this aggregate finding obscures the effect of particular agreement types in particular contexts. In low-income countries, agreements with an emphasis on social protection are associated with increases in GHE. When agreements have no social protection component they are associated with decreases in GHE for lower-middle-income countries, but not in other countries. In such contexts, IMF agreements either fail to enhance, or actually reduce, the capacity of health systems to meet health need.