The study seeks to answer two questions: Why and how was a national health service introduced in Italy in 1978. How, and how well, has the service worked. First proposals were made to improve public hygiene and access to health care in Italy in 1945. However, only in the 1970s was there political support for full reform. The principles of the national health service - full population cover, public funding, comprehensive services, local control - were agreed by most political parties; but there were also differences between parties over important issues. Parliament approved the law during an exceptional period in 1978 when the Christian Democrat party depended on the Communist party to sustain their government. The Servizio Sanitario Nazionale (SSN) has been implemented through the 19 regions and 2 autonomous provinces. 673 Unita Sanitarie Locale (local health units) provide the organisational structures for local management, with a wide range of services including general practice and hospital care, hygiene and prevention, occupational health and veterinary care. Terms of service are uniform across the country and negotiated nationally. About 15% of inpatient care, and about 30% of ambulatory care, is contracted to non-SSN salaried physicians. Public services in Italy are usually believed to be inferior to private services, to be excessively bureaucratic and of poor quality. Some evidence supports these perceptions, more commonly in the south than in cental or northern regions. Several features of the SSN, such as national planning, prevention and occupational health, and public participation, have not developed as intended in the reform. Neverthless, the SSN has also achieved several major objectives - a public health service available to all, an acceptable mix of public and private-contractual provision, public representation through regions and communes, and national financial control. On balance, the Italian health reform of 1978 has been a success.

This thesis explores both the proliferation and prominence of ‘performance’ in the NHS, focusing on the New Labour years from 1997-2010. The research’s main objective was to understand how performance policy impacts the work-place experience: to understand the nature of work undertaken by performance managers, the tools used and the effect of these techniques. The secondary objective was to understand the goals of performance management. The introduction and rise of performance saw a change in expert authority. A new set of professionals had arrived in the NHS: regulators, auditors and performance managers. This thesis looks at the performance managers’ body of expertise, drawing upon several forms of qualitative research. The primary research tool used was institutional ethnography, which included focused interviews, a case study and experiences and notes gathered during a period based as a participant in NHS organisations. Documentary analysis carried out in the first phase of this thesis revealed that the principal rhetoric employed by politicians concerned the function of performance management in reducing risk and harm to patients. However, further research based on interviews and ethnography suggests that performance was experienced as a process of rationalisation and stigma, with risk rarely mentioned in the same way as in policy documents. In particular, various aspects of rationalisation, including measuring, quantifying and tabularisation, were deployed, these processes being a means for state surveillance. Performance, it will be argued, was part of the bureaucratic machine by which efficiency and effectiveness were judged in areas where the state previously had little knowledge or information. The research draws heavily on approaches in Science and Technology Studies to consider ‘performance’ and audit as a form of socio-technological intervention as well the Sociology of Health to inform issues of organisational and work-based stigma.

Patient safety is an important topic for policy makers, health service clinicians and managers, and researchers. One way that many organisations are trying to improve patient safety is by incident reporting but they are meeting with limited success. The question this dissertation investigates is "What are the barriers to implementing and sustaining an Electronic Adverse Incident Reporting and Recording System in an acute healthcare environment?" As part of answering that question, this dissertation develops a socio-technical systems model of those barriers. A mixed methods approach (questionnaire survey and semi-structured interviews) was used to investigate the research question. By triangulating the findings from the questionnaire and interview studies, one technical barrier and three socio-barriers were identified. The technical barrier was Information and Technology, and the three socio-barriers were: 1) Attitudes and Values, 2) Training, Staffing and Skills, and 3) Leadership and Feedback. A model was then proposed which posits that the three socio-barriers interact with each other as part of the socio sub-system and that the socio sub-system interacts with the technical sub-system to form a socio-technical system. The overarching implication of the proposed model is that an NHS organization cannot just purchase a commercial Electronic Adverse Incident Reporting and Recording System and expect improvements in patient safety. The principle of joint optimization requires that changes to the socio- and / or technical sub-system be considered concurrently. The proposed model offers opportunities for future research such as investigating barriers to reporting in other national healthcare contexts and other high risk industries.

This thesis explores state of the art robust multivariate statistical methods and data driven techniques to holistically perform prognostics and health management (PHM). This provides a means to enable the early detection, diagnosis and prognosis of future asset failures. In this thesis, the developed PHM methodology is applied to wind turbine drive train components, specifically focussed on planetary gearbox bearings and gears. A novel methodology for the identification of relevant time-domain statistical features based upon robust statistical process control charts is presented for high frequency bearing accelerometer data. In total, 28 time-domain statistical features were evaluated for their capabilities as leading indicators of degradation. The results of this analysis describe the extensible multivariate “Moments’ model” for the encapsulation of bearing operational behaviour. This is presented, enabling the early degradation of detection, predictive diagnostics and estimation of remaining useful life (RUL). Following this, an extended physics of failure model based upon low frequency SCADA data for the quantification of wind turbine gearbox condition is described. This extends the state of the art, whilst defining robust performance charts for quantifying component condition. Normalisation against loading of the turbine and transient states based upon empirical data is performed in the bivariate domain, with extensibility into the multivariate domain if necessary. Prognosis of asset condition is found to be possible with the assistance of artificial neural networks in order to provide business intelligence to the planning and scheduling of effective maintenance actions. These multivariate condition models are explored with multivariate distance and similarity metrics for to exploit traditional data mining techniques for tacit knowledge extraction, ensemble diagnosis and prognosis. Estimation of bearing remaining useful life is found to be possible, with the derived technique correlating strongly to bearing life (r = .96).

Aims: The study aimed to determine the expectations and effectiveness of postgraduate advanced practice education programmes from the perspective of a student, a qualified advanced practitioner and a NHS Trust manager in England. Additionally, exploration of the translation of student learning from education programmes to practice, and identification of the similarities and differences between postgraduate advanced practice education programmes offered by different institutions were compared, in order to demonstrate outcomes on practice. Background: The past decade has witnessed a proliferation of advanced practice roles within healthcare practice both nationally and internationally. There is evidence to suggest, that service providers perceive that advanced practitioners are ill prepared for practice and lack specific competencies to deliver effective healthcare. Education programmes preparing advanced practitioners are developed in isolation and their professed effectiveness is currently not supported by sufficient evidence. Methods: A multiple case study design that incorporated three cases from different geographical areas within England was used to investigate the study aims. Documentary evidence provided contextual evidence of the programmes of study. Participants were selected from higher educational institutions and their associated healthcare partners. Semi structured student interviews (n=32) and advanced practitioner and manager focus groups (n=8) were conducted. Results: Findings demonstrated variation in the structure and organisation of the programmes and in the support provided to students. Perceived outcomes of the learning by participants included improved quality of patient care, improved advanced assessment, diagnostic, consultation and management skills, and behavioural changes. A lack of understanding of advanced practice roles by organisations and healthcare professionals was identified and supports earlier research evidence. A three-stage implementation and evaluation model was constructed to demonstrate an effective process for advanced practitioner preparation and evaluation. Discussion and Conclusions: This study provides evidence that advanced practice programmes can prepare practitioners to positively effect healthcare delivery. Evaluation of educational programmes is achievable and can provide valuable evidence to relevant stakeholders to promote and facilitate consistency and effectiveness in the preparation of advanced practitioners.

This dissertation aims to provide a strong contribution to the public debate which centres on health and social care integration in England. With ever increasing demands on the health and social care system, politicians have championed the integration between the two sectors as a major element to cope with this challenge. Indeed, verbal opposition to this policy is scarce, yet integration efforts do not tend to be readily observable and wide-spread. Moreover, service redesign efforts cost multiple millions of pounds, therefore, what could be done to improve these processes is critical and pertinent at this time of great challenge for our care services. The main objective of the goal-directed research in this dissertation is to uncover to what extent social psychological processes play a role in this seeming ‘disconnect’ between what people ‘say’ and what they actually ‘do’. To create this insight, a series of five social studies were designed using a mixed research methods approach, using new and interactive technology to capture this data. A total of sixty-three individuals volunteered to participate in the study. The results indicate that comparatively healthcare participants indicate higher levels of social empathy, social perspective taking, and willingness to reach out and share funding with those in social care during the explicit studies. Yet, the implicit data suggest a moderate to strong automatic preference for healthcare over social care by participants from the healthcare sector. The findings in this cast a certain doubt over the use of traditional behavioural analysis techniques such as surveys and interviews. We provide a way forward to increase the validity of these methods and provide recommendations for policy for health and social care integration in England.

No description available.

This thesis is comprised of a systematic literature review, empirical paper and critical appraisal. Firstly, a systematic literature review of qualitative studies exploring staff experiences of violence and aggression in the emergency department was conducted. A meta-ethnographic approach was used to review 12 papers. The results showed that staff working in the emergency department appeared to resign themselves to the inevitable experience of violence and aggression. Staff made attributions about the cause of violence and aggression which affected their emotional responses. They also often felt isolated when managing violent incidents and the experience of violence and aggression had significant consequences on their psychological and physical well-being. A consistent organisational response to violence and aggression was recommended through both frontline and management staff training. Secondly, the empirical paper explores staff perceptions of well-being and resilience using a constructivist grounded theory framework. 11 staff were interviewed from a range of professional backgrounds across two forensic services. A model of staff perceptions of the factors which contribute to well-being and resilience when working in secure forensic services was developed. Staff resources were depleted through: working with clients who have complex difficulties, experiencing constant change and through the indirect impact of pressure from external organisations. This had a subsequent negative impact on their well-being. Factors including breaks and reflection in and out of work, support from colleagues and witnessing client progress allowed staff to feel ‘re-charged’ and motivated staff to continue working. Clinical implications included: organisations providing opportunities for time and reflection in work for staff, self-care training for new starters and advice for managers. The final section outlined a critical reflection of the journey conducting research with staff in the current climate of healthcare and considering the findings within the existing resilience literature base.

This thesis assesses the methods used in economic evaluation, the relationship of economic evaluation to decision-making and investigates the possible limitations of economic evaluation as it is currently used to support policies aimed at maximising population health gain. It then evaluates alternative methods of analysing data from economic evaluations to better inform policy decisions. The hypothesis of this thesis is that a greater use of subgroup analysis in policy decisions could potentially improve the efficiency of allocating scarce health care resources. This study aims to investigate the impact on population health gain and service cost- effectiveness of using subgroup analysis within defined parameters to derive and evaluate estimates of effect, and compare it to the more traditional methods of statistical inference. Data from existing large trials are used to calculate cost-effectiveness ratios for the total study population and for subgroups. Total and subgroup estimates of cost-effectiveness are applied to patient populations through simulation, and outcomes predicted on the assumption that treatment decisions are guided by estimates derived from the trial. The distribution of cost-effectiveness ratios based on different rules for `allowing' the use of subgroup analysis results is compared with the distribution of cost-effectiveness ratios based on aggregate analyses. Results show that pre-selected subgroups can provide a stronger likelihood of maximising overall health gain. This thesis argues for optimisation in the use and interpretation of results rather than an over reliance on certainty and the resulting restriction on the use of available data. It concludes that under the scrutiny of a health care system for which the primary goal is health gain maximisation within resource constraints, policy decisions made using the results of subgroup analysis could result in a more efficient allocation of resources.

This thesis is an ethnographic exploration of how “quality” is made into an object of improvement in healthcare. Focusing on a specific method and brand of quality improvement (that of the Boston-based Institute of Healthcare Improvement [IHI]) and a particular quality improvement initiative (that undertaken by the Scottish Patient Safety Programme [SPSP] to improve the safety and quality of healthcare in NHSScotland), I frame “quality improvement” as an endeavour that can be approached as a practice of entification: described by Larsen as the process by which something is summoned into existence from an inchoate state, and made into a bounded entity. I seek to “thicken” the problematic of entification as laid out by Larsen through an analysis guided by linguistic anthropology and semiotics; governmentality and critical accounting studies; and the literatures on numbers and standards. The research is based on participant observation at IHI and SPSP training events conducted over an eighteen-month period across Scotland; interviews with people involved in the Scottish quality improvement initiative; and textual analysis of training and promotional materials associated with IHI and the SPSP. The dissertation unfolds in an iterative manner, constantly revisiting a series of binaristic contrasts that I use strategically in order to highlight what I discern to be two historically distinct styles of entification. I also develop the notion of “ideologies of entification” in order to better grasp how contrasting styles of entification are related to different social imaginaries and structures of feeling, and to engage the ways they are bound up with processes of subject-formation. I strive to link these insights to a range of other theoretical interventions, and in so doing provide a meaningful theoretical synthesis; an expansion of the concept of entification; and critical insights meant to enhance on-going efforts to improve the safety and quality of healthcare.