Introduction: Risk prediction models are used as part of formal risk assessment for disease and health events in UK primary care. To improve the accuracy of risk prediction, new risk factors are being added to established risk prediction models. However, current methods used to evaluate the added value of these new risk factors have shown to be limited. These limitations can be addressed using health economic methodology, but is yet to be used to evaluate and compare risk prediction models by means of their effectiveness and cost. Methods: A cost effectiveness analysis was performed using a decision tree framework. The decision tree was populated risk model effects and cost measures. The cost-effectiveness analysis derived the incremental cost effectiveness ratio (ICER) using the Youden Index and Harrell’s C-Index performance measures, and the net monetary benefit (INB). A probabilistic sensitivity analysis was performed, based on 10,000 iterations. A range of £0-£100,000 was used for the willingness to pay (WTP), which when combined with the INB, provided the probability the new risk factor was cost effective. This method was applied in two exemplar prospective cohort studies; adding family history (FH) to cardiovascular disease (CVD) risk prediction; and bone mineral density (BMD) to fracture risk prediction. Results: A cost-effectiveness analysis using a decision tree framework was shown to be an effective way of evaluating the added value of the new risk factor. Adding FH to standard CVD risk factors produced an ICER of £799.91 (-£5,962.15 to £5,968.22) and £7,788.76 (-£42,760.16 to £48,962.39) per percentage unit increase in the Youden Index and Harrell’s C-Index, respectively. The maximum probability of FH being cost effective is 0.7, with a minimum WTP of £15,000 (Youden Index). Further, treating low risk patients with statin therapy incorrectly was less costly (£788.40) than not treating them (£916.16). Adding continuous BMD measurement to standard fracture risk factors produced an ICER of £367.25 (-£4,241.88 to £4,828.50) and £4,480.54 (-£22,816.84 to £22,970.55) per percentage unit increase in the Youden Index and Harrell’s C-Index, respectively. The maximum probability BMD being cost-effective is 0.8, with a minimum WTP of £32,500 (Youden Index). Further, using BMD in a binary format to indicate osteoporotic patients, did not improve Harrell’s C-Index of standard fracture risk prediction (∆C-Index=-0.62%). Conclusion: A cost-effectiveness analysis was a novel method to compare two risk prediction models; and to evaluate the added value of a new risk factor. It identifies the added value of a new risk factor; encompassing the statistical and clinical improvement, and cost consequences when using the new risk factor in an established risk prediction model. Based on the added value of FH and BMD, there is a good evidence base to add these risk factors into routine risk assessment of the respective conditions. Increased use of this method could help standardise risk prediction and increase comparability of risk prediction models within diseases; producing a league table approach to evaluate, appraise and identify beneficial new risk factors and better risk prediction models.

Competing tensions are known to be experienced by middle managers in healthcare settings. The increased complexity and higher dynamic nature in acute healthcare contexts increase the demands expected of middle managers. There is limited research focusing on the leadership experience of nurse and allied health middle managers working within acute healthcare contexts. In view of this gap, the aim of this study is to explore the leadership perceptions of nurse and allied health middle managers. Their perceptions of the impact of leadership training and professional development practices are also explored. The Competing Values Framework provides a useful framework for gaining insight into the leadership experience of middle managers. The principal research question is: What is the leadership experience of nurse and allied health middle managers in an acute public general hospital? A qualitative approach using semi-structured interviews was held with nurse and allied health middle managers working within the main acute public general hospital in Malta. Through purposive sampling, 21 middle managers consented to participate in the study. Thematic analysis was conducted identifying codes and themes within the data, from which findings were derived. Findings suggest that nurse and allied health middle managers fulfil contradictory and competing demands within dynamic healthcare contexts, underlining the intense emotions experienced by them, and their struggle to achieve a balance across conflicting situations. Middle managers suggested that they would benefit from communities of practice development approaches and mentoring programmes, to help them cope with workplace demands and the contradictions within their role. A central recommendation of this study is the inclusion of middle managers in planning future leadership training and development programmes. This may be effected through a partnership approach with senior managers and trainers so that training significantly contributes towards enabling optimal performance of middle managers, and the ultimate improvement of patient safety and quality healthcare. This research has implications as to where and how resources for developing middle managers should be invested in acute healthcare contexts.

This submission comprises a body of published works which update and extend the range of theories-in-use in the practice of Group Relations experiential learning, bringing a relational psychoanalytic framework to the understanding of groups and organisational dynamics, the practice of organisational change consultancy and the challenges of taking up complex professional roles. The papers span a 15 year period, although the thinking that underpins them draws on a professional career of 40 years in social work, social work management, organisational consultancy and teaching for professional development. The past 25+ years have been in the context of small business management and ownership, which additionally allows for a perspective gained from fluctuating market and workplace practices. Throughout this career, I have worked extensively to create and promote conditions which can support professional judgement in challenging situations. I view this as a relational task which is both intrapsychic and interactional, and accessed through the making of links between inner world experiences of thoughts, feelings and fantasies, external world realities of organisational structures and processes, and the taking up of roles. I use psychosocial methodologies to help make sense of workplace dilemmas, and a broad repertoire of developmental interventions to effect change. Accompanying the published works is a commentary which outlines the papers and their particular contribution to the field of professional practice. What emerges from meta-analysis of the publications are the foundations for a theory of interaction based on a new framework for understanding and working in organisations, and consulting to group behaviour. I have called this ‘The Relational Terrain’ and I expound and illustrate it with material from the papers, and from my consulting work. I give evidence of the impact of these publications, of how and where ideas have been taken up, bringing fresh perspectives to established traditions, as well as practical value for clients attempting to effect change in themselves and their organisations. I suggest that there is now a groundswell of interest in the application of relational theories to group and organisational behaviour, and that this submission constitutes a body of knowledge which is ripe for a broader audience at this time.

This thesis introduces a study for knowledge management of information overload in the healthcare domain. The study selected the diabetes clinics of seven hospitals in Jordan as a case study based on obtaining consent letters from these hospitals. First, a comprehensive literature was conducted in order to explore the existing information overload problem in-depth and to investigate existing solutions that assist in developing a new framework for reducing this problem. The literature findings integrated six theoretical factors adopted from the literature to form a data collection survey representing the initial primary research stage where the mixed approach methodology was considered. The data was collected by approaching the medical staff in person, and was analysed to determine the arising problems affected by information overload, and to find out about the information type that is used, the way information is used/communicated, and how information is going to be held. The findings from the primary research analysis showed that the results were statistically approaching the average indicating to an average problem. The researcher afterwards produced an information flow and processing models for the information that is running into these clinics. Thus, a knowledge management framework is proposed in order to reduce information overload affecting these clinics by enhancing an appropriate existing method from the literature, and by enhancing the analytical primary research findings. The framework is based on sharing the information to the right person at the right time in the right place with the right quantity. Furthermore, a validation of the framework was conducted with the assistance of a subset of medical experts in the field existing in these clinics. In conclusion, the future research is that the framework will form the basis of teaching by future researchers for further possible enhancements.

Policy directives and the new NHS constitution require managers and leaders to adopt strategies that motivate and encourage teams to work collaboratively with staff and patients. These innovative ways of working are seen as a means of improving the quality and coordination of patient care, thus impacting on the patients’ experience. Despite this focus, the evidence of what constitutes and therefore what can deliver effective collaboration between managers, staff and patients is sparse. This study identifies a conceptual model of effective management strategies and behaviours that will assist in achieving partnership and collaborative working. This research is based in the real world which is complex and uncertain. The study uses an explorative framework and gains insight from a number of different perspectives. The methodological approach is a qualitative case study. Data was collected from an NHS Trust based in Wales and a District Health Board in New Zealand. Data was collected through document analysis and semi-structured interviews. The findings support a move from a managerialist approach (where managers are target driven, transactional and administer activity) to a more reflexive, egalitarian, transformational approach that can be adapted to cope with complex environments and function successfully in the zone of chaos (where problems are ill defined and messy). The ability of a middle manager to interpret context and operate a balanced approach would appear to be key to navigating a constantly changing and negotiated environment. This study supports adoption of a servant leadership model and proposes guidance for middle managers undertaking change. The guidance proposed is a move away from the dominant doctrine of managerialism and describes the principles for working collaboratively with front-line staff in the NHS and the New Zealand health system.

Current theoretical thinking asserts that leadership should be distributed across many levels of healthcare organisations to improve the patient experience and staff morale. Much medical education literature on leadership focusses on the training and competence of individuals. Little attention is paid to the interprofessional workplace and how its inherent complexities might contribute to the emergence of leadership. Underpinned by complexity theory, this research aimed to explore how leadership emerges in the interprofessional healthcare workplace. Epistemologically grounded in social constructionism, this research was undertaken in two phases, using narrative inquiry and video-reflexive ethnography (VRE) methodologies. Phase 1 involved nineteen individual and eleven group interviews with 67 UK medical trainees at all stages of training and from a range of specialties. Narrative interviewing techniques were employed to capture medical trainees’ conceptualisations and lived experiences of leadership and followership. In Phase 2, a work-based study was undertaken utilising VRE to explore how leadership is enacted in the interprofessional healthcare workplace. This occurred in two UK clinical sites: one GP practice and one hospital ward. Participants came from the entire interprofessional team. Multiple complementary forms of analysis were used across both phases including: thematic framework analysis; big ‘D’ Discourse analysis; structural narrative analysis; and interactional analysis (including little ‘d’ discourse analysis).Findings identified that leadership is not a single thing ‘possessed’ by individuals but rather leadership involves many processes. This research showed that the ways in which leadership is conceptualised, narrated and enacted is affected by many aspects including individuals, context, relationships and the systems in which leadership exists. The findings of this thesis therefore indicate a need to redefine the way that medical and healthcare educators facilitate leadership development and argues for new approaches to research in this field which shift focus away from leaders to, focusing instead, on leadership.

Since 1974, governments have created a series of statutory public involvement institutions in the English NHS: Community Health Councils; Patient and Public Involvement Forums; Local Involvement Networks; and, from 2013, local Healthwatch. This study presents the role of these institutions as a puzzle, given the growth of alternative forms of public involvement. Public involvement in the NHS tends to be studied for its contribution to democratising the NHS or for its role in a choice-led consumer market, but these analyses generally focus on involvement led by NHS personnel or by independent patient organisations. This dissertation uses a different body of political science theory to assess roles that statutory public involvement institutions may play in Ministers’ political management of the NHS. One approach is to see these institutions as ‘sheepdogs’, rounding up and organising diverse groups, thus providing a form of corporatist interest intermediation. Alternatively, they could be ‘watchdogs’, raising the alarm when standards slip critically and thereby helping to safeguard the NHS against disasters. The explanatory value of these two interpretations is reviewed over the period 1974-2010, using policy documents and archive material, including the records of these organisations and the archives of public inquiries into problems in hospitals. The findings suggest that at various times national political actors have used statutory public involvement institutions to manage the representation and mobilisation of interests and to alert them to problems in local health services. There is more recent evidence for the watchdog than for the sheepdog role. The watchdog role has been reappraised following the failure of statistical monitoring and regulatory police patrols to prevent disasters in the NHS. The discussion also shows how the sheepdog powers of these institutions mean that they can round up opposition, rather than moderating it, resulting in Ministerial reforms to statutory public involvement institutions.

Healthcare services are a necessity for every country, and particularly in developing countries, where the shortage of medical professionals is greatest. To resolve this issue, it requires substantial resources that are not available. Therefore, the recent advancement in Information and Communication Technology (ICT) provides the platform for innovative eHealth services and the opportunity for improving access to medical services. Despite Governments, International Organisations, and companies‟ growing interest in eHealth Services for enabling access to medical treatment using ICT, research in developing countries related to user behavioural intention of these services remains relatively scarce. This is a research study to identify and measure the motivational factors that would expedite the introduction and widespread use of eHealth services in developing countries. More specifically, it endeavours to understand what factors would motivate medical professionals to successfully adopt eHealth Services. The study aims to identify and measure the determinants that would lead to successful adoption of eHealth services. This thesis is, thus, a services marketing study. To achieve this goal, a literature review was conducted in order to develop an original conceptual model of eHealth services in developing countries. Based on the literature review, an exploratory qualitative study was undertaken to assess awareness and gain insight into specific motivational factors which are incorporated into the original conceptual behavioural model. A reliable and valid model to measure behavioural intention to use eHealth services in developing countries was developed. This model incorporates several influencing factors determining usage intention and the analysis also tests a set of hypotheses covering moderating effects. The experimental fieldwork was conducted in cooperation with the International Telecommunications Union Study Group on eHealth and with local medical institutions in several developing countries having formalized cooperation agreements with the University where the researcher works. The study draws on responses from a sample of 549 medical professionals from ten developing countries. As the nature of this study is exploratory, factor and multiple regression analysis were used to test the hypotheses.This thesis answered the research questions, “What are the motivational factors influencing the “intention to use” of eHealth services by medical staff in developing countries”, and the managerial sub-questions, “What do the empirical results imply for the development of marketing strategies for eHealth services in developing countries? Can medical professionals be segmented on the basis of eHealth early adoption dimensions? What marketing strategies are necessary to gain the acceptance and adoption of eHealth services in developing countries? The main contributions of this thesis to theory and practice are as follows: Overall Research Question: - What are the motivational factors influencing the “intention to use” of eHealth services by medical staff in developing countries? Value-added #1: Created a new unique behavioural intention model for developing countries (did not exist before) Value-added #2: Validated and measured new influencing factors Value-added #3: Validated new scales for a new domain, eHealth and in a new context, developing countries The Managerial sub-questions are: - What do the empirical results imply for the development of marketing strategies for eHealth services in developing countries? - Can medical professionals be segmented on the basis of eHealth early adoption dimensions? - What marketing strategies are necessary to gain the acceptance and adoption of eHealth services in developing countries? Value-Added #4: Principles of marketing strategies developed based on measured influencing factors Value-added # 5: Identified the early adopters of eHealth services based on moderation effects Value-added #6: Developed a Segmentation and positioning framework This study contributes to academic theory through the creation of a behavioural intention model for eHealth services in developing countries, and by extending and modifying the UTAUT model to a new service (eHealth) and a new environment (developing countries). eHealth has not reached critical mass and this research study aims to move this new innovative service from pilot to full-scaled schemes. The study contributes to management practice by providing a new understanding of the factors that would encourage medical professionals and medical administration to use eHealth Services. These results can be used to develop principles for a marketing strategy framework aimed at providers of eHealth services in the private sector. Specifically, this thesis identifies the early adopters of these services and proposes a market segmentation and positioning strategy focused on the key stakeholders in this field. The results of this study can also inform international bodies tasked with promoting eHealth solutions in developing countries, such as the International Telecommunications Union Development Sector to help in the progression of eHealth services in developing countries. eHealth is an important international topic and is on the agenda of international and governmental organisations, such as: the International Telecommunications Union (ITU), the World Health Organisation (WHO), the European Union (EU), and others for more than ten years. However, the diffusion of eHealth services is rather slow and for this reason it is important to understand the main obstacles and user influencing factors for developing an applied marketing strategy.

This study investigates whether the cultural differences, that are known to exist between countries, affect the attitudes of professionals in health towards the development and use of information systems. The study was motivated by the perceived failure of health information systems to deliver expected benefits, in particular in international developments, and also by the perception that attitudes of health sector professionals, who are current and potential users of the systems, can have an impact on the success or failure of these systems. Both structured group discussions and a self completion questionnaire were used in this investigation. As well as drawing on previous research on attitudes, a participative approach was taken to the development of the questions to be used, to reduce ethnocentricity in the design. Participants in the study were professionals working in the health sector in Georgia, Tajikistan, Uganda and UK, and professionals in other countries assisted in the study design and group discussions. Preparatory work for rolling out the research has also been carried out in other countries. As well as highlighting cross country differences, the results identified some significant issues in relation to the attitudes of health sector professionals towards information systems developments, common to all countries. The investigation has also led to the development of approaches, suitable for use in a cross cultural setting, that facilitate the identification of the attitudes of users towards information systems. These approaches can help to address the real-world problems faced when implementing health information systems by assisting in understanding the views of stakeholders to the systems, and how these views vary between different groups of staff or different countries.

The thesis explored herein is that the essential role of evidence synthesis in Health Technology Assessment is to reduce uncertainty in decision making. There is a strong preference in HTA for treatment recommendations and practice guidelines to be informed by evidence from systematic reviews of randomised controlled trials.