The aim of the programme was defined in the research proposal as an exploration ol the effects of implementing healthcare information systems on the duration of clinical tasks and the overall distribution of clinicians' time. An extensive literature review showed that the evidence base on this subject was highly inconclusive. This led to a reconsideration and change of research direction. It was decided to review existing health informatics theory to identify areas where a contribution might be made.

Scientific Abstract Organisational Change and the Delivery of Primary Care Services The role of organisational change in the development of Primary Care Services in the Irish Health Sector Introduction The research topic considers how organisational change can deliver better primary care services and health outcomes for the benefit of service users. The organisational change approach is based on local primary care teams delivering services through collegiate multidisciplinary team working. The service users are local communities who work with the teams to deliver best health outcomes. Methodology The research methodology consisted of semi structured interviews, focus group, and a national questionnaire survey. Interviews were conducted with different personnel including general practitioners, health care professionals, senior and local managers, and administrative staff. The focus group was conducted with members of the Arklow primary care team as part of a detailed study of how it functioned. The national questionnaire survey was circulated to every member of staff who worked in the initial ten primary care projects. Results These are: (a) Collegiate organisational development is an inclusive process that participates with all stakeholders. (b) Individual learning takes place in a group which is also learning. (c) When individual and group learning is transferred and applied in the workplace organisational learning takes place. Conclusions These are: (a) Ireland is developing primary care infrastructure as the basis of its national health service. (b) Skill mix and collegiate multidisciplinary team working practices for health care professionals are central to the new system of primary care organisation. (c) Community involvement with the local multidisciplinary primary care team is essential to the new structure.

This thesis thus provides a unique ongoing 'insider view' of my experiences as a senior manager over five years, and five NHS reorganisations. It is grounded in practice due to the high profile leadership role I took with regard to the implementation of the HlmP and its related initiatives. Significantly, I explore how disciplined attention to my own role and practice over time, opened up opportunities for others and myself for ongoing reflexive eo inquiry. This took active account of the intended and unintended consequence of my own approaches to policy driven collaborative planning, and my own role of managing tensions at the interface between the organisation and the performance managers above me. As such this thesis makes a significant contribution to existing limited literature on insider action research. I have evolved the notion of a poly-systemic environment and practice (poly- systemicity) as a method of conceptualising the context in which I and others were attempting to implement policy across multiple systems, sub-systems and boundaries. It is important that policy is developed within the context of these multiple systems and that it takes account of people's practice and experience (or at least allows for assimilation of these factors). I have found that taking account of these factors is key in people's ability to engage and create a sense of shared meaning and identity. Self and identity, in poly-systemic terms, is a set of multiple socially constructed roles shaping and adapting to the range of diverse contexts that people find themselves in at the multiple interfaces of systems within the NHS. A major conclusion of this research is that DOH driven performance management processes which are intended to improve the impact of the policy in practice, often have unseen or discounted effects. I argue that systemic tensions will be reproduced over and over again at different levels of the NHS, unless learning on the part of the system as a whole includes reflexive ongoing inquiry. The multi-directional and mutually influencing systemic effects of multiple systems and interface need to be kept in view through new forms of research and change. Change that still tends to be understood as a merely technical rational process in a very complex system has huge costs in terms of closing down choices for action and innovation at all levels of the system. This is especially true when those upon whom success in the NHS depends, repeatedly experience disenfranchisement and de-motivation in relation to policy implementation.

This thesis is a study of the reform of health systems from an international and an economic perspective. Its main unifying theme is to investigate the role played by incentives in the performance of health systems and their reform. In the first part, the thesis reconsiders the economic reasons that form the basis for public intervention in health markets, both in financing as well as in service provision. In fact, one of the key elements introduced with health reforms in the last few years has been greater competition in health insurance and provision, among private as well as public providers. It is thus interesting to start the analysis by revisiting the effects of competition in health markets on the basis of more recent contributions in microeconomic theory, our aim being to ascertain what would be the major deficiencies of unregulated markets, and to investigate into the impact of different public corrective measures. Chapter 2 looks at the effects of competition in the health insurance market and at the impact of different forms of public intervention to correct market failures. Chapter 3 presents a model of oligopolistic competition between two health providers, and it investigates the potential role of quality and/or price regulation as a means to extend coverage/improve quality beyond the point reached in correspondence to the market equilibrium. Then, the thesis focuses on the new resource allocation, contracting mechanisms and payment systems for providers (RAP reforms) implemented over the last few years, within the public sector, or intended to discipline the relationship with health care providers. Chapters 4 gives an introduction to the RAP reforms, their justification and main components. Chapter 5 focuses on payment systems and on efficiency issues, while Chapter 6 on the equity consequences of RAP reforms. Chapter 7 and 8 look at the health reforms implemented over the last decade in the former socialist countries. The evolution of health systems in those countries provides interesting lessons, illuminating the major weaknesses and limitations of the health reform model that has been prevailing and proposed world-wide over the last decade. Chapter 8 presents a qualitative study of the impact of the health reforms in Georgia, focusing specifically on the phenomenon of out-of-pocket payments, formal and informal, which currently are the prevalent source of funding for health in the region. A concluding chapter (Chapter 9) summarises some of the main findings of the thesis.

Laboratory services have a central role in surrounding the screening, diagnosis and management of patients and represent a significant expenditure for the NHS in Scotland, of which around 25% can be attributed to general practice use.  Some testing however can be regarded as ‘inappropriate’ which represents a substantial opportunity cost including the indirect costs of unnecessary further investigation of healthy individuals following false positive results.  This study aimed to evaluate the effectiveness and efficiency of two interventions to modify the test requesting behaviour of general practitioners in Grampian and Moray. A 2x2 factorial cluster randomised controlled trial design was used.  The two interventions, enhanced educational feedback and test report reminders, were introduced over a one year period.  The effect on the requesting behaviour of specific targeted tests was observed across the intervention groups.  The overall costs were considered taking into account the costs of delivering the interventions as well as potential savings. Target test requesting in the control group rose by 5.4% during the intervention period.  This compared to falls in test requesting in the feedback group (-2.2%), reminder group (-6.1%) and the group receiving both interventions (-16.8%).  Set-up and maintenance costs associated with the interventions compared very favourably with the potential savings that could be made due to reductions in test requesting. Both test report reminders and enhanced educational feedback are suitable vehicles for the delivery of educational interventions aimed at modifying laboratory test requesting behaviour.  Implementation of such into routine laboratory service could lead to substantial benefits for the NHS in Scotland due to a more rational approach to test use and an overall quality improvement in the diagnostic decision making process.

The research aim was to evaluate whether it is possible to reliably measure change in health and safety performance when a formal health and safety intervention is introduced to the UK healthcare sector.  The research methodology and design was informed by a review of relevant literature.  Field study data was generated using a six-point design.  This included: use of a before-and-after (longitudinal) design, use of comparison groups; use of an intervention that was of interest to participating NHS Trusts, use of a participative style which involved the participating Trusts; use of multiple measurement methods and multiple indicators of effectiveness. Seven NHS Trusts participated; two of which were a control group.  The intervention was health and safety management workbook, introduced only to the test group.  Evaluation of the impact of the workbook on health and safety performance involved two identical phases, the second approximately twelve months after the first.  Each phase consisted of a staff opinion questionnaire survey, based on previously validated work; and a new Health and Safety Executive (HSE) methodology involving management root cause analysis plus cost estimations of incident data. There was wide variation in the numbers of incidents reported within each Trust, although the mean difference between phases was not significant (P<0.1).  There was no significant difference between the test and control Trusts (P=0.05).  Incident rates were in broad agreement with official HSC data, so far as fatal/major injury rates wee concerned, although there was less agreement for minor incidents. These results suggested that Trust reporting culture may be linked to overall reporting rates but that captured incidents, (which met the project inclusion criteria and therefore represented more serious incidents), were independent of reporting rate, size and type of Trust.  The use of incident reporting rates as benchmarking indicators should therefore be used with caution until further work can be carried out to clarify the nature and scope of their limitations.  There is also a need to clarify to relationship between major and minor incidents and whether they share similar root causes.  This would help to establish whether recording only the more serious incidents with selective root cause analysis would be more cost effective than the processing and analysis of large numbers of incident reports.

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