This thesis explores accounting change in UK hospitals, from 1880 to 1974. Using a processual approach (Porter, 1981 Pettigrew, 1987 Bhimani, 1993 Dawson, 2003) to historical investigation the focus is on three accounting 'events': the introduction of Burdett's uniform system of accounts in 1893 the introduction of annual departmental costing in 1956, and the introduction of functional budgeting in 1974. There is a duality to the research which explores both the role of change agents and the contextual environment within which change takes place. For the first event, contextual factors such as the growth in hospital care, early 'managerialism' and moral concerns are first explored. These are identified as important in stimulating interest in accounting change, from both internal and external groups and institutions, but it is internal groups that take control of accounting reform. It is argued that economic, professional and technological forces were crucial in the spread of these accounts. The second event takes place after the nationalisation of voluntary hospitals in 1948 with an emphasis on the process of change after nationalisation. The interaction of dominant individuals, groups and institutions, as well as political and economic forces are all explored in an effort to explain the how and why of change. The role of the medical profession in the departmentalisation debate is discussed, together with possible explanations for the reluctance to adopt new management accounting techniques. The final event was preceded by a renewed interest in the concept of efficiency (Klein, 1995) and the thesis examines a number of managerial initiatives between 1956 and 1974. It suggests that there was a cautious approach to change among both accounting practitioners and civil servants and this, together with a disappointing response to previous accounting reform, combines to prevent more radical accounting change. The thesis adds to the limited information on public sector accounting and suggests that the controversies surrounding the introduction, and use, of 'new' accounting technologies are part of a long process which can be traced back to the pre-nationalised voluntary hospitals and constitute a recurring theme throughout the life of the NHS.

Shortly after winning a landslide victory in 2001, the Thai Rak Thai Party introduced the 30 baht Healthcare System, also known as the Universal Healthcare (UC) Scheme. For the first time, this made modern health services available to every Thai citizen for a nominal fee of 30 baht (well under one US dollar). Unsurprisingly, there were immediate improvements in healthcare outcomes in Thailand, and the programme was one of a number that consolidated the hold of the Thai Rak Thai Party in Thai politics, a hold that it and its successor parties continue to have. This research argues that these political motivations had a significant impact on the programme's design, and on the problems that emerged with its financial viability. This dissertation examines the background of the UC System (the 30 baht Healthcare System), and assesses its efficiency in the management of resources, equity of access, and service quality, and the long term viability of the UC scheme in terms of financing and the continued participation of private sector service providers. It finds that secondary data is very hard to access and provides neither a comprehensive picture nor satisfactory answers to these questions. The research used a qualitative case study approach to shed light on important aspects of the performance of the scheme, without aiming at comprehensiveness given the limitations of time and resources. The researcher faced significant reluctance from hospitals to reveal internal management strategies and costs and the initial goal of six case study hospitals was reduced to two. Nevertheless, these two provide very useful insights into important aspects of the scheme. The first is B-Care, a private hospital that joined the scheme in its very early days but then opted out when the financial arrangements proved to be unviable. The second was Baanpaew Hospital, a public hospital. Public hospitals are obliged to participate in the scheme but Baanpaew was exceptional in that it devised changes in management and specialisation that enabled it to remain financially viable, unlike many other public hospitals which face ongoing financial problems. The two case studies therefore shed light on the financial stresses to which the scheme led, and the types of responses that may be required to ensure the survival of the scheme in the future.

The importance of information and communication technology in healthcare has recently grown to an unprecedented dimension as more people are empowered by technology to participate more actively in their healthcare processes. New online applications for accessing healthcare information and for self-diagnosis have become increasingly available to diverse patient groups of different languages, educational backgrounds, and cultural orientations. However, the design of these applications typically follows Western cultural orientations. This approach has created a gap, which makes it difficult for users, who use the systems within their own cultural contexts, to derive maximum benefits from such use. As a result, the gap impedes the uptake, market success, and effective adoption of these e-Health applications in various cultural contexts. Moreover, as healthcare organisations increasingly seek to interact with patients, often in real-time, through enhanced web-based services, patient experiences often become tied to a largely ‘Western-driven’ style of patient interfaces, interaction, and look and feel that negatively impact the overall acceptance of these services across different cultures. This poses a tremendous challenge to technology adoption, in particular with regard to how to design culturally-aware and patientcentred e-Health applications that reflect the cultural diversity of today’s users and meaningfully empower them to better utilise such tools to enhance their day-to-day life. This research proposes to investigate the impact of a patient-centred culturally-aware design approach on the patient acceptance of e-Health web-based services, in particular, how e-Health web-based applications can be designed in a way that maximises their usability and ‘fits’ them into the cultural fabrics of individuals in different cultural contexts. To address this challenge, this research work examined existing literature in the fields of culture, technology acceptance and HCI, and identified relevant constructs that were used to develop a culturally-aware technology acceptance model for electronic health. Subsequently, the model provided a means for understanding the influence of different factors affecting patient acceptance and usage which were used as a foundation to inform the design of the Patient-Centred Culturally-aware e-Health Design Approach (PCCeDA) framework for e-Health web-based services developments. The novelty in PCCeDA is the notion of cultural awareness, which allows systems to personalise themselves according to a patient’s cultural profile while adhering to usability principles. As a result, the interface and contents presented to a patient are both dynamically tailored to better suit that patient’s cultural preferences, thereby increasing patient adoption. Based on PCCeDA, a proof of concept prototype called i-Diagnose was developed primarily to assess the validity of the framework and to answer the central questions of this research study. Evaluation results show that a patient-centred culturally-aware design approach enhances the effectiveness, usefulness and patient acceptance of e-Health web-based services in different cultural contexts. The main contributions of this work include: (i) a culturally sensitive technology acceptance model for e-Health (‘e-HTAM’) where both technology acceptance model and cultural dimensions are integrated to develop the e-HTAM model. The model highlighted various issues that need to be taken into consideration when designing patient-centred culturally-aware e-Health Design Approach applications; and (ii) a patient-centred Culturally-aware e-Health Design Approach framework that allows systems to personalise both the patient interface and the contents provided to a patient to better suit that patient’s cultural background. The research also includes a number of other minor contributions such as: (i) an approach for solving the static nature of Hofstede’s dimensions’ indexation, through the use of cultural parameters to dynamically model users’ cultural states, (ii) the introduction of personalisation based on cultural factors into the e-Health web-based services domain, and (iii) shed light on the electronic health acceptance state in the UAE as compared to the UK.

Procurement of NHS primary care buildings was reserved for the DH working through PCTs until LIFT was introduced. The DH anticipated that LIFT would effectively mobilise private sector finance and expertise in improving the quality of buildings. But LIFT’s suitability to achieve this is questioned on grounds that it uses market mechanisms that may fail when applied in health. This case-study explored with people directly involved in LIFT their views and experience of how it helped them in procuring desired buildings. It was driven by desire to understand whether and how contextual factors and mechanisms in LIFT supported staff efforts, hoping the findings would influence DH officials in revising the guidance to make LIFT effective. Evidence was primarily collected through in-depth interviews with 25 informants drawn at two PCTs, the LiftCo and LIFT buildings. Data from interviews was complemented by documentary analysis and tours to make observations at four LIFT buildings. The data was coded for analysis in NVivo. The key findings were organized into four analytical categories aligned with the research questions for interpretation to generate relevant answers. The study revealed that the important factors for progress in LIFT involved commitment of PCT boards; engaging PCT managers in strategic decisions and empowering them in influencing governance issues. Progress may be enhanced through DH officials encouraging increased collaboration between LIFT partners and promoting contractor competition in service delivery. Barriers to progress included the LiftCo over-prioritising efficiency, hiring of contractors lacking experience in health, and the DH not sufficiently supporting PCT managers in increasing their capacity to make LIFT effective. Informants believed LIFT could improve procurement provided ways of addressing the barriers were explored. LIFT outcomes are a result of factors in its contexts influenced by policy-makers and decisions taken by operational staff. Recommendations are offered for these constituents in LIFT and for future research. DH officials should get feedback on practicalities of LIFT guidance by engaging PCT managers in making strategic decisions and empowering them in translating their experiences into actions. This could make LIFT effective and reduce the risks that were highlighted.

There is currently little empirical research exploring the uptake of management and organisational knowledge in primary care settings. More is understood about the transfer of clinical research evidence into practice to improve outcomes for patients and to keep professional knowledge up-to-date. This study uses a longitudinal, comparative case study design to explore how Primary Care Trusts (PCTs) and emergent Clinical Commissioning Groups (CCGs) applied managementbased knowledges within their organisations, documenting how this changed in response to shifting events (political, economic) at the macro level. Both case study sites underwent profound processes of organisational change and uncertainty during the period 2010-2012, so we contextualise the study’s overarching findings in a wider process of policy ‘turbulence’. The thesis identifies sources of management knowledge accessed by health care organisations and professionals engaged in commissioning work over time. Our findings reveal that commissioning organisations drew upon varied forms of health care management expertise from a range of knowledge suppliers: management consultancy firms, policy advisors, health care think tanks, management academics and local knowledge ‘champions’. The process of management knowledge utilisation in the health sector is therefore described as especially non-linear, pluralist and contingent on external reform narratives that focus managerial and clinical priorities.

Background: Defining poor GP performance through the target-driven lens of the Quality and Outcomes Framework (QOF) has its limitations. General practices which consistently underperform on QOF may be disengaged with top-down quality improvement initiatives – their characteristics remaining largely unknown. Aim: Through an ethnographically informed social constructionist methodological approach, I set out to capture the qualitative characteristics of ‘poor performers’ which lie beyond QOF targets. Method: I spent time embedding myself in the day-to-day reality of five practices across England, which have consistently scored in the lowest 10% of QOF scores nationally, since QOF’s inception. As a participant observer, I conducted interviews with the practices’ teams, kept field notes and sourced practice documents. The data were then analysed to identify key themes pertaining to the practices’ reactions to QOF and organised into case studies. Findings: Contrary to what would be expected from ‘poor performers’, there was evidence of high quality service delivery in some of the participating practices. The overarching themes concerned professional values and responses to QOF surveillance. A typology of the participating practices is proposed. Implications: This is the first time QOF poor performers and their responses to QOF have been studied in depth and by bringing together rich multi-source qualitative data. This thesis is important in recognising the values driving ‘poor performing’ general practices and the multi-faceted nature of quality patient care, and thus in highlighting the limitations of ‘one size fits all’ quality improvement initiatives. Government regulation is discussed in the context of surveillance and presented within a Foucauldian framework, supported further by current theory. It is suggested that in order to be effective, performance management must appeal more directly to the values driving general practitioners and their teams. The study contributes to knowledge by attempting to reframe current understandings of responses to surveillance and by presenting a typology of persistently low QOF scoring general practices.

Background: Social media are powerful communication systems that enable sharing, networking and information generation on an unprecedented scale. However, there is limited evidence as to how social media mechanisms are adopted by patients within health to engage with others, locate and generate information, or as a source of support. The primary aim of the study was to adopt social media to enable patients to engage in the process of producing and sharing health information and examine the impact of engagement on a patients’ self-efficacy. Research approach: A realist synthesis progressed in two phases (Oct 2011–March 2015) to determine the influential mechanisms (M) of the study, the context (C) in which they work and the outcome (O), known as CMO configurations. Phase 1: development of Greater Manchester Kidney Information Network (GMKIN), staff and patient training (Oct 2011–Sept 2013), moderation and site refinement (Sept 2013-Oct 2014). Phase 2: six steps of realist synthesis to identify, test, and extend a set of theories/ propositions (Oct 2011–March 2015); mixed methods realist evaluation, observation of on-line activity, self- efficacy scales, blogs and interviews (0/6 months) with 14 patients (Nov 2013–Sept 2014). Findings: The study strengthened evidence that engagement plays a crucial role in a healthcare social media intervention, building on an existing engagement model and knowledge. Three levels of engagement were identified: influencing roles, the conversationalists and general browsing. Engagement, an overarching mechanism, was a continuous process; influenced by attention, novelty, sociability, information and interactivity factors. Disengagement was characterised by inattention, triggered by environmental factors and decoupling, resulting from overwhelming information, health issues and negativity. Notifications often persuaded patients’ to re-engage. CMOs were identified and explored, outlining the role of each mechanism (Social Network Sites, Facebook, Twitter, blogging and forums) in triggering outcomes. Patients’ engagement contributed to information generation, which satisfied information needs. Satisfaction of information needs thorough social engagement influenced self-efficacy (in 13 of 14 people) and better management of illness. Social outcomes included seeking employment and getting involved in other things. Conclusion: This study refined and extended propositions based on a real life intervention. It combined Social Media mechanisms and engagement concepts in the context of health and tested what worked for whom, when and how. Using an innovative approach it generated new knowledge in understanding social media impact, health engagement practices and communities of practice.

No description available.

No description available.

Uncertainty in decision-making for patients’ risk of re-admission arises due to non-uniform data and lack of knowledge in health system variables. The knowledge of the impact of risk factors will provide clinicians better decision-making and in reducing the number of patients admitted to the hospital. Traditional approaches are not capable to account for the uncertain nature of risk of hospital re-admissions. More problems arise due to large amount of uncertain information. Patients can be at high, medium or low risk of re-admission, and these strata have ill-defined boundaries. We believe that our model that adapts fuzzy regression method will start a novel approach to handle uncertain data, uncertain relationships between health system variables and the risk of re-admission. Because of nature of ill-defined boundaries of risk bands, this approach does allow the clinicians to target individuals at boundaries. Targeting individuals at boundaries and providing them proper care may provide some ability to move patients from high risk to low risk band. In developing this algorithm, we aimed to help potential users to assess the patients for various risk score thresholds and avoid readmission of high risk patients with proper interventions. A model for predicting patients at high risk of re-admission will enable interventions to be targeted before costs have been incurred and health status have deteriorated. A risk score cut off level would flag patients and result in net savings where intervention costs are much higher per patient. Preventing hospital re-admissions is important for patients, and our algorithm may also impact hospital income.