Background: There is growing recognition in health policies and professional guidance that youth-friendly services must include the values and views of young people in their healthcare. The term “engagement” has become increasingly used in literature to recommend that healthcare professionals should involve young people in participatory methods and include them in their decision-making. Yet, the engagement of young people within health interactions remains a complicated process, often influenced by lived contexts, value systems and lifestyle choices. Successful engagement of young people is often cited to ameliorate health-related behaviours, improve health outcomes and increase awareness of their health needs; yet, a paucity of research exists for healthcare professionals seeking to engage young people effectively in healthcare interactions. Study Aim: To explore and define young people’s engagement within their healthcare interactions. Methods: A grounded theory study was conducted over a six-month period to gather young people’s perceptions of their health interactions. Results: The grounded theory study identified that young people produce engagement-related behaviour by means of an interpretive process. Three interconnected theoretical categories emerged: (i) prejudgement, the beliefs with which young people enter into health interactions; (ii) learning to be a patient, the means by which young people learn from their interactions to develop in-context engagement-related behaviour; and (iii) validation, the selective interpretation of information to justify their perception of the interaction. The core category identified that young people demonstrate a reliance on affect heuristics within healthcare interactions, which may influence the extent young people feel able to engage with healthcare professionals. This was elevated into a substantive theory of affect-mediated engagement. Conclusion: Findings suggest that a dual-process perspective of cognition may be useful to understand how young people engage in their healthcare; this could potentially be used by healthcare professionals to target issues that impact on a young person’s engagement. This study’s findings form a basis which would benefit nurses, occupational therapists and other healthcare professionals in developing person-centred interactions that empower young people in becoming stakeholders in their own health.

Background: Electronic Patient Records (EPRs) are being introduced into many healthcare organisations around the world. In the UK, EPRs are seen as one mechanism through which the NHS can become safer and more efficient. The policy and financial support for NHS hospitals to implement these systems, implies a strong evidence base supporting the rationale that electronic records improve health outcomes and quality of care. In reality, there is limited evidence to support this, with a lack of understanding as to the best approaches to and the benefits, barriers and impact of implementing EPRs; particularly within the NHS. In this thesis, the implementation of EPRs into NHS secondary care organisations is explored. Methods: A range of methods were used to explore the implementation of EPRs into NHS secondary care organisations. A policy analysis studied national NHS IT policy documents and evaluations of national NHS IT policy between 1998 and 2015 to investigate whether progress has been made in relation to implementing EPRs into NHS secondary care organisations. A mixed methods approach was adopted to explore the approaches to and challenges and benefits of implementing EPRs in NHS trusts throughout England; this comprised an online survey and semi-structured interviews with chief information officers. Lastly, qualitative interviews explored NHS staffs’ perceptions and experiences of the benefits, barriers and disadvantages of implementing a maternity information system into a single maternity unit. Results: There has been little progress in implementing EPRs in secondary care since 1998, the reasons for which are multifaceted and include a paucity of guidance surrounding the optimum approaches to implementing EPRs with a range of additional social and technical factors. Proposed benefits of EPRs largely related to improved: information availability, accessibility, transfer and legibility; with a limited number of efficiency and patient safety benefits also reported. Conclusions: This thesis adds to a limited UK evidence base and provides a greater understanding of the approaches to and various social and technical factors associated with implementing EPRs into NHS secondary care organisations.

Objectives – The purpose of this research was to gain insight into the information behaviour of health service managers as they informed critical decisions unrelated to individual patient care. Methods – This research used two series of qualitative interviews, documentary analysis (a calendar study), a card sorting exercise and a demographic questionnaire to explore the workplace information practices of health service managers. Thirty-six managers were interviewed. Both interview studies used the critical incident technique and cross case analysis. Results are reported with observations and conclusions supported with interview content. The Second Interview Study also used within case analysis in the form of information transaction mapping. Information transactions, calendar study and card sorting exercise data were reported quantitatively. Results – Findings included that these health service managers practiced satisficing, integrating and balancing multiple types of information from multiple sources to inform their decisions until they reached the point of information saturation. After this point, additional information would not make a difference to their decision. Their dominant means of acquiring information was oral information sharing over information seeking. Conclusions – Healthcare services managers support decisions with both facts and value-based information. Lower levels of managers and hybrid managers might benefit from library and information services designed to support them as information gatekeepers. The findings may also encourage health researchers and health research funders to make sure their research informs information sources that health service managers find most convenient to use. These include explicit information such as professional standards, and interpersonal sources such as positional information gatekeepers, experts and conferences.

Aims This study aimed to identify the key elements of effective leadership in interdisciplinary health and social care teams providing community rehabilitation and intermediate care in England, and investigate their impact on services, staff, team dynamics and patient outcomes. Methods This mixed methods health services research investigated workforce issues through the use of a range of methods including a literature review, qualitative study and a cross sectional quantitative study. Fifteen staff interviews were conducted during the qualitative study. Data was recorded, transcribed and analysed thematically using a template approach. The cross-sectional study generated data from 10 teams, including 210 staff and 2210 patients. Results The results of the qualitative study show that because of the interdisciplinary nature of the workforce in community rehabilitation and intermediate care services and the unique context in which they operate, interdisciplinary team leadership (IdTL) does require a distinctive form of leadership. However, IdTL does demonstrate many of the same elements as generic theories of team leadership. The quantitative study found that there were significant associations between: Service structure and working practices and IdTL; IdTL and staff and team behavioural dynamics; staff behavioural dynamics and team behavioural dynamics. No direct relationship was found between IdTL and patient outcomes. Weak statistical relationships were found between staff and team behavioural dynamics, and patient outcomes Conclusions The research shows that effective IdTL can significantly improve staff and team behavioural dynamics. There is some indicative evidence of the effect of staff and team behavioural dynamics on patient outcomes. These results were achieved with a sample of only 10 teams, which provides encouragement that leadership in IdTL is worthy of further investigation.

The study of professional identities in health and social care (H&SC) was last prominent in the 1980s, with social theorists and policymakers taking an interest the way in which identities and roles were formed. This thesis proposes that the study of professional identity in H&SC requires renewed attention, especially in the context of expectations that students will both train and work across professional boundaries. Specifically, the thesis questions whether experiences of interprofessional education (IPE) and collaborative practice have any impact on perceptions of professional identity for those working in H&SC, and examines how socialisation processes influence the development of ‘professional identities’ as well as considering the implications for patient care. A case study of a large-scale interprofessional programme – the ALPS CETL – is also drawn upon to examine the long-term impact of IPE initiatives on the identities and roles of staff involved in interprofessional initiatives. The empirical elements of this study consisted of surveys of practicing (n=288) and academic (n=31) staff, and interviews with participants drawn from the same groups (n=33). Drawing upon both thematic and narrative analysis of the data, the thesis argues that previous conceptualisations of professional identity aligned to a ‘whole’ profession do not relate to the way in which H&SC professionals actually perceive their identities. As respondents were far more likely to identify as being part of a branch or sub-group of a profession, it is proposed here that the concept of an ‘intra-professional identity’ is a more useful way to conceptualise the identity of H&SC professionals. More ‘senior’ professionals appeared to be more comfortable with their own professional identity, and with working across professional boundaries, than junior colleagues. This has implications for the way in which IPE is ‘taught’. Finally, in order to address identified tensions between professional identities and cross-professional working, it is proposed that the concept of ‘interprofessional responsibility’ can and should be incorporated into the professional identities of all H&SC staff.

No description available.

Health economic evaluations, developed for the purposes of informing technology adoption decisions in publicly-funded health care systems, should strive to make use of all relevant evidence. Any failure to meet this objective will result in a partial representation of the evidence base and, consequently, there is a potential risk of obtaining misleading results. Unfortunately, a lack of comparability amongst the alternative measures of health-related quality of life (HRQoL) complicates the synthesis of this type of evidence. One solution to this problem is to specify a reference case measurement to promote comparability, although this may provide an incomplete representation of HRQoL effects or, in some cases, no evidence at all. The application of mapping functions - statistical algorithms that link HRQoL measures - might provide a means to incorporate a broader range of heterogeneous outcome measures for evidence synthesis. One method in particular, known as the common factor model (CFM), has been proposed in this regard due to its coherent mapping properties. Research involving the CFM has been conceptual to date and only a handful of case studies have ever been conducted. However, this method can be formulated as a structural equation model (SEM), an approach that has benefited from extensive application in other areas of research. The primary aim of this thesis is to investigate the plausibility of SEM methods serving as a generalised framework for the handling of HRQoL evidence. SEM methods are tested across scenarios involving aggregate data, individual patient data and a combination of both; in each case, a comprehensive synthesis of heterogeneous HRQoL outcomes using the SEM approach is compared against a restrictive synthesis involving a reference case measurement. In addition, the implications of these alternative approaches are explored from a decision-making viewpoint.

Within the field of health care, this study has addressed a lack of current research exploring social aspects of a clinical network. In presenting the final stage of this study, this document focusses on the engagement experience from a medical viewpoint. This is topical and of interest, as doctor engagement in the NHS is associated with enhanced organisational performance and improved patient care. There is little previous empirical research exploring the engagement experience from the perspective of doctors working in a clinical network. The final stage of this research study therefore presents a new theoretical understanding of this subject area. Throughout the study, the author has demonstrated that clinical engagement is at the heart of a successful clinical network. The study is qualitative in nature and takes an interpretive epistemological orientation. Data is gathered through a number of research methods and doctors’ perceptions of engagement are explored through emerging narrative accounts. Findings from this research study indicate that choice of engagement leads to both the engaged doctor, and the reluctant manager, and has highlighted that choice of engagement is influenced by a perceived internal and external conflict. Outcomes confirm that doctors will choose to engage when they have a personal interest and commitment, feel that they are listened to and have a voice, perceive that they are valued and respected, are involved and able to influence, have power and respect and where the environment that they work in fosters collaboration, facilitates the sharing of expertise and specialised knowledge and offers both personal and professional support leading to improved patient care. Exploring why doctors choose to engage in a clinical network has confirmed the requirement to create a culture for engagement and identified that successful engagement leads to improved patient care, a factor that has been constant throughout this research study.

Healthcare providers are motivated by a combination of financial and non-financial incentives. This thesis focuses on two specific forms of these incentives: pay-for-performance (P4P) and reputation. Despite increased use, there is limited evidence on how financial and reputational incentives interact, or on how financial incentives affect patients and professionals. We further our understanding with respect to P4P and make recommendations about the design of future schemes. We achieve the thesis aims by producing four empirical studies. Each empirical study uses data collected as part of a national P4P in the English National Health System, the Quality and Outcomes Framework. We begin with an investigation of the relevant importance of financial and reputational incentives in determining provider performance. We use administrative data for nine years of practice performance on a range of indicators totalling close to five million observations. This analysis covers a period during which the financial and reputational rewards were changing. We find that initially, financial incentives had a larger effect on performance. Over time, reputational incentives become more important. Our second study uses changes in the organisational structure of healthcare providers to explore whether the observed similarity in the performance of nearby practices can be explained by peer effects. We measure the performance of 8,000 individual practices and their peers for five years. When peer groups are merged, there is a reduction in peer effects for old peers and an increase in peer effects for new peers. Practices seem to be pulled down by the presence of poor peers in their group. In our third study we measure the impact of variations in the proportion of income at risk to P4P on the working lives of GPs. We combine administrative data with survey data from before and after the introduction of P4P. Our sample consists of approximately 2,000 GPs who provide detailed information about their working lives. We find that providers are unaffected by these variations despite income at risk being high. Finally, to observe the relationship between quality of care reported at the patient level and at the practice level we link practice performance with a detailed survey of the English population aged over 50 years. Correlations are generally smaller than expected and negative for some areas. Practices may have lacked an incentive to communicate their care adequately to patients and may have diverted attention away from areas of care without financial incentives. Non-financial incentives can be effective motivators when peer performance is observable. Professionals are also unlikely to associate negatively with income being related to their performance, along as incomes remain high. However, patients may suffer from a lack of communication about the type of care they are receiving.

It is a goal universally acknowledged that a healthcare system should treat its patients – and especially those in need of critical care – in a timely manner. However, this is often not achieved in practice, particularly in state-run public healthcare systems that suffer from high patient demand and limited resources. In particular, Accident and Emergency (A&E) departments in England have been placed under increasing pressure, with attendances rising year on year, and a national government target whereby 98% of patients should spend 4 hours or less in an A&E department from arrival to admission, transfer or discharge. This thesis presents techniques and tools to characterise and forecast patient arrivals, to model patient flow and to assess the response-time impact of different resource allocations, patient treatment schemes and workload scenarios. Having obtained ethical approval to access five years of pseudonymised patient timing data from a large case study A&E department, we present a number of time series models that characterise and forecast daily A&E patient arrivals. Patient arrivals are classified as one of two arrival streams (walk-in and ambulance) by mode of arrival. Using power spectrum analysis, we find the two arrival streams exhibit different statistical properties and hence require separate time series models. We find that structural time series models best characterise and forecast walk-in arrivals, but that time series analysis may not be appropriate for ambulance arrivals; this prompts us to investigate characterisation by a non-homogeneous Poisson process. Next we present a hierarchical multiclass queueing network model of patient flow in our case study A&E department. We investigate via a discrete-event simulation the impact of class and time-based priority treatment of patients, and compare the resulting service-time densities and moments with actual data. Then, by performing bottleneck analysis and investigating various workload and resource scenarios, we pinpoint the resources that have the greatest impact on mean service times. Finally we describe an approximate generating function analysis technique which efficiently approximates the first two moments of customer response time in class-dependent priority queueing networks with population constraints. This technique is applied to the model of A&E and the results compared with those from simulation. We find good agreement for mean service times especially when minors patients are given priority.