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This thesis considers the commissioning of secondary care by Primary Care Trusts (PCTs). It provides an in-depth analysis of the commissioning relations and decision-making between PCTs and NHS Trusts using the underlying assumptions of principal-agent theory as a lens for investigation. This qualitative research adopted a range of methodological approaches including the use of observation, interviews and documentary evidence in the analysis of three case studies. The case studies each comprised an NHS Trust and up to four PCT commissioners. Commissioning-related meetings were observed in order to gain an understanding of the ways in which PCTs and NHS Trusts acted as principals or agents, and how these relations were managed. These were followed by interviews with managers and clinicians from primary and secondary care to complement the observational data and to investigate additional issues such as the impact of multiple principals and tiers of principals and agents. Service and Financial Framework documents and Service Level Agreements were also examined. Analysis shows that commissioning was approached in a different way in each case study. The factors affecting the approaches to commissioning were perceptions of local and national pressures, accountability, a public service ethos, leadership, trust and local history. Incentives were not used in Service Level Agreements. In each case study, there was a weak link in the principal-agent chain of commissioning that had the potential to result in non-compliance with decisions. This weakness arose either between commissioner and provider, or between managers and clinicians. In either case, the greater use of incentives is suggested as a solution. Some PCTs did not appear to accept the legitimacy of their roles as commissioners. In addition, and unusually, the principals had an agent role; PCTs were providers as well as commissioners. These dual roles created conflicts of interest.

No description available.

The focus of my research was to investigate the dilemmas of change experienced by middle managers so that I can respond to the research problem (knowledge gap) concerning the ineffectiveness of change management strategies in the NHS.

This thesis explores changes in medical professional work and regulation in the context of emerging 'patient safety' health policies. The study engages with three components of this policy. First, to what extent is the concept of error promoted in theory and policy being taken up within managerial practice and is this coterminous with the medical interpretation and construction of error? Second, how do medical professionals regard the introduction of new reporting systems to collect information about errors in their work? Third, what new organisational systems are being developed to analyse and control errors and how do these diverge with those approaches advocated and practiced by medical professionals? It has been estimated that one in ten of all inpatient admissions experience some form of error in the delivery of care, totalling 850,000 events a year. Given such findings a new policy framework is being developed to improve 'patient safety' in the NHS. Following the Human Factors approach a new error management system is being introduced that consists of incident reporting procedures for the collection of information about errors, matched by techniques to identify the "root causes", and promote organisational change. Of importance for this thesis is the impact of policy on established forms of medical regulation. Through predominantly qualitative research techniques, this study has been carried out within a single NHS hospital case-study involving medical and managerial occupational groups. The empirical findings suggest, firstly, that the medical construction of error is indeed divergent from that advocated in policy and practiced in management and leads to distinct trajectories for the control of error. Secondly, medical professionals are generally disinclined to participate in managerial forms of incident reporting, and where such a system is in place there is a high degree of localised professional leadership. Thirdly, it was found that alongside new managerial systems for the control of errors, there were also a range of professional-led systems embedded within medical work and the local organisation of the hospital that had precedence of other centralised hospital systems. In consequence, the ability of managerial systems to penetrate the working environment of medicine was negligible. In conclusion, it is argued that while this policy could appear to challenge the basis of medical professional regulation the social, cultural and structural context of medical work is adapting to maintain a high degree of medical control and resist managerial encroachment.

This thesis presents an action research study concerned with strengthening decision-making within a councillor model of shared governance in a UK hospital trust. Shared governance seeks to flatten traditional hierarchies by empowering clinical staff to make decisions affecting policy and practice. Chapter 1 sets the scene for this exploratory case study through identification of the national and local health care context. The model of shared governance chosen for investigation is presented. An overview of the thesis is given. Chapter2 presents a literature review of shared governance framed by undertaking of a concept analysis. Existing evidence concerning shared governance and decision-making is examined. Chapter 3 considers methodology issues and justifies the selection of a qualitative approach that embraces action research as a means of promoting integration of findings into decision-making practice. Chapter4 sets out the methods used to collect data in response to the research questions. Issues around access to the research setting are discussed. Sampling decisions are made explicit and a description of the data collection process is given. Extensive use has been made of participant-observation as well as interview techniques. Chapter5 presents adetailed narrative of the approach to analysis centring on the use of basic and advanced data displays to aid qualitative data analysis. Chapter 6 details the study findings and culminates in the presentation of a conceptual model of shared governance decision-making. Chapter7 provides a substantive reflective narrative concerning my research practices and experiences throughout the action research journey, and the impact of these on my personal development. Chapter8 discusses the study findings in light of a summative review of the literature and evidence around shared governance and decision-making. Implications for practice and policy are identified along with areas for future research.