Since April 2013 and under the auspices of a controversial piece of legislation the Health and Social Care Act 2012 General Practitioners in their newly formed Clinical Commissioning Groups will be at the helm of the English NHS, making clinical and financial decisions for their respective communities. These 211 statutory bodies hold the reins on two thirds of the NHS budget. Accountability, I~'adership, and the potential impact on the patient are under the greatest scrutiny at a time of austerity and an increasing demand from an ageing and expectant public. This study is important because these new legislative requirements are not subtle policy nuances they are controversial, complex and inter-related and represent the biggest changes to NHS governance in the organisation's 65 year history. This research brings together the views and observations of fifteen key NHS policy makers, advisors, influencers and implementers as these new policy arrangements are implemented. These views are considered under three major headings: The General Practitioner and Reform, The Patient, and Governance, Leadership and Management. The data gathered from the interviews are considered within the context of theoretical literature on policy-making, implementation and research literature on health care reform. Despite the intention of the state to make commissioners more 'locally accountable to patients', and to enable 'clinicians to be empowered to make decisions' and to 'cut bureaucracy making £20b savings', the key findings of the study identify the significant lack of accountability in arrangements between Clinical Commissioning Groups and General Practitioners. The study found general disengagement of the key actors (General Practitioners) in implementing the legislative structure. Rationing and restricting access to services and the de-commissioning of services without wider public/patient debate has proved to be an ethical dilemma of General Practitioners, who in putting the patient first indicate that financial duties to balance spending and meet future spending cuts remain a significant tension, and a concern, bringing conflict to the NHS.

This research explores how medical directors discursively construct their identity in the challenging context of the National Health Service (NHS). The role of NHS medical manager was created as a hybrid bringing together the conflicting roles of doctor and manager and to help overcome medical resistance to management. The medical director, as the most senior doctor-manager, is a board appointment with responsibility for medical affairs. While this is presented as a high status position allowing doctors to take responsibility for managing their institutions the different demands and identifications could be a site for conflict between the role of doctor and manager within the medical director identity construction. The experience of medical director identity is explored through social identity theory (SIT) (Tajfel & Turner, 1986) and Butler's (1999) theory of performativity. This allows exploration of identity as both enduring and fleeting. Documents outlining the medical director role were examined and several conferences aimed at medical directors observed to provide context. Twenty incumbents were interviewed to explore how they understand their role and experience their identity. Discourse analysis was used to uncover identity experiences and to highlight power struggles enacted through the hybrid. The analysis reveals that the medical director role is ambiguous, that medical identity is robust and that medical management is difficult compared to clinical work. Managerial identity in general, is constructed negatively and from the perspective of doctors. In authoring their own managerial identity medical directors emphasise the positive intellectual challenges of the role but struggle with relationships with their medical colleagues, particularly those in difficulty. The importance of maintaining clinical credibility is both embraced and contested as a resource which bolsters and maintains medical identity and so distinguishes medical directors from the taint associated with the pejorative managerial identity that doctors construct of managers. Medical directors identify themselves as a bridge between management policies and medical professionalism. However, analysis of this discourse demonstrated the ways in which it might maintain separation and preserve medical uniqueness. In conclusion, while the identity of doctor is best understood through SIT as powerful, desirable and stable, medical director identity is seen to be a less stable performative achievement. The hegemonic struggle is localised in the identity of the medical director where the dominant discourse of medicine retains its ascendant status in the very role designed to reduce the divide between medicine and management.

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Call data, for NHS Direct North West Coast, were analysed to determine usage of the service by different sections of the population. The research reported here shows that not all population groups access NHS Direct equally. The service is used less than predicted by younger people, the elderly, men and South Asian ethnic groups. This study did not however confirm the findings of previous studies that lower socio-economic groups tend to use the service less.

The purpose of this study was to develop an organisational improvement approach in NHS commissioning using the principles of continuous improvement and Lean. This report presents the development and installation of a novel NHS Commissioning Improvement Framework (CIF) within a primary care trust context and evaluates the impacts made in practice. Through a programme of action research, this study has been able to show how the principles of Lean can be introduced into the day-to-day practice of a commissioning organisation and deliver measurable benefits to both patient and the organisation through the application of the CIF. For the past two decades (DH, 2000), it could be argued that the improvement agenda in the NHS has been the 'silent' partner in delivering performance targets; focusing efforts on improving access to treatment In my experience, the basic fundamental of improving patient experience has been overshadowed by the performance agenda. In recent years, there has also been a drive for improvement from a commissioning perspective. However, improvement processes are more suited to the needs of healthcare providers, thus commissioner-orientated improvement methodologies are somewhat lacking. The major contribution made by this study is a new commissioning improvement model (the CIF) that integrates the principles of continuous improvement and Lean into NHS commissioning. Structured into three main domains: Position, Process and Drivers, the new model highlights the importance of a high degree of workforce engagement and staff development. The action research process used was an intuitive part of the change process and provided a prospective view of what was required to further embed improvement into commissioning practice. Complemented by a programme of practice development and classroom education; an increase in workforce improvement understanding and capability has been seen to deliver a number of measured improvements for both patient services and commissioning organisation alike.

This thesis focuses on the different morbidity rates reported by men and women. Hypotheses are developed to account for this phenomenon, which are subsequently tested using the General Household Survey 1982. Chapter one looks at the history of medicine, identifying the paradigms which have shaped the discipline. These paradigms whilst being theoretically complementary have at times been in dispute. The disputed area is that between the social and the organic. Chapter two reviews the literature which suggests explanations for women's higher morbidity rates. These explanations stress the social differences between men and women. The adult roles of marriage, parenthood and employment are posited to be problematic for women, in terms of health, due to the gendered nature of child care and domestic tasks. It was felt that role overload for women would be exacerbated in a context of material deprivation. A number of hypotheses were then formulated which related adult roles and material deprivation. The next three chapters deal with the methodology to be used in the testing of the hypotheses formulated above. Chapter three begins by defending our use of secondary analysis as appropriate for this purpose. It addresses the criticisms of survey techniques, discusses the benefits and limitation of this methodological approach and looks at the varieties of research made possible with secondary analysis. Chapter four focuses on the origin and development of the General Household Survey. The quality of the data is discussed in terms of the sampling design and data collection. Also in Chapter four articles are reviewed to assess the GHS's research contribution to the behaviours of drinking and smoking and to the debate over inequities in health service provision. In Chapter five we operationalize our variables from the concepts generated in Chapter two. We also explain any data manipulation necessary to the analysis. Chapters six and seven tested the hypotheses formulated in chapter two. Gender differences in health outcomes due to adult roles were found and these differences were often exacerbated by material deprivation. With reference to the hypotheses in Chapter two and the findings of Chapters six and seven, Chapter eight uses logit analysis to address gender divisions in health. The findings of the three analysis chapters are discussed in Chapter nine.