In the early 1990s, a set of market oriented reforms was introduced into health care systems of the UK and Sweden, two exemplary cases of the reliance on planned budgeting and integrated provision of services. In the pursuit of increased efficiency, several County Councils in Sweden have followed public competition model while in the UK internal market reforms were introduced. It was expected, that the separation of functions of planners and purchasers from those of providers, would achieve higher allocative efficiency but it would also enhance users' satisfaction with care. This thesis used cataract surgery as a case study to trace the impact of competition among providers and the separation of purchasers' functions from the former on the set of selected indicators: choice, information, quality, responsiveness and efficiency. Qualitative research methods were employed to record the perception of changes of those indicators for patients, primary care providers, eye surgeons, managers and purchasers. A set of open ended and standardised questionnaires was designed to elicit the views of all actors involved and to measure the likely transformations. These data were then compared with quantitative figures obtained from hospital registers and national league tables where numbers of operations performed as day/inpatient cases, prices for service and waiting times for the first specialist appointment and cataract surgery were examined. Four study sites from outer London and the only existing large provider of eye services to Stockholm County Council were selected and used for the purpose of international comparison. The analysis of the data showed that the quasi-market reforms have resulted in a change of the attitude of secondary providers, which had some positive influence on quality of care expressed in reduction of waiting times at the outpatients' department and as tailored appointments for the surgery. Some improvements in the amount and type of information given to purchasers and patients could be detected, although as far as direct users were concerned, the demand for it has not been fully satisfied. However, the impact on choice available to patients and purchasers alike seemed to be adverse, an effect that was particularly strong in the UK case and which was precisely the opposite of what reforms proclaimed. This was partly a result of disincentives introduced by the reforms but it also reflected the ambivalence that patients had towards enacting their choices. Another finding was that General Practitioners were on the whole poorly informed about the changes and were unable to comment on many of the issues asked. This raises questions about the uncritical endorsement of vast responsibilities into the hands of intermediaries alongside the recent changes of the NHS. Responsiveness measured as changes in the waiting times for the first specialist appointment and for the cataract surgery itself showed an uneven trend. Both decreased in the short-term and then increased to the pre-reform levels after this issue ceased to be the priority on the governments' agendas, implying that these short lived effects must have been rather a result of specific interventions and not the consequence of the market's work. It was also demonstrated that those providers who successfully responded to the market incentives and delivered services of high quality efficiently, were also more keen to shift to the technologies with cost-saving potential. However, there was no clear evidence of the impact of those changes on the prices of service despite the increases in the numbers of operations. The overall conclusions are that market reforms even in its modest form were hardly allowed to work and when they worked they did not always produce what theory predicted. This was a result of the half-hearted belief in their effectiveness, the lack of clarity in policy formulation and conflicting objectives being pursued simultaneously, which possibly explains why most respondent groups could not see any major changes.

The shift in the balance between the primary, secondary and tertiary levels of the National Health Service is an established trend in health care. This has been motivated by various factors, including the desire to improve access to services. However, service shifts can stimulate further demand and thus undermine efforts to improve services overall. There is a need for "joined-up thinking" in respect of service shifts since existing analyses have been limited to isolated parts of the system, and little attention has been given to the actual mechanisms of the feedback or knock-on effects. The model-based methodology of system dynamics could be useful as it is designed for the study of the connections between different parts of systems and feedback effects. This thesis assesses the usefulness of system dynamics as a planning and evaluation tool for service shifts. A case study approach is followed, based upon a shift in cardiac catheterisation services from the established tertiary level to the secondary level involving three hospitals in England. The factors involved in service shifts are described, and the processes and causative forces at play across the different health service boundaries are captured by means of the system dynamics-based model procedure. The study reveals several interacting feedback mechanisms underlying changes in demand. It also demonstrates that by understanding the feedback structure, "joined-up solutions to joined-up problems" may be designed. For example, a more effective policy would be the service shift (to improve access) combined with the use of clinical guidelines (to suppress demand) and with changes to the forces that drive activity rates (to ensure that both the average waiting time and the waiting list length are controlled), In feedback terms, using clinical guidelines weakens existing feedback mechanisms whilst changing the forces that drive activity rates creates new feedback mechanisms.

In recent years, the quality of non-clinical elements of health care has been challenged in the UK. While dimensions such as the environment, communications, reliability, access, etc., all contribute to making patients feel more at ease during a time when they are at their most vulnerable, they often fall short of what they should be. This paper supports the shift towards greater emphasis on understanding the functional elements of health services in an effort to improve patient experience and outcomes. While there is an abundance of literature discussing the evaluation of service quality, much of this focuses on the SERVQUAL model and, although there is increasing debate about its relevance across sectors, no alternative has been offered. This paper argues that the model lacks substance as a tool to evaluate quality in the complex environment of health care. The study embraced multiple methods to acquire a greater understanding of service quality constructs within the health care sector. It was carried out in three phases. The first comprised critical incident interviews with service users, which highlighted both successes and failings in their care. This was followed by staff interviews and focus groups representing a cross section of the public, providing an insight into how different groups perceive quality. The data was used in the design of a detailed questionnaire which attracted in excess of 1,000 responses. Factor analysis was then used to develop a framework of key elements relevant both to hospital settings and to those services provided in the community such as general practice. The findings provide a four-factor model comprising: trust, access, a caring approach and professionalism, three of which are comprised primarily of human interactions. These findings suggest that although the original SERVQUAL ten-item model does have some relevance, with the adapted five-item model being far too simplistic, neither fully addresses the needs of a sector as unique and high contact as health care. The results point the way for further research to develop a detailed model to evaluate service quality in health care settings.

The aim of this thesis was to investigate decision-making in the management of minor illness, in the context of symptoms associated with analgesic use. In 2002, a cross-sectional survey was mailed to a random sample of the Scottish population (n=3000) asking about their use of medicines, particularly over-the-counter (OTC) analgesics. In 2004, qualitative interviews with 24 respondents asked about how and why people manage symptoms of minor illness associated with analgesic use in particular ways. Finally, in 2005, another survey containing a discrete choice experiment was mailed to a further 652 respondents to the original survey, to establish preferences for self-care and different services that might be used to manage minor illnesses. The survey showed that analgesics were the most commonly used OTC medicines. Paracetamol was the most frequently used drug, headache the symptom most often treated, and community pharmacies were most people's usual source of analgesics (for reasons of convenience). Younger, female, better educated people, those required to pay prescription fees, and those not using prescribed analgesics were more likely to have used an OTC analgesic than their relevant counterparts. Up to 8% of the population appeared to be at risk from inappropriate use of OTC analgesics. Interviewees responded to symptoms associated with analgesic use by consulting health care professionals, practising self-care or doing nothing. Reasons for practising self-care included convenience, influence of others, avoidance of medical interventions, supplementation of medical treatments, and perceived appropriateness. Factors that influenced how people managed symptoms mapped well onto Andersen's Behavioural Model of Health Service Use. The DCE found that people preferred to manage flu-like symptoms using unsupported self-care and were willing to pay almost £23 to do so. When advice from a health care professional was required, community pharmacy or GP were the most preferred sources. Other types of management (practice nurse consultation, complementary therapist and NHS 24 advice) were preferred significantly less.

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The changing face of patient’s populations in the UK has resulted in notable increases in cultural diversity that impact on health care service provision, access and utilisation; with health services underutilisation, prevalent more among immigrants due to heavy reliance on cultural and religious cure methods. The aim of this thesis therefore, was to explore how Nigerians in the UK engage with the British health system. This objective was pursued by integrating immigration issues, with factors associated with decisions to seek medical help, including health beliefs, access, attitudes, cognitions, and socio-political and religious experiences (past and present) that impact upon health outcomes. A triangulation approach was employed, involving a critical review of measures, and four empirical studies consisting of qualitative and quantitative research methodologies. Results show that health-seeking behaviours among Nigerians were best accounted for by their religious and cultural beliefs, as typified by their health context before migration. Religion was not found as a barrier to medical help-seeking; the regression analysis revealed that belonging to the Christian religious group predicted increased medical help-seeking; although assimilation to the British culture was associated with reduced religious behaviours. However, the role of other religious groups regarding medical help-seeking remains unclear, and needs a more focused study. In addition, care providers mainly agreed on the benefits of integrating the spiritual methods into formal healthcare systems, bringing some challenges which were tentatively negotiated through the theory of transformative coping (TTC). Findings have implications for research, policies, and clinical practice, particularly when culture-sensitive and integrated health interventions are tailored to the needs of the diverse immigrant populations in the UK.

This study took place in the UK, National Health Service (NHS), against a background of poor staff morale, continuous lack of funding and a perverse management performance measurement system. The study investigated the impact of Theory of Constraints (TOC), a change methodology previously employed in the private sector and now adapted to the health sector, on three NHS Trust departments, Neurosurgery, Eyes and ENT, especially in relation to reducing waiting lists in the system and improving throughput of patients. Data were collected over a period of forty months, on a number of NHS performance indicators, before and after the TOC intervention. An interrupted time series design with switching replications (Cook and Campbell, 1979) was used to investigate the impact of the intervention. An overall ARIMA analysis indicated that TOC had an impact in both Eyes and ENT. 16 out of 18 measures went in the direction of the hypotheses, the probability of these changes in the predicted direction by chance alone was 0.0006. However, there was a lack of significant improvements in Neurosurgery that was associated with the size of the system, complexity of treating neurological disorder, heavy reliance on support services, impact of emergencies on elective work and the motivation and receptiveness of staff to the proposed changes. In order for organisations to maximise the benefits of TOe organisations should take into account the social environment in which they exist. The importance of customising the intervention to the local need of each department, leadership requirements and robust project management, as failing to do so can potentially derail the change process.

A growing body of research has emerged over the last two decades describing how complementary medicine (CAM) and orthodox medicine might work together to provide a new 'integrative medicine' (IM) approach to healthcare. My research adds to that knowledge by providing an experiential insight into the problems and the possibilities of IM, specifically in the National Health Service (NHS) primary care setting in the UK. As a non-NHS massage therapist and researcher, I began the action research (AR) cycle by negotiating with GPs a 'transformative' approach to collaboration (Luff and Thomas, 1999:11). This approach entailed working, as seamlessly as possible, as a member of the clinic. I provided free massage therapy treatments for one afternoon each week (in two clinics), but only to patients referred by a GP who had identified them as having uncomplicated but debilitating musculoskeletal conditions. The aim was not to replace other therapies, or to study outcomes for massage therapy, but rather to participate in the clinic and to study the practical problems for IM by looking closely and reflexively at the interface between complementary and orthodox practitioners working with the same patients. The methodological approach of AR provided the framework for gathering contextual data whilst simultaneously affording reflexive and collaborative, inter- professional opportunities for problem solving, thus grounding the data in real-to- life experiences. This provided data from multiple perspectives, responding to the needs and views of the other stakeholders as well as those of the CAM therapist (myself as researcher/therapist). As planned, this research generated opportunities to identify both problems and collaborative solutions. However, the reflective cycles inherent in AR also _ brought to light unexpected, emergent themes, providing learning cycles which culminated in a new awareness of the barriers facing IM. The conclusions suggest that more thought needs to be given to ways in which the structural and inter-professional barriers inhibit IM. Recommendations identify that structural changes would help CAM therapists to understand and negotiate the centrist and complex governance in the NHS; and that improved opportunities for inter- professional dialogue would help to reduce the inherent problems of occupational closure and inter-professional conflict.

Integration of working practices has been promoted by successive governments as a means of service improvement in a variety of contexts in health and social care and the term 'integration' has become a seductive, popularized and overused signifier. The rhetoric and conceptualization of integration as a working practice appears to be based on confused and contested notions of what a practice is, thus serving to undermine both the fundamental principles relating to professional learning, values and identity as well as the (ontological and epistemological positions which inform them. Using a theory of change approach to evaluation, (Weiss 1995, 1998; Chelimsky,1997) that combines mixed methods for data collection, including some interviews, observations and a case file study (Thorpe & Thorpe 1992; Thorpe 1994) of recorded practice outcomes for service users in pre and post integration comparative periods, this case study (Stake, 1981; 2006) explores the process of implementation of integrated care practice through the comparison of four sites within one Local Authority area. This study focuses on the whole process of change in this practice context, including: the development of national (macro) policy promoting integrated working; the interpretation of that policy at the strategic (meso) organisational level and the operattonalisation of the concepts, enacted at micro level. The first part of this thesis is concerned with setting the scene and presenting the context and issues that form the basis of the study. The middle part presents some explanatory frameworks, derived from Social Practice Theory, that are applied to the issues emerging from the data in order to develop an understanding of how chang~ is represented, symbolised and enacted in particular clusters of practice. The final part constitutes a discussion of the findings and the development of typologies of integrated practice that are used to develop a continuum of integrative practice that may assist in identifying how to unlock practices that have become stuck and unable to respond to the call for change. The thesis concludes with some observations on the applicability of this method to other contexts of complex change activity.

The central aim of this study was to explore the success of NHS Continuing Healthcare (CHC) policy in improving the joint working relationship between health and social care in England. Until the 2007 National CHC Framework, eligibility criteria had been set locally, resulting in significant area variations. The Framework aimed to standardise criteria and make the process clearer and fairer to access; joint working in key areas was a central mandate. Study objectives were to identify changes in consistency in application of CHC eligibility criteria and uniformity of practices in response to the CHC Framework, and to consider whether this had led to more equitable access to NHS funded care for individuals. The research was conducted at a national level, involving the collation of secondary quantitative data, supported by research evidence, and at a micro level through an in-depth, triangulated investigation of three Primary Care Trusts, and their coterminous Local Authorities from different areas of the country. Research with the sites involved identification of quantitative data, and face-to-face interviews to determine their organisational cultures for partnership working and how this was translated to CHC. Findings showed that the introduction of the National CHC Framework had clarified the joint working tasks within CHC processes more clearly than earlier CHC policy reforms, but by separating health and social care responsibilities for provision, it obstructed holistic care, and failed to counter the budgetary pressures that drove both towards their professional boundaries. Despite there having been major improvements in terms of increased CHC activity, reduced area variations and fewer complaints to the Ombudsman, evidence suggested that these might have been due to factors other than CHC policy reform. More individuals were receiving CHC, but processes were still impeded by poor information giving, process complexity, and continuing area variations particularly in access by older people.