This thesis explores emotions within the context of the public sector board governance of two NHS Foundation Trusts. In this study, emotions emerge not as static but dynamic, emergent, and processional. It takes a social constructionist stance as emotions are viewed as 'lived' experiences, which are situated in a dynamic relational context as part of daily practice, and reflected in everyday language. It particularly looks at the way board members give meaning to their emotional experiences and use emotions strategically and tactfully to attain their personal agendas. This alternative view of emotions is framed by conceptualising boardrooms as dynamic social spaces, which pulse with emotions. These emotions are manifested in daily interactions that extend beyond boardrooms. Methodologically, the combination of both the ethnographic and narrative approach demonstrate how emotion emerges in situ as an enacted practice. The combination of various analytical strategies - thematic analysis, thematic analysis of narratives together with performance/dialogic analysis - demonstrates the hidden politics of emotions as they are performed both within and outside board meetings. The findings show that the myth of rationality is sustained as actors persistently try to maintain their distance from emotionality in order to be seen as masculine and, therefore, legitimise their emotions in the negotiation of their image as rational actors. In addition, emotions are manipulated and purposely induced for a collective action and performance to shift blame and manage personal agendas to protect self from accountability and to claim credit.

Healthcare and politics are intimately bound and are expressed at three levels. The macro level concerns policy, where politics and ideology shape multiple, sometimes serial, and often conflicting, health care 'reforms'. The meso level concerns translation of such policy at the level of institutional operation such as the workings of a hospital, and may involve 'management style'. Finally, policy and management decisions will interact with the day-to-day practices of clinicians and support workers at the micro level. Micropolitics involve translation of policy and management decisions into daily working practices, involving the complex interaction of evidence-based care, local traditions, patients' idiosyncratic needs, and the skill and capability mix of multiprofessional clinical teams working with a variety of hi- and lo-tech artefacts. Following the advice of Actor-Network-Theory's (ANT) methodology - to conduct an ethnography by 'digging where you stand' - this thesis looks deeply into a small slice of micropolitical teamwork activity in the UK National Health Service (NHS) for better appreciation and understanding. Two case study contexts - an Emergency Department (EO) and a Mental Health (M H) ward - were studied in depth over an extended period th rough postmodern observation and video ethnography, supplemented by interviews. Data were analysed to reveal patterns of micropolitical activity - ways in which power acted locally to shape clin ical activities. Major forms of sovereign power ('power over') or key 'texts' in the NHS - dictated at the macro level of policy, and translated at the meso level of hospital management - include what have become 'mantras', such as 'patient-centredness'. However, at the micro level, such texts were seen to be disrupted by a variety of 'subtexts' of activity. Subtexts in both contexts included (i) 'patient throughput' (and throughput pressure); (i i) 'patients and their relatives as key decision makers'; (ii i) 'risk and patient safety'; and (iv) 'clinical uncertainty'. Such emergent 'subtexts' of activity explicitly shape micropolitical teamwork practices and behaviours, often reshaping , and even subverting , stated macropolitical imperatives or policy texts such as 'patient-centred ness' . Power was seen to be productive, as forms of resistance to sovereign (reproductive) power. Such 'capillary power' characterized the playing out of subtexts across systems of work to shape identi ties in flu id team settings. Drawing particularly on Cultural-Historical Activity Theory (CHAT) as a conceptual framework, th is thesis challenges lingering sociological models of 'medical dominance' and doctor-nurse power differences, to promote a more complex picture of daily micropolitical teamwork life in two clinical settings in which politics are 'performed'.

The potential of governance through partnerships and the third sector to solve state and market failures has been taken up internationally. Yet this solution poses theoretical and practical challenges because these instruments further complicate an already complex field to action concerned with social problems. While the third sector and governance are much studied, approaches that connect their roles in welfare governance to broader theoretical issues are underdeveloped. This thesis seeks to fill this gap by developing a systems-theoretical, relational approach that adopts the complexity and cultural turns and that was developed in a dialogue between. ethnography and theoretical inquiry. The case study involved a Local Strategic Partnership in an English district in a period dominated by Third Way • policies. The theoretical inquiry draws on Luhmannian systems theory and Jessop's strategic-relational approach. Overall, the thesis explores, empirically and theoretically, discourses and semantics, descriptions and self-descriptions, policies, network and organisational features, decisions and undecidabilities, paradoxes and contingencies and the self-potentiating complexity of selections. In particular, it considers the variety of first- and second-order observations of failure and their role as a stimulus to continuing attempts at governance despite the recurrent experience of failure. In this way, the thesis explores the inevitably complex unfolding dialectic between two sides of a fractally structured part-whole paradox in societies characterized by functional differentiation and network governance. This paradox has two sides. The state is but one institutional ensemble in a complex society that is nonetheless charged with governing the whole society; and the third sector is expected to represent the side of 'society' to the state and to deliver state objectives. Each side has its own fractal complexities, reinforced through their interaction. The thesis concludes by highlighting the analytical potential of this approach to understanding the complexities of governance in and through the third sector.

This thesis analyses the growth of regulation in the National Health Service (NHS) between 1985 and 2004. It argues that the development of the NHS over this period conforms to the pattern, asserted more generally in existing scholarship, of a rise of the regulatory state in Western European countries. One conventional explanation for the pattern of development-the increasing importance placed on establishing credible policy commitments-is shown to be compatible with observed patterns of development in the NHS. Building on earlier work, which argued that the organisation of the NHS was underpinned by an implicit concordat between politicians and the medical profession, it is argued that regulatory state type institutions potentially reconcile the imperative of credible commitment to the concordat with demands for greater governmental intervention in the provision of health services. Adapting an analytical framework developed by Brian Levy and Pablo Spiller, this thesis argues that regulatory reforms in the NHS are unlikely to achieve their publicly pronounced objectives if the legal and administrative framework for regulation does not demonstrate credible commitment to the implicit concordat. This is labelled the 'regulatory commitment hypothesis'. In order to assess the plausibility of this hypothesis, three episodes of regulatory reform are examined which, on the basis of the modified Levy and Spiller framework, can be said to engender varying degrees of commitment. The three episodes are: (1) the Limited List of NHS Drugs; (2) The National Institute for Clinical Excellence; and (3) the Commission for Health Improvement. Overall, an examination of these three episodes of regulatory reform provides grounds for cautious support for the regulatory commitment hypothesis.

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The National Health Service [NHS] has increasingly become the focus of revised health policies. They take the form of reorganised administrative arrangements for delivering care, alternative methods of allocating funding of care, and recently innovations in emphasising the quality of care through clinical governance. The most recent policy initiative attempts to involve patients in their own care. These changes have all followed the original NHS legislation (The NHS Act 1946), when Aneuran Bevan committed the government to provide welfare based primary and secondary health care. Since 1997 the present government has concentrated NHS policy on adapting the service towards 'shifting the balance of power': away from providers of health care and in favour of service users. Attempts at 'shifting' on behalf of users has required professional staff and health service managers to adapt their working practices and intellectual principles to encompass the managerialist-consumerist philosophical approach to the phenomena known as patient involvement, also referred to as the democratic approach to participation. The approach to assessing this phenomenon has been defined by the World Health Organisation (WHO) as 'responsiveness' of organisations to change in line with service user influence. The value-base of health care has become affected to the extent that service users have to be included in decision making processes which affect the trajectory of the patient's condition, and their quality of life. This is especially critical for patients with a long-standing, chronic, and in one of the case studies to follow, a possibly terminal condition. This thesis reviews the impact of the 'shifting balance of power' and 'involvement policy' upon three patient groups; cancer patients, those with mental health conditions and those with Parkinson's disease. The thesis adopts a case study approach in order to examine the relationship of the patients in each group with the relevant NHS teams of professionals and managers. Several policy documents published by the Labour governments of 1997 and 2000, and the resulting legislation, are used to evaluate the impact of this policy. The degree of change in the practice of involvement by service users in NHS planning of health services in a UK locality (Cambridge and Huntingdon) is identified through theories of involvement. These theories are used to first, systematically evaluate the level to which service users are effectively involved in the NHS system, secondly, to examine and evaluate the pathways through which representation occurs, and finally, to assess the changes in treatment, and the impact upon the quality of life of the patients as a result of their inclusion in the decision making concerned with their care. The study provides a method for evaluating involvement not clearly identified previously, and neither adopted by the WHO, nor used in the context of health services. Recent literature has identified the need for this type of evaluation.

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The population of the United Kingdom is increasingly ageing and diseases, like cancer and stroke, are becoming more common in our society. This is having a detrimental affect on the performance of the National Health Service. Various schemes and services have been introduced to increase efficiency, and key performance indicators help to identify areas of best practice. By realistically modelling healthcare facilities with analytic and simulation models, based on queueing theory, we can provide detailed information to healthcare managers and clinicians. These models can help to identify issues and cost inefficiencies for early intervention. Analytic models are less data and computationally intensive, and provide results in a quick time frame compared to simulation models. However, they tend to be mathematically complex which means healthcare managers can find them difficult to understand, and are more reluctant to implement the solutions. Simulations are more data and computationally intensive compared to analytic models, but they are much easier to explain to healthcare managers when they are built in a user friendly environment. This means that managers tend to be more willing to introduce the results of the model into their department. Therefore, we use both analytic and simulation models in this work to utilise the benefits of both techniques. In this body of work a novel analytic cost model has been presented for a system which can be regarded as a network of M/M/∞ queues. The model considers the flow of patients through primary and secondary care, and is based on a mixture of Coxian phase-type models with multiple absorbing states. Costs are attached to each state of the model allowing the average cost per patient in the system to be calculated. We also provide a model which assesses whether the implementation of a new intervention is cost-effective. The model calculates the maximum cost the intervention can incur before the benefits no longer outweigh the cost of administering it. These analytic models have been applied to stroke patients deemed eligible for thrombolysis in order to assess the cost-effectiveness of thrombolytic therapy. We also present a novel simulation model for stroke patients, who are eligible for thrombolysis, in order to validate our analytic models. 'What-If' scenarios and Probabilistic Sensitivity Analysis have also been carried out to provide healthcare managers with more confidence in our models. An analytic model has been presented for a complex system of M / M / c queues in steady state. The model analyses the system to find bottlenecks and assesses whether the staff are being efficiently utilised. Two resource allocation models have then been defined: the first determines the minimum number of resources required within the department, and the second efficiently distributes the resources throughout the department. These resource allocation models have been applied to orthopaedic Integrated Clinical Assessment and Treatment Service (ICATS) data to reduce the current queues within the department. A novel simulation model has also been created for orthopaedic ICATS which includes extra variation and realistic features. This allows us to assess how robust and reliable our analytic models are, as the results are applied to our simulation model which has different assumptions. The novel analytic models provide very similar results to the simulation models built for each healthcare environment. This implies that our analytic models are robust and reliable even when applied to a department which includes different assumptions. Therefore, our analytic models will provide reliable results when healthcare managers need to make decisions in a short time frame. Simulation models have been found to be a good validation technique for analytic models, as healthcare managers understand them better. Extra components can also be easily included within a simulation model, such as complex distributions to represent the inter-arrival and service rate, and realistic features such as shift patterns.