This thesis addresses issues relating to the accessibility of primary medical care within the context of the National Health Service. A review of the literature is undertaken which identifies access as a key issue for patients, doctors, and health care planners. A basic framework using the geographical, organisational, and psycho-social elements of access to care is adopted for a detailed consideration of these distinct elements of accessibility. Five studies are described. The first of these relates to the provision of out-of-hours care by five general practitioners in one practice in central Edinburgh. The association of reduced access (a completely booked appointment system) with an increase in subsequent out-of-hours workload is reported. A case study of upper respiratory illness presenting out-of-hours investigates the impact of doctors' choices made regarding the management of out-of-hours contacts on subsequent consultation patterns. While the first study considered the operation of the appointment system as a factor influencing out-ofhours workload, the operation of a practice appointment system was studied in more detail in the second study. This work investigated the consequences of increasing appointment length on clinical workload, appointment system operation, patient "flow" (waiting and consultation times), and consultation and doctor behaviour. Changing from booking eight patients per hour to six patients per hour was associated with an increased matching between supply and demand for appointments, increased numbers of patients requiring to be fitted in as "extras", and reduced waiting time for patients seen under the new arrangements. Surgeries in which an undergraduate medical student was present were observed to be different from non-teaching surgeries with respect to a number of measures. Variations in the operation of appointment systems have been judged by some to have important sequelae in the decisions made by patients as to where they might receive care. Such judgements form the basis for the central study of this thesis where the impact of varying doctor accessibility on the decision taken by patients to self refer to a hospital Accident and Emergency Department was investigated in nineteen of twenty six practices in the West Lothian district of Lothian Health Board, Scotland. Information was collected about practices and their appointment systems over an eight week period and a questionnaire survey of patients attending participating practices or the local Accident and Emergency Department was undertaken. This study highlighted the importance of distance from Accident and Emergency as a factor influencing the use of Accident and Emergency services, and also highlighted the importance of patients' perceptions of doctor availability as a contributing factor in patient's consulting behaviour. The relationship between patients' perceptions of doctor availability and practice list size was investigated using data obtained from the questionnaire survey of patients attending West Lothian practices during one week of 1994. Practices rather than patients formed the unit of analysis in this investigation where patients' perceptions of doctor availability were reported for urgent and non-urgent situations separately. A significant negative association between practice list size and the perceived availability of general practitioners is described and regression modelling used to investigate the association between patient satisfaction with doctor availability, patients' perceptions of doctor availability, and practice list size. The final two studies describe the potential for using geographical information systems (GIS) technology in investigating the accessibility of primary care. Some of the features of GIS technology (mapping of geo-referenced information, construction of polygons, buffers and convex hulls, contour plotting and construction of spider maps) are demonstrated using data obtained from West Lothian as a case study. Plotting of polygons representing practice areas is used in the final study, which investigated the accessibility of general practitioners as, reflected in the size of their practice catchment areas. Using this approach, an association between quality of primary care and the size of practice catchment area is described and questions are posed regarding the lack of available guidance for general practitioners in relation to defining the size of the area in which they provide services. Access to primary medical care requires a consideration of the quality of services to which access is being provided. Health service planners, doctors, and their patients must ensure that quality in relation to service delivery is matched by quality in relation to the arrangements by which that service is accessed. This work contributes to and informs that relationship.

This thesis explores the empirical and methodological issues that arise when conducting economic analyses of genomic technologies in the UK National Health Service. The main focus of the thesis is the identification of the most appropriate economic evaluation approach to use in this context. Health economists are currently uncertain as to whether existing extra-welfarist approaches are sufficient to evaluate genomic technologies. Clarification is required because alternative methods, such as the welfarist approach, may lead to different adoption decisions, which will impact on population health. The advantages and disadvantages of alternative approaches are demonstrated using a clinical case study: the use of genomic testing to guide treatment decisions in chronic lymphocytic leukaemia (CLL). Two forms of extra-welfarist economic evaluation are conducted - a cost-effectiveness analysis (CEA) and a cost-utility analysis (CUA) - along with a welfarist economic evaluation which took the form of a cost-benefit analysis (CBA), informed by a discrete choice experiment (DCE). These analyses consider several test-treatment strategies, reflecting different combinations of testing and the use of both existing therapies and new treatments such as ibrutinib. Information is also generated on patient preferences in this context, via the DCE, and the results of a survey are presented in which stakeholders are asked to consider which form of economic evaluation best captures the true costs and benefits of genomic testing in CLL. The results of the CEA, CUA and CBA all indicate that the optimal strategy is to not adopt genomic testing in this context. The different approaches are then compared to assess their relative merits. The key finding - which is supported by the stakeholder survey - is that the extra-welfarist approach to economic evaluation is most appropriate when assessing genomic interventions. However, an evolution in methods is required to ensure that the results of these analyses provide decision-makers with sufficient information to facilitate the efficient allocation of scarce healthcare resources in this context.

The National Health Service (NHS) in the United Kingdom provides a range service for its population including primary care and hospital services. The impact of the 2008 economic and financial crises prompted a tightening of public budgets including health. Over the next few years, and most likely beyond, the NHS is planning for unprecedented levels of efficiency saving in the order of £ billions. With little doubt, the NHS will need to review its way of working will need to do more with less. Simulation is an established technique with applications in many industries including healthcare. Potentially, there are huge opportunities for simulation use to make further inroads in the field of healthcare. Despite the potential, arguably, simulation has failed to make a significant impact in health. Some evidence has tended to suggest that within health there has been poor adaption along with poor linkage to real-world problems, as perceived by healthcare stakeholders. The aim of this thesis is to develop a model to help address real-world healthcare issues as recognised by healthcare stakeholders. In doing so, this thesis will focus on a couple of real-world problems, namely:  What space is needed to meet service demand, when is it needed and what will it cost?  What space do we have, how can it be used to meet service demand and at what cost? The developed simulation space demand model will demonstrate its value modelling dynamic systems over static models. The developed models will also show its value highlighting space demand issues by groups of patients, by time of day. Real, readily available data (arrival and length of stay, by patient group) would drive the model inputs, supporting ease of use and clarity for healthcare stakeholders. The model was modular by design to support rapid reconfiguration. Dynamically modelled space information allows service managers and Healthcare Planners to better manage and organise their space in a flexible way to meet service requirements. This work will also describe how space demand can linked with building notes to determine Schedules of Accommodation which can be used to cost floor space and consequent building or refurbishment costs. Furthermore, this information could be used to drive business plans and to develop operational cost pertaining to the floor area. This body of work debates using function-to-space ratios and attaching facilities management cost. Our findings suggest great variance in function-to-space ratios. Our findings also suggest that moving to median or lower quartile function-to-space ratios could potentially save hospitals £ millions in facilities management costs. This thesis will reflect on the level of modelling taking place in the healthcare industry by non-academic healthcare modellers, sometimes collectively known as Healthcare Planners, the Healthcare Planning role in space planning and their links with healthcare stakeholders. This reflection will also consider whether healthcare stakeholders perceive a great need for academic healthcare modelling, if they believe their modelling needs are met by Healthcare Planners. A central theme of this thesis is that academic modelling and Healthcare Planning have great synergy and that bringing together Healthcare Planners’ industry knowledge and stakeholder relationships with academic know-how, can make a significant contribution to the healthcare simulation modelling arena.

The last decade of the 20th century saw unprecedented changes in the organisation of health and community care services in the UK. A substantial change occurred in the roles and functions of professionals. Continuing professional education CCPE) became more pivotal and within that interprofessional education (IPE) gained prominence, on the assumption that it promoted interprofessional collaboration. The crucial elements in this process were the changes in the distribution of power between the stakeholder groups in professional education and the associated shifts in the discourses. The most noticeable background change has been in the transfer of power in the running of the welfare state from the professional to the management group. This thesis argues that this has led to much closer control by management of professional behaviour. The control is actualised through increased emphasis on teamwork, a tighter governance of CPE and the promotion of IPE. Guidance for professional development comes no longer from within the individual concerned but is superimposed from above. Yesterday's takers of initiatives have, perforce, become today's followers of orders. It is further maintained that alongside the changes in power distribution there has been a shift in balance between the prevalent discourses. A rhetoric of co-operation exists between the key stakeholders - managers, educators and professionals - yet each group holds its own construction of the professional and consequently the education that is requisite. Thus, managers want professionals capable of providing an efficient service, educators wish to promote adult learners capable of change, and professionals themselves wish to promote their independence and selfgovernance. Professionals are insufficiently aware of these differences in perspective. They need to be alert to threats to their autonomy in the face of the managerial 'efficiency ethos' - since losing autonomy is arguably neither in their interests nor those of their clients.

Objective: The study analysed the UK’s successful salt reduction policy and seemingly less successful nutrition labelling policy, using theoretical policy frameworks, to explain their evolution and identify lessons for public health practitioners; Methods: Case-studies on nutrition labelling and salt reduction were developed from semi-structured interviews with government, NGO, academic and industry participants recruited through snowball sampling. Process tracing analysis was used to triangulate the data with the grey and published literature, and explore how aspects of the complex processes were explained by the following frameworks: Policy Networks, Punctuated Equilibrium Theory, Multiple Streams Framework, Contextual Interaction Theory, Policy Success Framework and Multi-Level Governance. Analysis and discussion: Several high-profile reports attempted to stimulate action on diet and health in the UK during the 1980s. However, government and industry actors only became ‘motivated’ to act after the 1996 BSE crisis and ‘focusing event’, which led to the Food Standards Agency’s (FSA) establishment in 2000. FSA developed the UK’s successful salt reduction programme through a process of cross-sectoral ‘negotiated agreements’, resulting in reductions in population intakes. By contrast FSA’s traffic light nutrition labelling scheme evolved as a battle between public health actors who championed its more equitable performance and a dominant industry group against its “demonization” of foods. Companies adopted a rivalGuideline Daily Amount scheme and undermined the national traffic lights scheme by framing it as a “barrier to trade” in EU ‘venues’, resulting in a formal EU investigation. Nutrition labelling’s complexity, including multiple formats and veto opportunities, contributed to its struggles. Transparent monitoring and sanctions were critical to salt reduction’s success under the FSA (2000 – 2010), but their absence from the subsequent Responsibility Deal (2011 – 2015), attenuated interpretations of “success” among public health actors. Both policy processes were highly political and public health practitioners would benefit from enhancing their political skills.

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Despite previous studies investigating the possible influences of the neighbourhood, parents and peers for adolescent health and well-being, there is a lack of consensus about the relative importance of these different contexts. This study used an ecological framework to examine the relationships between structural and social neighbourhood characteristics, family support, peer relationships, youth volunteering and adolescent psychological adjustment, perceived health, weight and health related behaviours, and overall life satisfaction. The main cross-sectional study of 209 adolescents and 65 of their parents took place in two UK locations, a large multicultural town and a rural village. As a strategy to strengthen the methods of perceiving and assessing neighbourhood constructs, the research included a qualitative study of 11 adolescents. Thematic analysis was used to explore teenagers’ perspectives of the neighbourhood and its relevance for health and happiness. The qualitative study found that opportunities for social connections within the neighbourhood, community cohesion and family support were said to be relevant for adolescents’ well-being, confirmed in the main quantitative study. Neighbourhood social cohesion was a significant predictor of health and life satisfaction. Neighbourhood deprivation, social cohesion and the proximal support of friends and family were all significant predictors of psychological adjustment. In contrast the lack of a relationship between neighbourhood deprivation, based on administrative data, with life satisfaction and health suggests an inconsistent role of neighbourhood deprivation for children’s health and well-being. Investigation of the potential role of adolescent neighbourhood volunteering found that teenagers who engaged in more helping behaviour were also likely to report better health, engaged in fewer ‘health risk’ behaviours and had fewer behavioural problems. Future research including longitudinal and using more refined measures of the neighbourhood that incorporate the views of adolescents, including objective measures such as observations may clarify the processes by which neighbourhood characteristics are relevant for adolescent well-being.

This study examines notions of government and market failure in British healthcare by tracking and analysing the changing views of opinion formers. Presenting original data that highlights the attitudes of today's opinion formers towards populist notions in health economics it provides a unique insight into the limits and boundaries of contemporary debate. Significantly, the research concludes that swathes of elite opinion no longer support the National Health Service (NHS) in its traditional nationalised guise. While opinion formers instead now believe in a much greater plurality of public and private healthcare today's elite not only question the idea of state healthcare but they also remain sceptical of a purist libertarian market. Indeed, in noting that healthcare has always attracted the interventionist attentions of those with state power, the study questions in fundamental ways the meaning of such terms as 'market' and 'private sector'. In highlighting the timeless propensity for medical and health professionals to seek legislative favour, it argues that the world has never actually seen anything resembling a real market in the bio-medical paradigm and its forbears. Healthcare has always been a deeply corporatist venture run in association with a range of mystical, military, religious, or purely political statist elites. The study begins with an historical overview of healthcare from the military hospitals of the Roman period, through the religiosity of the Middle Ages, the mutuality of the nineteenth century, the statism of the National Health Service and the recent rise of public private partnerships. Examining such concepts as monopoly, consumer ignorance, moral hazard and externality, it also analyses notions of public versus private goods in the context of today's healthcare.

Professionals are a group of workers who have attracted scholarly interest for many years. More recently, interest has stemmed from the fact that their professional identity and traditional ways of working have been challenged, by changes in the environment in which they work, including the internationalisation of markets and the introduction of new policies and legislation at a national level (Evetts, 2011; Muzio and Kirkpatrick, 2011; Waring and Bishop, 2011; Hinings, 2005; Powell, Brock and Hinings, 1999). The professional identity of workers such as lawyers, doctors, accountants, social workers and teachers is argued to be deeply embedded (Ackroyd, 1996; Bloor and Dawson, 1994; Freidson, 1970), with attitudes and values being more in line with those of the profession and its associations than the employing organisation (Raelin, 1985; Gouldner, 1957). Traditionally, professionals have enjoyed considerable discretion over how they carry out their work, and have focused on delivering their service to their individual clients, rather than concern themselves to any great extent with clients in a collective sense and the management of their organisations (Evetts, 2003; Freidson, 1989; Raelin, 1985). This was enabled by management practices based on collegial decision making and informal processes, (Cooper et al, 1996; Greenwood and Hinings, 1993; Ackroyd, Hughes and Soothill, 1989; Mintzberg, 1979). The 1980s, however, saw a departure from this type of management practice. New, managerialist cultures were introduced in the public sector by policymakers, with certain private sector style practices such as management by objectives, performance indicators and outcome measures (O’Reilly and Reed, 2010; Hunter, 2008) being prioritised. Similar managerial change also evolved within professional service firms in the private sector (Ackroyd and Muzio, 2007; Sokol, 2007; Brock,2006, Hinings, 2005).

The aim of this thesis is to examine whether it is morally defensible to use lifestyle as one of the criteria for rationing health care. I argue that it is not justifiable to use former lifestyle to select patients for treatment. Chapter one outlines the principles of the NHS and discusses the reality of rationing in health care provision in Britain. I maintain that there is a prima facie legal and moral right to health care and explore whether this right imposes a responsibility on individuals to maintain a healthy lifestyle. Chapter two critically examines some of the criteria, which are used to ration health care. Government policy documents, such as 'The New NHS: Modern.Dependable.' (Department of Health 1997: 13) suggest that patients should be treated 'according to need and need alone.' I argue that the concept of medical need is indeed one of the proper criteria for the distribution of medical resources. However, it is not the only relevant criterion and should be considered along with other factors such as patient choice, clinical and cost effectiveness. Other criteria including age and lifestyle may also be relevant, but in so far as they affect the probable clinical outcomes of treatment. Chapter three clarifies some of the contemporary approaches to distributive justice and explores their implications for the allocation of health care between individuals. I suggest that an eclectic approach should be adopted where consideration is given both to promoting individual choices about lifestyles and protecting the welfare of the community. None of these theories of justice suggest that taking lifestyle into account when allocating scarce resources must be unjust. Chapter four investigates whether individuals should be held responsible for their lifestyle. I argue that some health related behaviour is voluntary and therefore people might be held responsible for the consequences of their behaviour. However, in many cases health related behaviour may not be voluntary, because it may have been unduly influenced by factors beyond the control of the individual. Even if it is voluntary, it may be justifiable or excusable in some cases. I discuss whether risk takers deserve any blame, and maintain that withdrawal or delay of medical treatment as a punishment for former lifestyle is always wrong. Chapter five argues that it is essential for health care professionals to inform people of risks to their health. This does not interfere with their liberty, and allows them to make choices based upon their own values. I also examine whether it is justifiable to use more coercive strategies, such as persuasion, manipulation and legal prohibition in order to encourage people to maintain a healthy lifestyle. Chapter six argues that it is not possible to implement a policy to ration health care partly on the basis of lifestyle in a fair way. I propose an alternative policy, which involves taxation on certain products associated with risk. Chapter seven examines a variety of cases of rationing based on lifestyle. I conclude that rationing according to former lifestyle is not morally defensible.