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The aim of this study was to explore clinical psychologists' experiences of therapeutic relationship ruptures, specifically in the context of the UK National Health Service. The role of the context in which therapy takes place has been neglected in previous research on ruptures. Semi-structured interviews were conducted with ten clinical psychologists. Their accounts were analysed using a constructionist Grounded Theory approach. The grounded theory, 'ruptures in context' was developed. This comprises four categories, as interpreted by the researcher, by which participants understood the processes and situations of ruptures. In this, various levels of complexity are recognised, such as, influences from outside the therapy dyad, the possibility of positive ruptures, and a working environment that gives a very unclear message: support for psychologists experiencing a rupture, and pressure not to have one in the first place. The resulting theory provides clinical psychologists and clinical psychology training providers with a greater understanding of the perspectives of clinical psychologists on ruptures. I argue that more open recognition of ruptures and attention to their impact upon clinical psychologists are important aspects of developing the profession's future vision. Implications for clinical practice and further research are discussed.

Revalidation, as a government-led healthcare professional regulatory reform process, marks the largest and potentially the most significant development in the history of healthcare professional regulation within the United Kingdom (UK) National Health Service (NHS). Revalidation, as an emergent regulatory reform, is a professionalisation dilemma for healthcare professionals as it would appear to be diametrically opposed to the notion of professional autonomy and self­regulation; the theorised core characteristics of health professionalism (Dixon-Woods et al., 2011; Freidson, 1970a). At the time of implementation, the impact that this reform would have upon professional groups was unknown. The national rollout of revalidation therefore presented a real time opportunity to witness the operationalisation of such a top-down regulatory reform. Drawing on the concepts of professional 'licence and mandate' (Hughes, 1958) and the 'professional project' (Larson, 1977) as a theoretical framework, I used a focused ethnographic approach to answer the following research questions: Over-arching research question: How are regulatory mechanisms, such as revalidation, interpreted and utilised as part of a 'professional project'? Sub-questions: How is revalidation being implemented within an NHS organisation and how does this compare with national recommendations? How are plans for revalidation being received and implemented within maternity services? How are regulatory mechanisms such as revalidation impacting upon professional roles and responsibilities within maternity services? The overall contribution of my research study lies in providing insight into the intended and unintended consequences of revalidation as contemporary healthcare professional regulatory reform. From a practice perspective this study illustrates how formal regulatory mechanisms were shaped at local level by the informal processes of the research organisation. From a theoretical perspective this study challenges the concept of organisational professionalism (Evetts, 2012; McClelland, 1990), whereby national and organisational objectives, such as revalidation, are theorised to control and regulate professional groups. I argue that professionals engaged with revalidation as part of an ongoing, professional maintenance project of professional status and survival. This was an ultimate acknowledgement that in order to maintain a licence to practise (Hughes, 1958), engagement with revalidation was a statutory requirement.

Innovation and research have been key features throughout the sixty years the UK has publicly funded a National Health Service. Over the last thirty years, in planning health service reforms, successive Governments have drawn on the values of the private sector, where innovation is considered an imperative If firms are to survive in the global market place. Consequently, the innovation imperative is now at the heart of UK health policy.

This thesis will report details of two studies conducted within the National Health Service in the UK that examined the association between HRM practices related to training and appraisal with health outcomes within NHS Trusts. Study one represents the organisational analysis of 61 NHS Trusts, and will report training and appraisal practices were significantly associated with lower patient mortality. Specifically, the research will show significantly lower patient mortality within NHS Trusts that: a) had achieved Investors in People accreditation; b) had a formal strategy document relating to training; c) had tailored training policy documents across occupational groups; d) had integrated training and appraisal practices; e) had a high percentage of staff receiving either an appraisal or updated personal development plan. There was also evidence of an additive effect where NHS Trusts that displayed more of these characteristics had significantly lower patient mortality. Study one in this thesis will also report significantly lower patient mortality within the NHS Trusts where there was broad level representation for the HR function. Study two will report details of a study conducted to examine the potential reasons why HR practices may be related to hospital performance. Details are given of the results of a staff attitudinal survey within five NHS Trusts. This study examined will show that a range of developmental activity, the favourability of the immediate work environment (in relation to social support and role stressors) and motivational outcomes are important antecedents to citizenship behaviours. Furthermore, the thesis will report that principles of the demand-control model were adopted to examine the relationship between workplace support and role stressors, and workplace support, influence, and an understanding of role expectation help mitigate against the negative effects of work demands upon motivational outcomes.

This thesis investigates the factors involved in the processes of health policy change. It questions the validity of path dependency theory in the context of changes observed within the United Kingdom health system under the Conservatives between 1979 and 1997. The development of the National Health Service (NHS) ‘internal market’ reforms is considered together with five specific cases of change affecting public-private boundaries. The research combines literature research, including biographical and archival sources, with a selection of interviews with important actors from the health policy arena of the time. The cases are mapped using an adapted version of the three policy streams developed by Kingdon for the analysis of agenda-setting processes, as a structured basis for comparison. The research finds little evidence of the self-reinforcing processes that are required to generate path dependency, or that a change of path can take place only at a critical juncture.It shows that small changes can produce substantive and enduring changes of path. It also identifies that the factors involved appear to go beyond Kingdon’s three streams, and attaches importance to the potential for disloyalty to the status quo. Cultural or technical change, as well as policy change, can generate disloyalty amongst those who deliver services. The presence of the potential for disloyalty is, therefore, an important factor in the achievement of a change of path. Taken together the changes between 1979 and 1997 show a notable consistency of purpose in pursuit of a dual agenda of consumerism and public spending control. Whilst analysis of individual cases of change can suggest an absence of strategy, each case plays a part within a remarkable consistent Conservative programme of change the roots of which predate the National Health Service.

No description available.

Patient-Reported Outcome Measures (PROMs) are increasingly used in health services research and clinical practice for the quantification of patient experiences, including quality of life, mood (e.g. depression), and satisfaction with services. Such PROMs usually take the form of questionnaires. The underlying measurement model is derived from psychometric theory, specifically Classical Test Theory (CTT). This model requires statistical analysis of questionnaire data to establish the quality of data so collected, with emphasis on the reliability (reproducibility) and validity (domain-specific measurement) of the data.

This thesis explores the tensions between policy and practice in community participation in Health Improvement Programmes (HImPs). The HImP is used as a vehicle through which partnership working and public participation is health planning in the ‘new NHS’ may be explained, The literature review discusses key theories and models of community participation, power and policy implementation which informed the development of my key research questions and strategy. A review of the global, national and local influences upon a community participation in health planning is supplemented with primary research in the form of a detailed case study of one locality’s response to the national requirement to involve the public in the development of their HImP. A multi-method case study was employed using the following methods of data collection: observation, interviews, questionnaires and documentary analysis. The research presented identifies a number of issues as significant in affecting a locality’s approach to public participation, including: power; the organisational cultures(s) within the HImP partnership; the attitudes and capacity of those charged with developing participatory activities; and the impact of national priorities on local flexibility to respond to community identified priorities. The application of Alford’s (1975) structural interests theory to the findings provides a useful framework for assessing power relations and understanding why the HImP fails to represent community interests in the way that had been hoped. A number of recommendations are made to facilitate participation in health planning in the future, including: the need to address the national culture of risk avoidance; the need for better training in public participation skills for personnel charged with developing participatory opportunities; and the need for a mandatory performance framework related to community participation as a mechanism to ensure that participation issues are given the same attention as other nationally monitored issues.

Public participation is an increasingly prominent policy in the United Kingdom and elsewhere. This thesis locates one example of participation within wider debates about the constitution of contemporary society, changing welfare-state governance, and the challenges of operationalizing such initiatives. It relates the particularities of this case to practical, policy and theoretical questions. The thesis begins by considering the rise of participation in historical context, relating its aims to social-theoretical commentaries on late-modern society. This framework informs an examination of rationales for participation, an analysis of policy discourses on public involvement in health, and consideration of the challenges of making participation happen. The remainder of the thesis presents the results of an empirical study of one example of participation: service-user involvement in a programme of pilot cancer-genetics services, managed by the third-sector organization Macmillan Cancer Support. Using interview, observational and documentary data collected over a three-year period, it offers a longitudinal perspective on the practice of involvement, drawing on various actors’ perspectives. Considered over five empirical chapters are competing rationales for involvement put forward by different groups of actors, the micro-processes of involvement, and the varied outcomes of negotiations across the seven pilots studied. In reconciling the theoretical and policy literatures with empirical findings, the thesis highlights certain tensions. Policy-level ambiguities permit the coexistence of multiple discourses about the purpose of involvement, the identity of those involved, and the influence it should command, resulting in conflict as participation is put into practice. Policies designed to avoid directiveness and facilitate local discretion create dilemmas for those charged with implementation, especially third-sector organizations whose intermediary role means they must reconcile divergent views of diverse stakeholders in participation practice. The result is a situation where pragmatic negotiations take precedence over any theoretical or normative vision for participation in determining its remit, scope and influence.