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This thesis charts the development of medical services in the Highlands and Islands of Scotland from the establishment of the new Poor Law in 1843 to the inception and development of the Highlands and Islands Medical Service from 1913 to 1936. It begins with a brief survey of the topographical, social and economic conditions of the Highlands from 1845. It was within that context that the administrative structures that constituted Highland medical services were situated. They are traced in detail as is the interdependence which developed between local authorities, poor law administrative structures and, later, public health authorities, within the political context of the gradual extension of the authority of the state, enlightened medical thought, land reform and ‘new liberalism’. It is argued that those factors, together with the longer-standing perception of the Highlands as an area requiring special attention, culminated in the establishment of the Highlands and Islands Medical Service enquiry, known as the Dewar enquiry. Established in 1912 it investigated the level and adequacy of medical services in the region. It recommended the establishment of a central body to improve the provision of medical services for the majority of the population and it also highlighted a need for a greater number of fully-trained nurses. The Dewar enquiry’s methodology is documented and its findingsassessed and evaluated. The development of district nursing is examined in a separate chapter to avoid duplication and to facilitate its specific features to be highlighted. The recommendations of the Dewar enquiry resulted in the establishment in 1913 of the Highlands and Islands Medical Service, which provided the first State-funded medical care for the Highland non-pauper population and also aimed to improve the conditions of medical practitioners working there. It is widely described, uncritically, as a ‘forerunner of the National Health Service’. Existing secondary literature on it is generally superficial, largely uncritical and relies primarily on published annual reports. One of the aims of this study has been to use new primary sources to investigate in detail its structure, administration and policy development and to provide a more balanced analysis of its development and impact. This study challenges the veracity of the view that it was an unqualified success and demonstrates that while it was unique, innovative and did achieve improvements in many areas of medical and nursing service, by 1936, there were still accepted weaknesses in the provision of medical and nursing services. Furthermore, integral to the Servicewere many of the tenets of self-help and philanthropy; voluntary contributions from all individuals and bodies related to it were embedded into its policies and administration, closely monitored by the Treasury. Following Cameron and Hunter’s work on land reform this thesis makes a contribution to historical understanding of the development of public policy in the Highlands, within a medical context, during the second half of the nineteenth and early decades of the twentieth century. The period of study ends in 1936, the date of the Cathcart Report, which reviewed the state of Scottish health services. The principal achievement of this thesis is to present a fuller and more accurate understanding of the complexity of the nature and development of medical services in the Highlands, with particular emphasis placed on the Highlands and Islands Medical Service. Widely held perceptions of it have been moderated while its importance has been demonstrated, not as a forerunner of the National Health Service, but as a striking example of the modification of the Victorian self-help ethic within the context of a publicly-funded subsidised service for a particularly vulnerable section of society. A major conclusion is that many of the problems inherent in the Highlands and Islands, related to geography, isolation and weather, which were insurmountable in the nineteenth and early twentieth centuries, still exist today and present a greater indomitable force than any level of medical service can mitigate against.

The assessment of need underpins the delivery of community-based care. Following the NHS and Community Care Act (1990), the principle of needs-led assessment was reinforced as it applied to the assessment and care management process. Translation of needs-led assessment into practice in Scotland has been further influenced by policy-based organisational change including the introduction of Single Shared Assessment and Community Health Partnerships. This study seeks to describe the political and practice landscape within which needs-led assessment exists, identify and explore factors which influence needs-led assessment, and consider the practice implications of the policy driver for community-based practitioners across the main disciplines of health and social care. Following a short pilot, the main study was undertaken using sequences vignettes within a semi-structured interview involving 105 social workers, health and housing staff. Key findings indicated a cloak of consensus around definitions of need and assessment with perceptions based upon a medical or social model of care or a professionally or personality-driven assessment of need. A preoccupation with the outcome of assessments caused many respondents to describe needs with reference to the interventions or resources required to address them. The practice of needs-led assessment, according to study results, was hampered by an awareness of resource availability, concerns over client compliance and risk and, an underlying alignment to the values and principles upheld by the employing discipline.

Clinical leadership, along with other means such as whole system working and multi-disciplinary teams, has been promoted as an important method of engaging clinicians in reform and improving the efficiency and effectiveness of healthcare. Consequently, a key human resource strategy within NHS Scotland has been to invest in training and development to build clinical leadership capacity across the organisation. However, clinical leadership is a contested concept, with no readily accepted definition and is subject to debate between competing professional and managerial logics and identities. As such there has been little investigation into how clinical leaders’ identities are developed at an individual, relational and collective level, how such identity construction affects the development of clinical leaders, and how learning from such development can be transferred back into healthcare organisations. Thus, this thesis investigates the impact that development programmes can have on participants’ identities, through their human capital and social capital, and the organisational factors that influence the degree of learning transfer. Focusing on a phenomenological case study of an eighteen-month ‘flagship’ leadership development programme for senior clinical leaders across NHS Scotland, the thesis explores the notion of development programmes as ‘identity workspaces’ (Petriglieri, 2011) where participants can step back from their daily routines to reflect and work on their identities and examines whether such workspaces are seen as useful by participants and their managers. Data were gathered through semi-structured interviews, observation of key events and analysis of relevant policy, programme and participant documents. The longitudinal study, undertaken between December 2008 and May 2011, examines the processes, practices, and tensions underpinning leader and leadership identity development. It highlights the importance of studying not only how identities are constructed, maintained and regulated, but also how past identities are deconstructed and unlearned, and the emotional and psychological effects that these processes can have on clinicians. These data supported the view that identities are formed within social and discursive contexts and evolve and change over time in relation to an individual’s experiences and changes in the wider environment. They also provided support for the claim that leadership programmes can play an important role in the social construction of a leader’s identity as they initiate bonding, brokering, bridging, and legitimising activities which enhance their social capital and reaffirm their identity at a relational and collective level. However, for this identity to be embedded and sustained over time, individuals require a degree of autonomy to implement change as this both reinforces their own sense of self as a leader and encourages others to act reciprocally. Furthermore, developmental support was seen as necessary by participants to encourage a common understanding of leadership which enables the construction of leadership identities at a relational and collective level. Lastly, by examining how clinicians participating on the programme understood and enacted their dual-role, the thesis explores the diverse meaning attributed to the notion of clinical leadership. It considers the internal and external challenges facing clinical leaders and proposes that it is important for clinical leaders to assume a dual-professional identity that allows them to move from being a clinician to a professional clinical leader who combines clinical and leadership expertise. Thus, the thesis provides a contribution to the relatively limited academic literature on clinical leadership and professional leadership development more generally and adds to research on identity work, social identity theory and intellectual capital. In particular, it emphasises that working on and changing ones’ professional identity is not an easy process as it involves first deconstructing and unlearning past notions, beliefs and behaviours before a new sense of selves can be reconstructed. The research took place within a dynamic policy context that encompasses recent work on engaging clinicians in leadership, embedding strong clinical governance and accountability, and overcoming the economic challenges facing public services both in Scotland and the UK. The thesis makes a contribution to practice by informing ongoing policy relevant debates on leadership development and the value of clinical leadership as well as other dual-professional identities in the Scottish National Health Service and the Scottish Government.

The extent to which the knowledge mobilisation potential of public health networks is actually achieved in their functioning has not been previously studied. There are prescriptions from policy documents and from research literature as to the form networks in health should take and the way they should operate. However, there has been little research connecting the nature of the networks and the manner in which they function to their knowledge mobilising ability. Constituted in 2006, the Scottish Public Health Network (ScotPHN), which is the primary vehicle in Scotland for mobilising public health knowledge and informing policy and practice, constitutes the location for this study investigating this knowledge mobilisation and how networks function in public health. Feedback from the consultation conducted prior to the formation of ScotPHN was obtained. Interviews were conducted with the members of the ScotPHN steering group, a project group and the stakeholder group. Two ScotPHN steering group meetings were also attended by the author as an observer. The consultation feedback, transcripts of the interviews and those of steering group meetings were analysed using the constructivist version of the grounded theory approach. The process involved coding and abstracting codes to categories and themes. The emerging themes were reviewed in the light of existing literature on networks and knowledge mobilisation. These themes were then used to develop a model to understand how the network operates and consequently mobilises knowledge. The study shows that prior to its formation ScotPHN was expected to address the fragmentation of the public health workforce; significantly enhance links amongst existing public health networks; support ground level knowledge exchange amongst practitioners and significantly enhance multisectorial working. None of these expectations appear to have been met. ScotPHN has, however, managed to fill the gap left by the demise of the Scottish Needs Assessment Programme (SNAP). ScotPHN’s structure and the manner in which it is controlled lead to it being akin to a policy community rather than an issue network. The generic public health concerns of the steering group and the selective nature of the project group prevent it from functioning as an issue network. The dominance of people from the medical profession also causes a social closedness in the ScotPHN steering group. The limited multisectorial participation in its activities results in: a lack of constructionist learning; limited inclusion of the social context of knowledge; and a deficit of Mode 2 knowledge mobilisation. In the context of knowledge conversion there is some evidence of externalisation but no socialisation. ScotPHN is not a network that can be classed as a community of practice. This study highlights how health policies, which have advocated the establishment of networks, could derive considerable guidance from research into how networks actually function. With respect to the knowledge mobilisation activity of these networks the study finds that top-down and prescribed structures are unable to capture the transdisciplinarity and diverse intellectual frameworks that contribute to public health knowledge. It is seen that the hierarchical network structures can undermine the engagement of actors from the less represented sectors. Additionally the study finds that the established patterns of professional power and control further hinder multisectorial engagement.

Scotland has the highest rates of child obesity in Europe with more than 1 in every 4 children aged between 2 and 15 being overweight or obese in 2008. The need to curb the nation’s unhealthy eating habits through Scottish public health policy has been acknowledged, although there remains a shortage of policy addressing the eating habits of infants and young children as they develop in the context of family life. This is matched by a shortage of empirical research which uses nationally representative longitudinal data on Scottish children, to look at how diets of children under five develop within the home. This doctoral research seeks to explain how children’s nutritional trajectories develop from birth through infancy and into early childhood in contemporary Scotland within the context of maternal resources, maternal use of nutrition advice, and family meal habits. Theoretical concepts pertaining to social constructionism and the symbolic meaning of meal rituals, as well as theories of risk and responsibilisation, human capital and health behaviours, and discussions about agency and structure, frame the research questions and the interpretation of results. The research draws on the first three annual sweeps of the Growing Up in Scotland nationally representative, longitudinal survey of families and young children. The analysis is based on multivariate proportional hazards regression and logistic regression models. The empirical analysis shows that maternal education is a consistently superior predictor of children’s nutritional outcomes, when compared to maternal occupational classification and household income, and that children of more educated mothers have healthier diets throughout infancy and childhood. This points to the utility of human capital theories which stress the importance of education, rather than income, and also reflects on the need for policy to recognise the structural nature of nutritional inequalities. More educated mothers are also more likely to be proactive in using healthy eating advice, resonating with theories of risk awareness and medicalised childhoods. Surprisingly, mothers from disadvantaged backgrounds are more likely to use advice from health professionals, possibly as a result of health professionals actively targeting their support to more ‘at risk’ families. Yet these mothers are also more apprehensive about the interference of health professionals in aspects of childrearing. Relevant policy reflections pointed to the need to identify how support for mothers from more disadvantaged backgrounds can be provided in formats which help to overcome the culture of mistrust towards health professionals prevalent among disadvantaged parents. Nevertheless, positive associations between infant diet and maternal use of breastfeeding advice from health professionals are found, in line with theories of power-knowledge, lending support to information-based policy initiatives as a tool for improving infant nutrition. The analysis also indicates that children who are breastfed, and children who are weaned later have healthier diets in their toddler years, which contributes to the proposal of a theoretical typology explaining how young children’s nutritional trajectories evolve from the pre-partum period through infancy and childhood. Finally, the analysis suggests that communal patterns of eating play an important role in children’s dietary quality, attesting to the importance of the meal ritual as a vehicle for socialising children into developing particular tastes for food. Thus, there seems to be room for policy initiatives which address not only what children eat, but how young children and families eat in the context of everyday family life.

Managed clinical and care networks (MCNs) have emerged in Scotland as a collaborative form of organising within health and between health and social services. Bringing together disparate disciplines and professions their aim has been to allow work across service and sector boundaries to improve care for patients. Whilst MCN prevalence has increased and policy has moved to centralise this method of organising, many research questions remain. These include: how can we understand the form, function and impact of MCNs, and further, what are the underlying motivations for practitioners and managers to organise in this way? Focussing in on the work of 3 voluntary MCNs operating in Scotland, the centrality of practice emerges. Practice is defined broadly to encompass both the interactions between practitioner-patient and practitioner-population. From this, the MCN becomes conceptualised as a set of activities focussed around ground-level clinical MCN service issues and top-level policy direction. Through considering work the interplay between ethics and scientific evidence emerges. The inherent uncertainty and suffering of daily practice comes to the fore, these concepts are brought together within a framework, morals-in-practice. Further, using the hermeneutic dynamics of alterity, openness and transcendence, MCNs can be understood as providing a space to foster creative responses to the wicked problems created by health and social service design and delivery. The organising opportunities provided by MCNs thus arguably serve several organisational and social functions, providing a forum to: mutually support and respond to the intrinsically challenging nature of practice understood; debate morals-in-practice helping to ensuring collective clinical governance; sharing of organisational knowledge; planning, delivery and audit of services; and creatively respond to wicked problems. By focussing in on the work, the practice particularities of each individual MCN are resultantly emphasised, whilst still maintaining recognition that much of the NHS operational context is more widely shared. Through this these voluntary MCNs, at least, can be viewed as an organising form which has emerged in response to the complexities of modern health and social service, care, design and delivery.

Western governments face increasing demands to achieve both cost efficiency and responsiveness in their public services leading to radical and challenging transformations. Following the imposition of New Public Management (NPM) approaches within England, it is argued that similar elements of NPM can be also seen within Scottish healthcare, despite policy divergences following devolution. This thesis considers the influence of NPM on Scottish hospital frontline nursing staff in their work. It explores the ways in which managerial practices (specifically professional management; discipline & parsimony; standard setting & performance measurement; and consumerism) have shaped the working relationships, interactions, and knowledge-exchange between managers, staff and patients and the ability of staff to carry out nursing duties within an acute hospital setting. The study is a qualitative interpretivist study grounded in the methodology of adaptive theory and draws upon the works of Lipsky (1980) in order to explore how the front-line nurses cope with and resist the demands of the workplace. Based on thirty-one qualitative interviews with front-line nursing staff in an inner city hospital in Scotland, this thesis presents the findings resulting from nurses’ views of management, finances, policies, targets, audits and consumerism. The findings show that these nurses believe there has been a proliferation of targets, audits and policies, an increasing emphasis on cost efficiency and effectiveness, a drive for professional management and a greater focus on consumerism in NHS Scotland. These are all closely linked to the ethos of NPM. From the findings it can be seen that many elements influence the working relationships of the frontline hospital nursing staff. The study suggests that the main reason for conflict between managers and nursing staff is due to their differing foci. Managers are seen to concentrate on issues of targets, audits and budgets with little thought given to the impact these decisions will have on patient care or nurses’ working conditions. Furthermore the findings highlight high levels of micro-management, self-surveillance, control and the regulation of the frontline nursing staff which has led to tensions both between nursing staff and managers, but also with patients and the public. Finally, although there has supposedly been policy divergence between Scotland and England, this thesis has identified many similarities between Scottish and English polices and NPM approaches continues to influence the working relationships of front-line nursing staff within this study despite the rhetoric that Scotland has moved away from such practices.

In Scotland, life expectancy and health outcomes are strongly tied to socioeconomic status. Specifically, socioeconomically deprived areas suffer disproportionately from high levels of premature multimorbidity and mortality. To tackle these inequalities in health, challenges in the most deprived areas must be addressed. One avenue that merits attention is the potential role of general medical practitioners (GPs) in helping to address health inequalities, particularly due to their long-term presence in deprived communities, their role in improving patient and population health, and their potential advocacy role on behalf of their patients. GPs can be seen as what Lipsky calls ‘street-level bureaucrats’ due to their considerable autonomy in the decisions they make surrounding individual patient needs, yet practising under the bureaucratic structure of the NHS. While previous research has examined the applicability of Lipsky’s framework to the role of GPs, there has been very little research exploring how GPs negotiate between the multiple identities in their work, how GPs ‘socially construct’ their patients, how GPs view their potential role as ‘advocate’, and what this means in terms of the contribution of GPs to addressing existing inequalities in health. Using semi-structured interviews, this study explored the experience and views of 24 GPs working in some of Scotland’s most deprived practices to understand how they might combat this growing health divide via the mitigation (and potential prevention) of existing health inequalities. Participants were selected based on several criteria including practice deprivation level and their individual involvement in the Deep End project, which is an informal network comprising the 100 most deprived general practices in Scotland. The research focused on understanding GPs’ perceptions of their work including its broader implications, within their practice, the communities within which they practise, and the health system as a whole. The concept of street-level bureaucracy proved to be useful in understanding GPs’ frontline work and how they negotiate dilemmas. However, this research demonstrated the need to look beyond Lipsky’s framework in order to understand how GPs reconcile their multiple identities, including advocate and manager. As a result, the term ‘street-level professional’ is offered to capture more fully the multiple identities which GPs inhabit and to explain how GPs’ elite status positions them to engage in political and policy advocacy. This study also provides evidence that GPs’ social constructions of patients are linked not only to how GPs conceptualise the causes of health inequalities, but also to how they view their role in tackling them. In line with this, the interviews established that many GPs felt they could make a difference through advocacy efforts at individual, community and policy/political levels. Furthermore, the study draws attention to the importance of practitioner-led groups—such as the Deep End project—in supporting GPs’ efforts and providing a platform for their advocacy. Within this study, a range of GPs’ views have been explored based on the sample. While it is unclear how common these views are amongst GPs in general, the study revealed that there is considerable scope for ‘political GPs’ who choose to exercise discretion in their communities and beyond. Consequently, GPs working in deprived areas should be encouraged to use their professional status and political clout not only to strengthen local communities, but also to advocate for policy change that might potentially affect the degree of disadvantage of their patients, and levels of social and health inequalities more generally.