This study was designed to explore organizational change in primary health care, specifically the introduction of Local Health Groups which were meant to create radical change at local level across Wales. The aim was to gain a better understanding of the factors that influence the formation and development of organizations receptive to change. The specific questions included: firstly, what structural and organizational changes were made for the promotion and development of Local Health Groups Secondly, what leadership behaviours did the selected health professionals apply to their roles as Chairmen, in terms of building organizations capable of change and development And thirdly, what lessons can be learned for leadership and organisational reform, and policy implementation at local level for the future The policy decision to devolve decision-making in health care to primary care professionals at local level provided the opportunity to conduct a prospective study. A case study approach was selected to explore the experiences of all 22 Local Health Groups, through the reported experiences of the Chairmen as the lead figures responsible for forming and developing the new organizations. Data were collected using three waves of face-to-face interviews, supplemented with Minutes of Board Meetings tracing the study period: April 1999 to October 2001. Some limited observation of key events was also carried out. The study was conducted at a time of considerable turbulence in the health system in Wales. Firstly, it appears from this study that the structural changes made to implement the new policy were inadequate to that task. But some Chairmen appeared to exercise specific skills that enabled them to manage the consequent uncertainty in the system more comfortably than others. In addition, key leadership behaviours appeared to influence the development of change promoting organizations. These included strategic vision: the ability of the lead figures to articulate an attractive vision of the future, and persuade others to pursue it. Secondly, the ability to forge constructive working relationships with a wide variety of stakeholder organizations proved to be pivotal. Thirdly, the ability to identify key features of the organization and build on them to create unique organizational identities and services emerged as a key leadership behaviour in this context.

In recent years traditional approaches to the assessment of health hazards have struggled to connect with the concerns of local communities, resulting in disputes over the interpretation of risk. The Nant-y-Gwyddon (NyG) landfill site in the Rhondda valley, south Wales, was shut down in March 2002 on the recommendations of an independent investigation, following five years of concerted and highly publicised protest action by a group calling itself Rhondda Against Nant-y-Gwyddon Tip (RANT). This local environmental protest provides an interesting case study in the sociology of public health risks and community mobilisation. The research has aimed to explore the key processes and relationships involved in the evaluation of perceived threats to public health in the period up to the closure of the tip in 2002. Rich documentary data formed the primary evidence for the case-study, and this has been used for two main purposes: first, to construct an historical account of the protest focusing specifically on the actions and perspectives of the residents who became local activists and secondly, to explore the positioning of the main actors in relation to some of the key issues and events. This research contributes to theory in several ways. The findings are illustrative of the different kinds of knowledge and expertise brought into play by both residents and statutory bodies, and as such connects with the literature on types of expertise, local knowledge and popular epidemiology. The research also highlights the need to locate such struggles in their broader social and cultural contexts, and suggests the importance of concepts such as dependency, hegemony and counter- hegemony, for understanding lay-expert relationships and protest more broadly. Following this, various examples are also given to suggest the development of several counter-hegemonic features of the residents' campaign, across epistemological, social and political domains.

Where possible, policies to improve public health should be evidence-based. Where political pressures and shortage of evidence force action in advance of evidence, effectiveness can be evaluated during policy rollout. Because the aetiology of public health issues is complex, successful policies will likely be complex in their design, their implementation and their interaction with their contexts and target audiences. Process evaluation is therefore crucial in order to inform consistent implementation, and alongside outcomes evaluation, in order to understand how outcomes are produced. However, limited methodological guidance exists for process evaluation. This thesis develops a mixed-method framework exploring programme theory, diffusion, implementation, participant experiences and reach, which is applied to the evaluation of the Welsh National Exercise Referral Scheme (NERS). A logic model is developed via discussions with policy representatives. Diffusion is explored via qualitative interviews with policy representatives and local coordinators. Implementation checks draw on routine data, observation and self-report. Participant experiences are explored via qualitative interviews. Social patterning in reach is explored using routine monitoring data. The study identifies challenges diffusing NERS into local practice, in relation to communication structures, support, training provision and the mutual adaptation of the scheme and its contexts. Implementation checks indicate a common core of discounted, supervised, group-based exercise, though some divergence from programme theory emerged, with unfamiliar activities such as motivational interviewing and patient follow-up protocols delivered poorly. Nevertheless, relatively high adherence rates were achieved. Key perceived active ingredients in practice included professional supervision, enabling patients to build confidence and learn to exercise safely, and the patient-only environment, seen as providing an empathic context and realistic role models. However, lower uptake emerged amongst non-car owners, with higher adherence amongst patients already moderately active at baseline, older patients and non-mental health patients. Implications for ERS implementation, outcomes interpretation and process evaluation methodology are discussed.

This investigation explored the Welsh Life Sciences (LS) sector through a Grounded Theory approach. Semi-structured interviews with senior stakeholders from academia, government, industry, NHS Wales, third sector and professional institutions were conducted. A conceptual framework was developed to help understand the complex interactions within the Welsh LS sector. Gap analysis was systematically applied to the data in order to design a model for potential interventions to positively influence the Welsh LS sector. The model was then compared with current and forthcoming policy and policy recommendations to produce an integrated intervention termed the “Welsh Healthcare Innovation Pipeline” (WHIP), to result in the adoption of new innovation within NHS Wales through sourcing, trialling, assessing, procuring, and adopting healthcare innovations through an integrated framework. The proposal is that the WHIP would be adopted across Wales after being piloted sub-regionally within the West Wales region.

NHS Direct Wales (NHSDW) is a nurse-led 24-hour health advice and information line. This study estimated the effect of deprivation on the demand for, and outcome of, direct calls to NHSDW after controlling for potentially confounding factors. The author analysed anonymous data from NHSDW on 410,000 calls over 2.5 years, including patient characteristics (age, gender, relationship to caller, ward of residence) and call characteristics (whether for triage or information, day of call). To each call she added ward data including: the corresponding Welsh Index of Multiple Deprivation score; population density; and distance from nearest Emergency Department (ED). She used multiple linear regression to model the relationship between deprivation and demand and binary logistic regression to model the relationship between deprivation and outcome. Confounding variables explained 33.0% of variation in advice call rates; and 27.5% of that in information call rates (both significant at 0.1% level). Deprivation was not a statistically significant predictor of these rates (significance levels 0.158 and 0.244 respectively). Deprivation had more effect on outcomes: an increase in deprivation from one fifth to the next fifth increased by 13% the probability of receiving advice to call 999 emergency care within triage calls [Odds ratio (OR) 1.127; 95% confidence interval (Cl) from 1.113 to 1.143]; and that of receiving advice to seek care face to face rather than self care by 5% (OR 1.049; Cl from 1.041 to 1.058) for triage calls and by 3% (OR 1.034; Cl from 1.022 to 1.047) for information calls. In short, deprivation had no detectable effect on demand for calls, but a positive effect on the outcome of the call. While it is possible that the data underestimated the ‘need’ of deprived patients for healthcare, they yield no evidence that NHSDW should seek to improve access from those patients.