No description available.

No description available.

No description available.

The focus of this thesis is patient and public involvement in the UK National Health Service (NHS) following the White Paper, The New NHS: Modern, Oependable (DoH 1997). It offers a critical analysis of the delivery of the promises made in the White Paper, with particular reference to a detailed case study of one Primary Care Group (PCG) during the period 1999 - 2002. The study is set in the policy context of profound organisational and structural change in the UK NHS, which has included an increasing emphasis on developing mechanisms for involving patients and the wider public. The case study is based on observation of several key structures and processes within the PCG and in-depth interviews with key stakeholders - medical and nursing practitioners, PCG managers, members of partner organisations, the lay member of the Board and community representatives. Using a theoretical framework that draws on Lukes' analysis of power, the study explores how the roles of patients and members of the public were perceived and constructed, the effectiveness of involvement and some of the main issues and challenges. The study revealed immature structures and processes, confusion over the why, how and when of involvement activities, tensions between centrally driven targets and local control and relatively little understanding of how acknowledging and addressing existing power relationships is fundamental to developing meaningful involvement. The thesis concludes that attempts to develop patient and public involvement in isolation from theoretical and philosophical issues undermine the impact that traditional and historical patterns of power and control can have on current and future developments in respect of policy and practice. In particular, creating the conditions necessary to enable all stakeholders to identify, articulate, negotiate and argue for their perceived needs will require ideological as well as structural and organisational change.

No description available.

Public involvement in primary care has gained increasing acceptance through a sustained position in government policy since New Labour began in 1997. When Primary Care Groups (PCGs) were introduced (Department of Health 1997), they were seen as vehicles for public involvement, reflecting devolution of power and local decision-making. During the process of this study (1999 - 2006) policy directives have highlighted a number of paradoxes, with the potential to impact on public involvement. Detailed development was left to local discretion, set against a national agenda that emphasised citizenship and consumerism. The purpose of this study was to explore, interpret and understand how public involvement policy was interpreted and implemented within the new organisational structures. The study was designed to address the research question `How is public involvement defined and operationalised within PCGs'. Due to the pace of organisational change, the research expanded to track lay experiences within Primary Care Trusts (PCTs). The research methods included case study, national survey, telephone interviews and the development of a conceptual framework for public involvement in primary care. From the analysis of the national survey and two in-depth case studies, the study provided a detailed profile of lay members across England. Issues regarding representativeness and the identification of a potentially discriminatory appointment system were raised. Despite inadequate training lay members were strongly represented in public involvement and health-related issues but less so in financial and operational areas. There were widespread difficulties with individual capacity and a minority of members identified themes relating to isolation, exploitation and lack of skills recognition. There was little evidence of strategic and organisational development in implementing and responding to involvement initiatives. The majority of approaches to public involvement within this study focused on information exchange and therefore, were tokenistic in relation to power sharing. The impact of the national agenda was evident and the lack of specific central directives relating to involvement led it to remain a low priority. As the move to PCT status became central, public involvement was reclaimed as a management prerogative. The analysis showed that the concept of citizenship, so central to Third Way politics was poignantly missing. The study reflected a focus on service users and the different roles of citizen and user were not clearly demarcated. The use of Foucault's concepts of governmentality and discipline provided an explanatory framework for elucidating the study's findings. The effects of governmentality embedded in policy directives and disciplinary mechanisms within NHS organisations were identified as crucial factors for the lack of significant progress of public involvement over the period of the research study.

Clinical practice benchmarking is a new quality improvement benchmarking approach that involves structured learning from others in order to improve, accepting the subjective nature of health care. Evaluative research of clinical practice benchmarking requires mixed methods, quantitative and qualitative. This challenges the current reliance upon quantitative consideration of the effectiveness of quality improvement approaches. A worked quantitative example is provided and demonstrates that descriptive statistics support comparison activity only. It rejects the value of inferential statistics, since benchmark scores relate to subjective statements. Therefore, inter-rater reliability is poor and it is not possible to directly attribute any change in clinical practice benchmark scores to actual changes in practice. Following the quantitative analysis, a qualitative research study was undertaken from an interpretative perspective to evaluate the effectiveness of clinical practice benchmarking as a quality improvement approach. Particular emphasis was given to exploring the organisational factors that support its effectiveness. Data were gathered through semi-standardised interviews of nursing leaders of local paediatric benchmarking activity and frontline nurses, with rigour ensured through reflexivity and a critical approach to the analysis. The main empirical contribution of this work provided new knowledge about nurses' understanding of clinical practice benchmarking. They defined it as using all evidence to agree best practice, focusing upon collaboration to support sharing, rather than competition. The findings identified the organisational factors that ensured the effectiveness of clinical practice benchmarking. The main enablers were motivation of those involved and supportive leadership, underpinned by an organisation that promotes learning and innovation. This research provides compelling evidence that clinical practice benchmarking is an effective approach to quality improvement in health care. However, it requires acceptance of the importance of the subjective nature of health care and the necessity for qualitative approaches to evaluation. Methodological insights from this study also inform future evaluative research.