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The overall aim of this thesis was to identify actions needed to introduce professional change in histopathology in order to respond to the Government's Modernisation Agenda for Pathology and meet cancer targets by reducing the turnaround time taken for a patient to receive a diagnosis and therefore start treatment. In addition, change methodology was examined to help cope with increasing workloads, both in terms of numbers of specimens and degree of complexity, and to break down assumptions of professional boundaries to establish the skill requirements to make best use of newly developed roles and applied technology. The work took the form of action research and the outcome from each step informed the direction of the rest of the project and resulted in changing working practices. The project work included the development of training programmes and examinations to support extended and expert roles for biomedical scientists which would help to solve the recruitment and retention crisis in histopathology.

Radiology departments across Scotland are currently challenged with increasing workload demands together with 24/7 service sustainability. Planned care must be aligned with unscheduled care to ensure equity of access for all patient groups. In addition to the workload, government and local policies have altered the pattern of healthcare provision and thus the spread of referrals throughout the 24 hour period. Nationally there is a move to redesign radiographic out of hours (OOH) duties to respond to government policies with consideration to the subsequent effect on core hours arrangements. This is hoped to aid recruitment and retention. There is, however, no structured model that defines the staff resource required in general radiography for an unscheduled workload. This is an essential component in determining the resource required to meet the needs of a 24/7 service. This study aimed to ) develop a model that encompassed a defined staff resource per workload and embedded this resource in an application that provides satisfactory 24/7 service cover. A detailed workload analysis of a data extract from the radiology information system (RIS) was undertaken to comprehend workload patterns and trends in the principal study centre. A workpattern model was developed by deductive analysis and reasoning of the data derived from the above evaluation. This determined the staff resource required dependent on the workload. The workforce profile was determined by-means of the principle of crew pairing to determine skill mix. Applications of this model over 24/7 were explored: the theory of adaptive planning was employed to describe the staff resource required for general radiography across the 24 hour period dependent on the non-deterministic nature of the workload while responding to cost effective patient management. The findings were extrapolated in case studies of the principal study centre, a teaching centre and an urban general hospital. An attitude survey was undertaken in the three case study centres, (rural, urban and teaching centres) with differing workload streams relevant to the characteristics of the different centres. Radiographer attitudes to this workpattern model and modular application were evaluated by likert scale responses. This investigated whether they considered that the model and application would be appropriate in centres of differing characteristics and also whether there " are currently sufficient numbers and the appropriate grades of staff to support the model. Attitudes to the effect of the model on radiographers personal development plans and work life balance was also evaluated. The workpattern model developed allows a structure to be imposed on the staffing resource required dependent on local workload statistics. Thus this model could be applied to all hospitals regardless of characteristics. The modular application is flexible and therefore suits local adaptive planning, meeting the needs of the 24/7 service.

Decision-analytic models are increasingly used to inform health policy decisions on adoption and specification of large-scale screening programmes, and to establish the rationale for further scientific inquiries into the effectiveness and cost-effectiveness of alternative screening strategies. While recent years have witnessed considerable methodological advancement in analytical techniques for handling uncertainty in decision-analytic models, the measurement and valuation of health benefits in terms of quality-adjusted life years (QALYs) remains an area of contention, particularly in specific populations such as children. This thesis aims to advance both areas in the context of modelled evaluations of newborn screening programmes.

Literature Review: The literature review presents an overview of non-attendance at colorectal cancer screening appointments and evaluates intervention strategies developed for increasing attendance. Although the review suggests that interventions increase attendance rates above baseline rates in services, there still remains a significant problem with non-attendance. Limitations of the studies and directions for future research are discussed. Research report: The study aimed to increase attendance at forthcoming Hepatitis C screening appointments within a substance misuse service. A two-fold intervention (an information leaflet and an implementation intention intervention), was developed and Theory of Planned Behaviour variables were explored. Participants (N = 161) were randomly allocated to one of four groups which received, prior to their appointment: (1) TAU, (2) a Theory of Planned Behaviour questionnaire, (3) an information sheet or (4) a combined intervention of the information sheet and implementation intention induction. Attendance at appointments was monitored; no significant differences in attendance rates were found between groups. Education and employment status were found to be significantly related to attendance. Addressing barriers to attendance through an information leaflet and an implementation intention intervention were not successful in increasing attendance rates in this 'hard to reach' population. Future directions for research in this area are suggested.

Background: The NHS Health Check programme is one of the boldest commitments to primary prevention in cardiovascular disease (CVD) internationally. It offers risk assessment and management to the entire 40 to 74 year old population, without existing vascular disease. I aim to assess its early impact in general practice, and examine workload implications. Methods: Modelling the population at high risk of CVD in England; comparing CVD risk prediction using two risk scores, and two methods of data imputation for missing risk factor data; the assessment of CVD risk factor recording before the programme and Health Check uptake, using patient-level medical record data from general practice in Ealing, London. Results: Prior to the programme, in Ealing, there was good recording of blood pressure (85.6%) and smoking status (95.8%) in a general population; cholesterol recording was lower (55.6%). Uptake of the Health Check was lower than national estimates at 45% compared with 75% projections, and there were small increases in statin prescribing, reaching 45 percent of the eligible population. Health Check uptake were greater in south Asian patients (adjusted odds ratio=1.80 (1.37-2.36)). The JBS2 CVD risk score generated overall higher estimates of risk than QRISK2 (mean of 13% compared with 11%); this was significantly greater in south Asian men, the group exposed to the JBS2 risk multiplication factor. Modelling, using QRISK2, predicts 2 million patients at high risk in England, with screening and management costing £176 million. Cost using the JBS2 risk score are estimated to be over two times higher JBS2 Conclusions: Poor uptake of the NHS Health Check and interventions will severely limit the population-wide impact of the programme, Given this, and other limitations, I suggest a targeted approach to screening may be an appropriate alternative, and demonstrate from previous literature the complimentary use of population-wide prevention is likely to significantly improve CVD prevention.

Willingness to pay is increasingly being used in health technology assessment, although a number of methodological issues remain unresolved. Using data collected from four studies, this thesis presents the findings from a direct comparison between alternative format designs to elicit willingness to pay for two alternative colorectal cancer screening tests; faecal occult blood (FOB) testing and flexible sigmoidoscopy (FS) testing. Along with the willingness to pay values estimated using the open-ended, payment scale, closed-ended and iterative bidding formats, information is collected on household income, attitudes toward health promotion and personal risk perceptions to determine the nature and value of responses. In comparison with the alternative formats, the closed-ended question design produced significantly higher WTP valuations and different justifications for those valuations. It is hypothesised that the yea-saying effect may explain this difference. The payment scale format achieved a higher completion rate compared to the open-ended design and both formats produced broadly similar valuations. Although a subsequent study suggested evidence of range bias within the payment scale design. The iterative bidding format produced higher valuations than the open-ended and payment scale but lower than the closed-ended, it is hypothesised that valuations obtained using different initial bids demonstrate the existence of starting point bias. Across all studies, respondents who have a high health motivation, are well educated, have a high household income and who are particularly worried about the disease have a positive effect on the willingness to pay for colorectal cancer screening.