This qualitative research informed by the interpretivist paradigm analyses how senior management team members in the Irish public and independent mental health sectors have influenced the evolution of clinical governance. A 54 item schedule (the Organisational Progress in Clinical Governance schedule) [OPCG] is utilised to inform a process of semi-structured interviews. A review of the-clinical governance and-other literature is undertaken to frame the research question, to highlight originality and position expectations. Newell and Burnard's 'Pragmatic Approach to Schematic Content Analysis' in conjunction with NVivo is used as the data analysis framework. A reference group is utilised in advance of the study and 25 executive and director level senior management team members are interviewed in their capacity as senior leaders and experts in the research area of clinical governance evolution. 5 separate healthcare organisations (3 public and 2 independent) were purposively selected. Participants completed the OPCG prior to participating in semi-structured interviews. The interview schedule was informed by the results of the OPCG and the literature review. Senior management team members were drawn from an interdisciplinary perspective. Processes to establish the rigour and plausibility of the study are outlined including the use of multiple coding, a reflexive diary and respondent validation. Following data analysis, findings are distilled and presented. Recommendations for education, practice, management and governance are expounded. These refer to strategies to enhance leadership capacity, commentary on the expanding role of regulation in healthcare, discussion of the differences apparent between HSE and independent sector mental health providers and the implementation of key national policies specifically ICT. Additionally, current issues in recruitment, staff and staff management processes, formal and informal power structures, in-service training and education, evaluation of health service re-structuring at national and regional levels and the re-imagining of strategic alliances with the higher education sector are explored.

Background: The primary care consultation is the arena in which UK patients typically first formally present their mental health concerns. Despite the 'interactive' nature of the management of mental health, most consultation research has focused on the behaviour, perspectives, or characteristics of only one of the participants. There has been no sequential, real-time analytic work, despite GPs reporting that such interactions are difficult and related training is lacking. Objective: To analyse the interactive management of mental health in the primary care consultation, specifically, the way patients present their mental health-related problems and how GPs respond, and patient requests and GP offers for mental health-related sickness certification. Method: Conversation analysis (CA) was used to examine an existing set of 76 audio-recorded 'early' mental health consultations, from a wider corpus of 506 patient consultations, collected in 2004, from 5 practices in London, involving 13 GPs. Consultations were classified as 'early' mental health consultations if: (A) the patient scored 11 or more on the HADS depression questionnaire, (B) they scored between 8-10 and there was emotional content in the consultation or (C) the HADS depression score was under 8 but there was a GP diagnosis of depression, post-consultation. The first analytic section was on patients' problem presentations: From the 76, 15 consultations were examined. 7 of these consultations fell into classification A. These 7 also fell into category B, as they all contained emotional content. 6 fell into category B (but not A) and all 15 fell into category C. The second analytic section was on GPs' responses to patients' trouble talk surrounding an emotional issue. From the 76, 23 consultations were examined. 9 consultations fell into classification A. These 9 all also fell into category B. 8 fell into category B (but not A). While all 23 cases fell into classification C, 6 only fell into C (not A or B). Sickness certification: From the 76, 10 consultations were examined. 7 cases from the wider corpus (ongoing mental health consultations) were all selected. In total there were 17 consultations examined during analysis. Only the 10 consultations from the 'early' sample were classified. 6 of these fell into 2 classification A. 5 of these 6 consultations also fiited into B, one did not, as there was no emotional content. 2 of the A categorised consultations did not fit into C, as there was no diagnosis of depression. 2 consultations fell into classification B and also C (but not A) and 8 fell into classification C. Findings: Patients typically present first experiences of mental health problems as late-arisinq concerns, through indirect means, preferring a collaboratively built presentation. This delayed presentation format contrasts to physical health problems, which typically get presented after the GP's opening question. In 3 out of the 11 problem presentations of a previously un-experienced common mental health problem, the problem was not taken up by the GP. However, within these problem presentations the GP typically did not initially acknowledge the concern and the patients would have to re-do the presentation of the problem before it would be addressed. GPs claimed and demonstrated understanding of patients' emotional troubles through various means. The impact of these understanding displays on the interaction was influenced by their lexical content, their spoken delivery and where they were positioned with regard to the progression of problem presentation. The responses resulted in either the expansion of the problem presentation or its curtailment. Building and successfully demonstrating understanding, resulted from a series of turns of talk which employed 'interpretive talk' from the GP and in which both GP and patient were fully engaged i.e. they were both contributing more than one word responses before the topics conclusion and through their responses they both expanded and progressed the discussion of the problem. In consultations in which sickness certification was mentioned, patients displayed an awareness of the constraints on the issuing of a first certificate through their request formats and their indirect efforts to induce an offer. GPs often indexed the patients' interactional work to secure a sick certificate through the offer format 'do you want', which oriented to the certificate being a desire rather than a need. Both GPs and patients treated repeat certification as non- problematic. Conclusion: Patients used a variety of strategies to cautiously 'manage' the introduction, elaboration of, and decision-making regarding their mental health concerns. This cautiousness suggests that patients are uncertain of how legitimate their common mental health problems are and of how they will be received by the GP. Cautiousness was less apparent when the problem was a 3 4 repeat occurrence. Throughout the analysis a 'collaborative' approach to talking about and 'managing' the common mental health issues led to a more productive discussion.

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There is substantial evidence concerning the inability to achieve desired results and impact through what are commonly described as IS or IT projects, or implementation. The UK health sector provides a fertile ground for research, at a time of unprecedented investment, but with what is perceived to be a relatively poor record of achievement. Mental health services are held to be particularly problematic. This thesis explores the part played by technical, informational, organisational and human aspects, the relationship between these, and how in practice they are interpreted within what is defined as IS implementation. The aims were, a) definitional, concerning the specification of IS implementation, b) context appraising, to examine the impact of the host (mental health) context on both process and results, and through these c) problem solving, to propose an approach to IS implementation based on theory and practice. Drawing from interpretive theory, soft systems methodology and social cognitive theory an in-depth, longitudinal comparison study was performed, principally focussing on a single UK mental health Trust, and a directorate within that Trust. A multi-method approach included document review, questionnaire, structured and semi-structured interview, definitional exercises, focus groups, and action research. Findings concern the inability of organisations to manage the complexity of the process of implementation within challenging, multi-faceted contexts. To address the causes rather than symptoms of this difficulty it is necessary to re-interpret implementation itself, and its human element. A broad definition was proposed as a basis for an inclusive and balanced approach, and an Interface Management toolkit was produced. It is proposed that implementation should be considered and approached in practice as a dialectical situation, interpreting implementation as change within an organisation which encompasses technology. Alternative existing and proposed ideologies of change are suggested to frame a productive relationship between theory and practice.

Mental health has a long history of proving to be a tough concept to define. Multiple forms of knowledge and representation seek to inform as to the nature of mental health, all contributing to the production of immense complexity as to the experience of living with mental health difficulties. This thesis sets out to explore this, by getting as close as possible to mental health service users' actual experiences. A range of forms of knowledge that pertain to inform as to service users' experiences are explored, prior to analysing a corpus of interviews with service users. These are analysed through the development of a Deleuzian Discourse Analysis. Service users' experiences are analysed in terms of the relation between discursive and non-discursive factors, which include forms of mainstream psychiatric discursive practice, such as the application of diagnostic criteria and administration of treatments, along with how such practices are experienced in non-discursive dimensions of service user embodiment and space. The challenges facing service users are seen to operate around identity and control in relation to forms of psychiatric knowledge, along with presenting particular problems with regard to how user embodiment is felt, primarily in relation to psychiatric medication, and how these are driven into the production of service user spaces, i.e. day centres. Finally, a politics of affectivity is offered, as a way to unfold the complexity of service user experience, and to emphasise the existence and potential for change that can be gained through deterritorialising mental health.