Thesis (M.P.A.)--University of Hong Kong, 1991.

Thesis (M.P.A.)--University of Hong Kong, 1991. / Also available in print.

Thesis (M.Soc.Sc.)--University of Hong Kong, 1986. / Also available in print.

No description available.

An Enterprise Culture, which looks to replicate improvements to quality and efficiency demonstrated in the private sector, has evolved from health care policy in the English NHS. The aims of this research were to explore the theory underpinning the application of the policy and to challenge and test if the Enterprise Culture has provided a framework for performance improvement in a rural District General Hospital (DGH). The evolution and characteristics of the Enterprise Culture resulting from the convergence of political policy relating to health care revealed a centralised command and control approach to performance expectations and a decentralised means of achieving them through managers and competitive markets. Using a mixed methodology with a dominant quantitative, less dominant qualitative emphasis, this research examined the theory through a critical comparison of the Enterprise Culture present in a single case study of a rural DGH with the Purpose, Process, People (PPP) framework which has led to private sector success. Firstly, the study looked to understand the nature of the central Enterprise Culture target for hospital emergency care: that patients spend less than four hours in the Emergency Department. A quantitative analysis of service demand from patients found that attendance patterns offered opportunity to use PPP techniques to meet the four hour target, but that greater data availability would be necessary to make detailed calculations. A quantitative analysis of the resources provided revealed that capacity was not calculated, planned or monitored to meet demand. Furthermore, an ethnographic study of the operational activities of the hospital’s emergency care system uncovered a lack of defined process and competent actors, departmental barriers and reactionary decisions leading to poor performance against the four hour wait target. Secondly, an intervention was introduced to examine the Enterprise Culture’s ability to generate efficiency and quality improvements. The intervention (care plans and drug chart provision for patients who required clinical observation) addressed a need, specific to the case site and was identified and implemented by clinicians and managers within the hospital’s emergency care system. Practical barriers to conducting research in rural a DGH were encountered during the intervention and its evaluation. The intervention 2 also revealed that although the Enterprise Culture enabled an improvement intervention to meet local needs, pressure from the central target and the competence of people enacting the process did not support its continued efficacy. In conclusion, in my contributions to subject knowledge, I argue that the Enterprise Culture present in the case site does not support the policy aims for generating quality and efficiency. The central four hour target remains too influential and causes reactionary operational activities. Processes and staff competent in following them are not adequate to meet the demands placed on the service of the emergency care system studied. Finally, the whole emergency care system has a great influence on the Emergency Department’s performance and should be considered when evaluating its performance and decisions about service structure.

This thesis applies a conceptual framework to determine the key insights that complex adaptive system theories provide to the novel challenges facing the introduction of clinical governance in two English Primary Care Trusts (PCTs). It presents empirical research on governance through qualitative case studies of the implementation of clinical governance arrangements within two North West PCTs, during a time of flux and change. The study is located within the English National Health Service (NHS) between 1999 and 2005. The Department of Health (DH) describes clinical governance as an evolving organisational structure and process that: "Provides NHS service organisations and individual health professionals with a framework within which to build a single, coherent local programme for quality improvement." (Department of Health, 1998a p.33). The thesis reviews the literature on governance models, quality improvement frameworks and complexity-based approaches to establish an appropriate theoretical base to the study. The literature relates to the nature of PCTs as a networked structure with autonomous parts. This approach contextualises the origins of clinical governance and related quality concepts. The study encompasses the introduction of the most recent contractual arrangements for primary care in 2004 (NHS, 2004). The research question posed is: "How can governance of quality improvement programmes be managed in a way that is appropriate to the characteristics of English PCTs?" Detailed evidence demonstrates the nature of local clinical governance programmes and the implementation within two North West PCTs, from the perspective of those involved. The results of the analysis show that multiple perspectives were taken into account in the decisions made about the content and delivery of clinical governance programmes. It is suggested that the application of a complex adaptive system conceptual framework helped to provide insight and interpretation of the accounts of those involved in the two case studies. The variation in clinical governance approaches across the two PCTs is explained in part by the strategic and policy orientation of each PCT. The results are consistent with the argument that the characteristics of quality improvement programmes in two PCTs go beyond linear based concepts, and can be thought of as real-world exemplars of the emergent properties of complex adaptive systems. In practice, the lessons learned provide opportunities to inform future management approaches to quality improvement programmes in PCTs.

Background: Antimicrobial resistance (AMR) is a widely recognized threat to global health that has been accelerated by the overuse of antimicrobials. Policy and regulatory interventions offer a useful approach to bring about widespread change in antimicrobial use. Objectives: This dissertation aims to investigate and characterize the role of policy interventions on antimicrobial use, to understand which policy levers have been used, which interventions have proven to be effective, and to identify analytic strategies that assist researchers and policymakers in developing evidence-informed approaches to address human AMR. Methods: To investigate effectiveness of policy interventions, I developed a systematic review and evidence map and appraised the quality of research on government policies to reduce antimicrobial use. To evaluate the extent of policy action on AMR in the Canadian context, I conducted an environmental scan of AMR action between 2008-2018. Finally, to facilitate advances in the scientific evidence base on antimicrobial resistance policy, I developed a framework for planning, conducting, and disseminating AMR intervention research. Findings: Governments have a variety of policy options at their disposal to respond to the growing threat of AMR, however, most of these policy options have not been rigorously evaluated and their effectiveness is unknown. Some regulatory, communication, guidelines, and fiscal interventions have been effective in particular settings, however, the interventions were too disparate to generalize about the effectiveness of any particular policy approach and reporting gaps in pose challenges for interpreting and replicating study results. In Canada, policy interventions have been too few, too small and too uncoordinated to achieve our AMR goals. Building on these findings, I developed a framework for planning, conducting, and disseminating AMR intervention research that identifies challenges, areas for increased coordination with policymakers, and best-practices for overcoming common limitations in AMR research. Discussion: Governments around the world have committed to respond to AMR, however, rigorous evidence to inform their policy and regulatory strategies is lacking. As the threat posed by AMR grows, it is increasingly important to strengthen the scientific evidence base on AMR policy interventions, to learn from existing policies and programs, and integrate scientific evidence into the global AMR response.

This thesis describes what counts as evidence and what constitutes an evidence-informed approach to health policy development, particularly policy with an equity focus. While health policy is increasingly aiming to be ???evidence-based???, a narrow conceptualisation of this can neglect the importance of the powerful and dynamic context of public policy-making. An evidence-informed approach recognises and works with a broader range of contextual influences. The aim of this thesis was to extend and deepen understanding of how evidence informs policy that promotes health equity, through a tracer study of policy development in Australia. The objectives of the research were to examine influential types of evidence, their role and function; to investigate the context, processes and relationships that contributed to evidence informed health policy, and to gain a deeper understanding of how health equity, and evidence on equity, was conceptualised and considered in the policy process. Two Australian state government policy initiatives in the area of early childhood intervention were investigated through interviews with key policy actors in both states, and media, political and policy documentary analyses. A theory-informed framework was developed from the literature to guide this research. This thesis has led to the development of a number of theoretical models, insights and working principles to guide evidence-informed policy development. The models emerge from a conceptual framework that describes how clusters of information (contextual, expert opinion, scientific studies, policy audit, and economic) combine with a number of policy conditions (necessity, opportunity, capacity, relationships, actors and processes) to become a ???case for policy???. What follows seems to be several primary insights to the types of evidence that inform health policy; the identification of an ???adopt, adapt, apply??? phase in policy-making; and the existence of an ???equity policy gap??? ??? exposing the rare translation of equity principles into policy action. Findings from this study call for recognition of research as only one information source in policy development. The successful integration of research and policy is more likely if research evidence is seen within, and as a part of, a more complex policy development system.

This thesis describes what counts as evidence and what constitutes an evidence-informed approach to health policy development, particularly policy with an equity focus. While health policy is increasingly aiming to be ???evidence-based???, a narrow conceptualisation of this can neglect the importance of the powerful and dynamic context of public policy-making. An evidence-informed approach recognises and works with a broader range of contextual influences. The aim of this thesis was to extend and deepen understanding of how evidence informs policy that promotes health equity, through a tracer study of policy development in Australia. The objectives of the research were to examine influential types of evidence, their role and function; to investigate the context, processes and relationships that contributed to evidence informed health policy, and to gain a deeper understanding of how health equity, and evidence on equity, was conceptualised and considered in the policy process. Two Australian state government policy initiatives in the area of early childhood intervention were investigated through interviews with key policy actors in both states, and media, political and policy documentary analyses. A theory-informed framework was developed from the literature to guide this research. This thesis has led to the development of a number of theoretical models, insights and working principles to guide evidence-informed policy development. The models emerge from a conceptual framework that describes how clusters of information (contextual, expert opinion, scientific studies, policy audit, and economic) combine with a number of policy conditions (necessity, opportunity, capacity, relationships, actors and processes) to become a ???case for policy???. What follows seems to be several primary insights to the types of evidence that inform health policy; the identification of an ???adopt, adapt, apply??? phase in policy-making; and the existence of an ???equity policy gap??? ??? exposing the rare translation of equity principles into policy action. Findings from this study call for recognition of research as only one information source in policy development. The successful integration of research and policy is more likely if research evidence is seen within, and as a part of, a more complex policy development system.

In recent years there has been increasing interest in improving the quality of policy through building the policy capacity of public sector institutions. To date, however, there has been little evidence on which to base capacity building interventions. This thesis presents a study of policy process and policy capacity in the Department of Human Services (DHS) in the Australian State of Victoria. Policy capacity was defined as the organisational infrastructure that supports effective policy development and implementation (including individual competencies). The study drew on the health policy, public policy and public administration literature. Data collection methods involved (i) individual in-depth interviews with policy workers in four policy-oriented organisational units of DHS to explore the policy process and policy capacity, and (ii) a focus group and individual interviews with experienced policy workers to explore potential capacity building strategies. Findings indicate that building policy capacity requires attention to four domains: building and managing a policy-competent workforce; developing formal processes and guidelines for strengthening the policy process; strengthening organisational culture and policy leadership; and strengthening structures and relationships to support policy capacity. Building capacity also involves negotiating tensions between policy capacity and two other elements of governing capacity (administrative capacity and state capacity). The appropriate choice of capacity building strategies depends on context and contingency, including the specifics of particular policies, times and settings. Accordingly, the thesis concludes that a focus on developing policy leadership at the middle and senior levels would be a strategic approach to building policy capacity. Policy leadership involves local level judgement, mentorship, initiative and responsibility, and the ability to mobilise organisational resources to build policy capacity.