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 examines some social policies and public health measures in the small county of Bedford, within the national context, 1904-38. No other such study exists which covers these aspects; it will, therefore, fill a gap in the body of knowledge. At this time, national and imperial needs for a healthy British race were paramount in the minds of politicians and social reformers, particularly in the face of competition for industrial and military supremacy from other powers, including Germany and the United States of America. Certain key themes permeated this era: the changing functions of local and central government, the role of the state and voluntary sectors, and a medical profession divided between those employed in preventive medicine, and those in private practice. However, war, the preparation for war and its after effects have been found to be the most significant factors. George Newman (1870-1948), figures large, because he played a major part in public health initiatives, firstly, as part-time County Medical Officer of Health to Bedfordshire County Council (1900-07), and then at central government level, as Chief Medical Officer of the Board of Education (1907-35), and of the Ministry of Health (1919-35). Two methodological tools were used in this thesis. Historical research was carried out using, mainly, primary source material, and an empirical study was undertaken using a descriptive case study approach. These methods enabled the collection of quantitative and qualitative data and helped to determine both the final content, and the form in which the research was presented. Chapter 1, the Introduction, provides a background to the key figures and themes discussed and describes the intra-county differences in Bedfordshire. Chapter 2 concerns infant mortality, as it is an indicator of the health ofthe whole community. Chapter 3 describes the health of school children, because the Government was particularly anxious about their condition, as they would be needed for industrial and imperial expansion, and in the event of war. Chapter 4 concerns the welfare of children. It provides examples of how the state and voluntary sectors strove to preserve child life, despite problems such as orphanhood and cruelty, and yet still attempted to meet the needs of the British Empire for labour. Chapter 5 discusses women's health, as it was relatively neglected by central government in this period. It takes the form of a case study and makes use of oral testimony from a cohort of 84 women who lived in Bedfordshire in the inter-war years. Chapter 6, the conclusion, examines the effect of war, the role played by the voluntary and state sectors, and the divided medical profession. It also considers the extent to which Bedfordshire led, or lagged behind national social policies and public health measures, and the progress made towards a healthier nation until 1938, the last full year of peace in Europe before the outbreak of World War II.

The following thesis presents an analysis of power and control in the English National Health Service. Notably, it focuses upon power and control over knowledge; over defining what is 'valid' knowledge; over the production of that valid knowledge; and over how, what, when and where that knowledge is used in everyday clinical practice. The issue reaches to the heart of professional conception and definition and hence, control over professions themselves. The thesis attempts to demonstrate the relationship between the different professional groups in the NHS, through the analysis of national, regional and local documents, and interviews with managers, doctors, nurses, dietitians and physiotherapists in three case studies, the thesis shows the complex pattern of relations and behaviour at play. Particular attention is paid to Michael Power's notion of audit and the 'Audit Explosion', which provides a framework for the thesis, and to the work of Michel Foucault, especially his ideas about power, control and panopticism. These are used as a useful metaphor to understand and explain NBS research and audit in relation to the NHS professions. The thesis ends with a cross-case analysis which draws together the rich variety of data and concludes with an analysis of the wider sociological implications ofthe thesis.

Partnership has enjoyed fresh attention since the 1990s and consequently is a growing yet increasingly fragmented area of research. With the incoming Labour Government in 1997, policy has aimed to replace conflict with co-operation in employee relations. Partnership is an approach to managing the employment relationship based on the search for common ground between management, employees and their representatives and involves the development of long-term relationships built on high levels of trust and respect. Approaches to, and models of, partnership are still at a formative stage with no consensus on how partnership develops effectively. Despite the recognition that to understand partnership fully the study of the processes involved is necessary, little is known about these processes involved. Furthermore, the current body of literature on partnership in a UK context is limited in terms of its theoretical basis. The research set out to identify through which theoretical mechanisms partnership works. Informed by social exchange theory, the study examines the viability of partnership within the NHS and attempts to understand the conditions for its successful development. Two stages of empirical research using a mainly qualitative design were conducted. The first stage of fieldwork involved a preliminary investigation of the introduction of partnership in the National Health Service. The aim of this stage was to trace the introduction of partnership and to understand its antecedents and what had set out to achieve using data from eleven in depth interviews with key players at national, regional and local levels throughout the service. Stage two followed a case study approach and investigated the development of partnership in four NHS Acute Trusts. This stage involved a range of techniques (i.e. semi-structured interviews, focus groups, and documentation) examining the views of fifty five respondents from management and trade union representatives across the four Trusts and used data from 543 questionnaires to investigate employee's experiences of partnership. The study contributes to the partnership literature on the developmental processes of partnerships by utilising social exchange theory to better understand the viability of partnership. In particular, examining partnership from a social exchange perspective enabled a deeper understanding of the decision processes involved when deciding whether to co-operate. The study demonstrates that the theory (and its related concepts) can be helpful in examining the viability of partnership in understanding the mechanisms that lead to its successful development and the maintenance of the relationship over time. In assessing the viability of partnership, the thesis identifies the conditions under which partnership produces its effects and demonstrates how these differed in terms of changes in both the climate and the behaviour and attitudes of participants. In sum, the idea of social exchange would seem to provide an underpinning rationale for partnership. Some support for a new and expanding role for the trade union involving jOint work in developing policies was found. Trade unions appear to have a legitimate role in the relationship which is on the whole accepted by key management and trade union players. However, the union role has a low profile amongst managers and employees and trade unions lacked the organisation needed for partnership to be effective. Moreover, if trade unions are going to reap the potential rewards of partnership there should be a continuing effort to address the problems of capacity and capability (by increasing the numbers and capability of union representatives) in order to raise the profile and acceptance of the union among management and employees. In addition, there is a requirement for adequate training and support to ensure that these representatives have the attitude, skills and confidence to become effective representatives of the workforce.

Previous research has examined patients’ level of satisfaction with the care, in an attempt to develop health care services that match patients’ expectations and needs. Nevertheless, there is still considerable debate among researchers over conceptual and methodological issues. This research programme investigated factors that contribute to patient satisfaction with health care in two fairly different European health care systems (the UK’s NHS and Greece’s ESY). A further aim was to develop a scale to assess patient satisfaction and health care evaluations within these two cultural contexts. In order to achieve those aims, a sequential exploratory strategy incorporating, qualitative and quantitative designs was used to explore patient health care evaluations, patient satisfaction, expectations, health care experiences, interpersonal qualities of the doctor-patient relationship and health care contextual factors at both micro and macro level. Three studies were conducted: Studies 1a and 1b examined levels of patient satisfaction with health care delivery in Greece and the UK respectively. More similarities than differences were found between the two samples, but aspects of health system evaluation differed. The data obtained from this study informed the development of the Patient Expectation and Satisfaction Scale (PESS). The psychometric properties of the preliminary version of the scale were subsequently tested in non clinical populations in Greece and the UK (Studies 2a and 2b). The pilot testing of the PESS was based on a proposed theoretical framework suggesting that patients’ expectations depend on the nature of past experiences and current expectations. The variable that influences some of the differences between the two countries is health culture in terms of contextual health care differences. Although findings revealed similarities between the two cultures, differences were found relating to dissatisfaction, health care evaluations, expectations and the quality of the doctor-patient relationship. A revised version of the PESS, based on these findings, was administered to hospital outpatient populations in both countries (Study 3). The Patient Satisfaction and Expectation Model that emerged from this analysis incorporated three levels of patient satisfaction: at the micro level, the macro level and the interpersonal level. The importance of patients’ understanding of professional competence and its salience as a predictor of the effectiveness of the doctor-patient relationship was highlighted. The quality of the doctor-patient relationship emerged as an important determinant of patient satisfaction and adherence. The overall findings of this research programme suggest that patient satisfaction is multidimensional; despite contextual differences between the two health care systems, a universal concept exists that includes health care expectations, health care experiences, interpersonal qualities and aspects relating to operational and organisational structures at both micro and macro level.