The central hypothesis of this study was that the allocation system for NHS hospital and community health services between 1997 and 2003 was not meeting key principles of compensating for differences in the need for services and unavoidable costs. The review and analyses in this study indicate that the underpinning assumptions used when formulating the need adjustment were not robust and that this led to the selection of inappropriate proxies for need. In addition it is concluded that the age adjustment underestimated the costs of elderly care. This study has concluded that the pay adjustment, which was the largest in the formula, did not reflect actual unavoidable differences in cost because the Warwick studies that were used to set the adjustment ignored the monopsonistic nature of the NHS. As a consequence the pay adjustment was based on the assumption that NHS salaries should be related to local salaries. This study identified unavoidable additional costs of providing healthcare in rural areas. These findings were consistent with other comprehensive studies on healthcare costs in Scotland, Wales and Northern Ireland. This study concludes that the exclusion of a market forces adjustment for rurality was inconsistent with all other comparable allocation formulae in the Home Countries. The absence of a rurality adjustment resulted in rural areas receiving a lower proportion of NHS funding than was justified and this is referred to as the Inverse Share Law. This study concludes that the central hypothesis was correct and that a rurality adjustment was justified, but that the principal determinant of service quality was an adequate focus on efficiency.

There is a noticeable absence of studies reflecting the personal views and experiences of black British African Caribbean (BBAC) people as students and clinical participants in UK nursing careers. Previous research about their nursing career choices has always been reported as part of other mixed BME cohorts and migrant groups. Indications in the literature suggest that they were being actively discouraged by their families from choosing nursing as a career, because of their parents’ and grandparents’ negative experiences as migrant workers in the NHS, leading to very low or non-participation in the profession. This study set out to address this gap by giving them a distinct voice, independent of other cohorts. It explored the factors which influence their decision and their experiences, throughout a variety of life stages, from school through to university and into clinical practice. This was to identify whether the findings from earlier research are still relevant from their perspectives rather than that of their parents. Participants and schools in the study were recruited by purposive sampling, and data was collected in three phases, a pilot study phase, a survey phase and an interview phase. A quantitative and qualitative interpretive approach were adopted underpinned by a mixed methods design. Descriptive statistical analysis of the survey and qualitative content analysis (QCA) of the interview transcripts were utilised to enable interrogation of the data. Findings are discussed within the context of available empirical evidence, related policy perspectives and theoretical underpinnings. Four main themes emerged from the study, as specific influencing factors on their experiences. These are: careers advice and choice for nursing, support, discrimination/racism and personal resilience. The findings reveal that BBAC people receive little or no careers advice about nursing at any of their life stages. Consequently, they make uninformed decisions about modern nursing careers, leaving a gap in their knowledge. However, they are not discouraged from choosing nursing as a career, by their families. When they choose a nursing career, they are fully supported and encouraged by their parents and families, in order to survive as students and clinical practitioners. However, institutional support as students and practitioners is weak and very poor. Despite this, they do not intend to actively discourage their own children from making nursing a career choice. Racism, discrimination and racialisation remain core factors influencing their social, educational and other lived experiences, despite numerous equality legislation and implementation. These have a continuous negative impact on them as visible minority students and practitioners in the NHS. They respond to these negative experiences by developing personal resilience aided by strong social and cultural support provided by their families and community. These findings make a unique contribution to the knowledge base by giving BBAC participants their own distinct voice. This was achieved through listening to them at varied points in their life stages, from school through to university and as eventual professionals in nursing. This is important new knowledge, which has ensured a clear recognition of their personal perspectives, in their own voices. These insightful new observations are necessary to build a specific knowledge base about them and are very positive for future participation of BBAC people in nursing careers and the NHS. An adapted model for inclusive participation is proposed, based on the findings of the research.

This thesis examines a middle manager’s response to strategic directives on integrated care in a National Health Service (NHS) organisation and the development of an awareness of prejudice that acknowledges its relationship to the process of understanding. The research focuses on an integration of two community NHS trusts and an NHS hospital trust into one integrated care organisation (ICO). A change programme was initiated and promulgated on an assumption that integrating the three organisations would facilitate integrated care. However, despite the use of organisational change approaches (such as communication plans and systematic approaches to staff engagement), implementing the strategy directives in practice remained problematic. What emerged during the integration process was resistance to change and a clear division in the different ways of working in the community NHS trusts versus the community and hospital trusts – differences that became apparent from the prejudices of individuals and staff groups. The proposition is that prejudice is an important aspect of relationships whose significance in processes of change is often overlooked. I argue that prejudice is a phenomenon that emerges in the processes of particularisation, which I describe as an ongoing exploration and negotiation in our day-to-day activities of relating to one another. Our pejorative understanding of the term ‘prejudice’ has overshadowed more subtle connotations, which I propose are unhelpful in understanding change in organisations. However, I suggest a different way of thinking about prejudice – namely as a process that should be acknowledged as a characteristic of human beings relating to one another, which has the potential to generate and enhance understanding. The research is a narrative-based inquiry and describes critical incidents during the integration process of the three organisations and focusing on interactions between key staff members within the organisation. In paying attention to our ongoing relationships, there has been a growing awareness of disconnection from traditional management practices, which advocate systematic approaches and staff engagement techniques that are designed to encourage cooperation and reduce resistance to proposed change. This thesis challenges assumptions surrounding prejudice and how middle managers traditionally manage organisational change in practice in their attempts to apply deterministic approaches (which assume a linear causality) to control and influence human behaviour. I have taken into consideration a hermeneutic perspective on prejudice, drawing on the work of Hans Georg Gadamer, and have argued from the viewpoint of the theory of complex responsive processes. This offers an alternative way of thinking about management as social processes that are emergent in our daily interactions with one another, that are not based on linear causality, or on locating leadership and management with individuals. It provides a way of taking seriously the relationships between individuals by paying attention to what emerges from the interplay of our expectations and intentions. This leads to a different way of thinking about the relationship between prejudice and strategic directives, which I argue are not fixed instructions but unpredictable articulations of our gestures and responses that emanate from social interaction and continually iterate our thinking over time. This paradoxically influences how we make generalisations and particularise them in reflecting on and revising our expectation of meaning I suggest that it is not possible to predetermine a strategic outcome; and that traditional management practice, which locates change with individuals – and reduces aspects of organisational life, such as resistance, into a problem to be fixed – obscures our capacity to understand the processes of organisational change in the context of a much wider social phenomenon. I therefore conclude that my original and significant contribution to the theory of complex responsive processes and to practice is encouraging a different way of thinking about prejudice – as a process that can be productive and generate understanding, when considered as encompassing our expectations of meaning, linked to our own self-interests. This then opens up possibilities for transforming ourselves in relation to others – and, through this process, to transform the organisations in which we work.

A study was conducted to investigate mental health professionals' experience of change in three NHS Trusts in England. The aim was to understand the professionals' experience of change, applying the psychological contract as a sense-making tool using an extended contract model (Guest, 1998; George, 2009). The concept of the psychological contract was first introduced within psychoanalysis (Menninger, 1958) to explain the relationship between client and therapist. The psychological contract has evolved over the years to be applied in occupational settings to explain social exchanges between employees and the organisation (George, 2009). Semi-structured interviews were conducted with 15 mental health professionals from community NHS teams, with one participant from an inpatient ward. A hybrid thematic analysis using inductive and deductive coding was applied to capture both the theoretical framework of the psychological contract and the subjective experiences of the participants. Results revealed that the psychological contract could serve as both a cognitive and emotional sense-making tool of change for participants. Findings also revealed the influence of contextual political and social factors around change in the NHS. Novel findings included mediators in the change process such as participants feeling supported to negotiate psychological contracts and upholding personal and team values. The findings are discussed in terms of clinical implications for managing professionals' experience of change in the NHS.

Previous research has reported that inequalities exist in uptake of NHS sight tests in relation to socio-economic status, and that community optometric services have potential to improve system efficiency. The current research found inequalities in sight test outcome related to socio-economic status and the type of practice that a patient visits (multiple, or independent). Patients attending multiples were more likely to receive a ‘new or changed prescription’ relative to ‘no prescription’ compared to patients that attended independent opticians (36-71% more likely). Those living in the least deprived areas were also less likely to receive a new prescription (1-12%) and those aged <16 years were less likely to be referred (9%). The study examining the need for a Minor Eye Condition Service in Leeds and Bradford found it would produce theoretical cost savings, whilst maintaining high patient satisfaction. Subsequently, a MECS was commissioned in Bradford. The study attempting to collect data from MECS across all areas of England found that data is not routinely collected, or shared. The limited data available typically showed that 73-83% of patients were retained in optometric practice with 12-18% receiving a hospital referral. A prospective evaluation of a COVID urgent eye care service found that teleconsultations frequently did not resolve patients’ eye problems (27%). These telephone consultations failed to detect some serious conditions such as scleritis, wet macular degeneration, retinal detachment. The results from the thesis support the view that the current method of delivering eye care in England is contrary to the public health interest.

Using data for every elective procedure in 2007 in the English National Health Service, we found evidence of socioeconomic inequality in the probability of having a procedure cancelled after admission while controlling for a range of patient and provider characteristics. Whether this disparity is inequitable is inconclusive.; Using data for every elective procedure in 2007 in the English National Health Service, we found evidence of socioeconomic inequality in the probability of having a procedure cancelled after admission while controlling for a range of patient and provider characteristics. Whether this disparity is inequitable is inconclusive. Copyright A[c] 2012 John Wiley & Sons, Ltd.; � Using data for every elective procedure in 2007 in the English National Health Service, we found evidence of socioeconomic inequality in the probability of having a procedure cancelled after admission while controlling for a range of patient and provider characteristics. Whether this disparity is inequitable is inconclusive.

The creation of the National Health Service is treated, analytically and historically, as a planning process involving major changes in the social organisation of health as a part of the larger set of social and economic reconstruction policies undertaken by the wartime Coalition and postwar Labour governments. Definitions of 'health' are considered as relative both to social expectations and ideology, and to theoretical models of the organisation of health services. These models are identified with certain socio-political agents or interests in the providing and consuming of health services: professional groups, public and private authorities, non-professional workers, and the public. The models of the health service advocates and of the medical profession are considered as reference points. A framework is presented for the analysis of the representation of these interests, by the state, in the planning and operation of the NHS, and as beneficiaries of its services. Through a detailed historical consideration of internal health service planning documents of the major interests, including the medical profession, the health service advocates representing the Labour party and trade unions, and recently released documents of the Ministry of Health and the Coalition and Labour Cabinets, the interaction of the interests with the two governments and with each other is traced, and the reconciliation by the state of the health service models proposed by them is analysed. It is argued that the changes wrought in the social organisation of health in Britain can be described according to certain principles of the organisation of pre- and post-NHS health services: principles of public access, structure of services, structure of administrative control and structure of planning representation. Tne major interests were represented differentially by the state with respect to each of these criteria; similarities and differences between the approaches of the two governments to the representation of interests are examined, and it is concluded that, although the health service advocates and the public benefited from a free and universal scheme, the public and non-professional health workers enjoyed considerably less representation than the medical profession in the particular services provided by the NHS and in its planning and administration.