Introduction: The English National Health Service (NHS) is rationalising services to ensure healthcare remains sustainable. Implementation of Service Line Management (SLM) is recommended, as it is believed to empower clinical leaders to improve resource use and make cost efficiency savings in areas such as operating theatres (OT). The aim of this study was to examine if, how and why, SLM affects theatre utilisation. Methods: A mixed methods multiphase process evaluation design was used. Three years of theatre utilisation quantitative data, 35 semi-structured interviews and focussed observations were undertaken. The study focussed on elective colorectal surgery in two English NHS hospitals. Results: OTs were found to be inefficient. SLM implementation was minimal. Theatre data was not valued or used to affect performance and interviewees felt, in part, due to organisational structures, unable to control processes. Consequently, minimal impact on the cost effectiveness and efficiency of OTs was identified. Conclusion: To improve the cost effectiveness of OT, NHS hospitals need to invest in data systems and develop organisational structures that devolve control to clinical leaders and promote staff collaboration. Without these elements, SLM cannot be implemented and its potential impact will not be established.

Introduction The presented research sought to understand variation in the clinical quality of general practice. Methods Clinical quality indicators relating to Cardiovascular Disease and Diabetes were analysed in general practices in Sandwell and the Black Country. General practices showing unusually high or low performance across indicators were identified. Semi-structured interviews were then conducted with practice staff to explore reasons for variation. Results Differences emerged between practices' leadership, culture, care systems and approaches to quality measurement and improvement. General practices were categorised into four types within a newly developed typology of general practice organisations: "biomedical", "holistic", "corporate" and "externally reactive", where there was some evidence that practice type influenced variation. Discussion Variation in general practice clinical quality appeared linked to differences staff held in their views of what constitutes quality in general practice, as explained through the practice typology, with an implied trade-off between achievement of different quality priorities. The research is limited by the study population, specified disease focus and quality measures adopted to examine variation. However, the results highlight the importance of moving to a shared definition of quality in general practice which may influence the measurement and understanding of variation in this setting and the developed practice typology.

In the UK approximately 60% of deaths occur in acute hospital settings to people from different cultures and religions. This thesis explored the experiences of bereaved relatives from the Christian, Jewish and Muslim faiths, doctors, nurses, healthcare assistants and religious leaders to explore the essences of bereavement and implications for providing religiously appropriate end of life and bereavement care in an acute hospital setting. Phenomenology provided the philosophical and intellectual framework and van Manen’s (1984) four existential dimensions of temporality, spatiality, corporeality, and communality the structure. Chronological story telling allowed exploration of the ‘lived’ experience of bereavement and demonstrated that current bereavement theories and practice are not always reflective of the diverse needs of a multifaith and multicultural population. Similarities and differences in the requirements of the 3 Abrahamic faiths became apparent through the experiences of all participants and the importance and significance of doing the right thing, at the right time for the right person in a sensitive and caring way was demonstrated. The impact of end of life care on the bereavement experience was palpable throughout participant recollections. The study highlighted education and training needs not only of hospital staff but of the general public and the need for a more holistic approach to bereavement theory, policy, practice and research.

Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality but widely underdiagnosed. This thesis explores methods to improve case finding for COPD in primary care. It includes two systematic reviews - the first evaluated the diagnostic accuracy of screening tests and showed that handheld flow meters are more accurate than the COPD Diagnostic Questionnaire. The second evaluated the comparative effectiveness of different case finding strategies and found that inviting symptomatic ever smokers for a screening assessment may be more efficient than inviting all ever smokers directly for diagnostic spirometry. The thesis then reports the development and external validation of two risk prediction models for COPD using data from electronic health records and a cluster randomised controlled trial. These models can be used to assess the risk of undiagnosed COPD to help target patients for case finding and can potentially be integrated with clinical information systems. Finally, primary care providers were interviewed to explore their views on case finding for COPD, including potential benefits and harms, as well as barriers and facilitators. This suggests that more training and support for community respiratory services may be needed in order to improve the timely diagnosis of COPD.

Policy, training and research reflect the importance of patient involvement in decisions about their care. Adoption demands certain skills though, may result in conflict, or be too threatening for patients. Using an iterative process, politeness theory was used to analyse the linguistic management of these threats and challenges in videos of GP consultations. The collaborative nature of GPs’ positive politeness had persuasive effects, whilst their negative strategies gave rise to examples of ambiguity causing confusion. Patients’ negative politeness demonstrated discomfort when presenting potentially contentious decisions whilst their use of positive politeness acted as a means of promoting cooperation. GPs used positive politeness when supporting patients’ decisions, offering reassurance and redressing damage to face, conversely disagreement was conveyed by the absence of such strategies and lack of reparative work. Difficulties were identified in the way in which space for patient participation was created and managed, and the strategies used to convey information. The contrast in GP responses to patients’ decisions highlighted how subtle barriers to participation can be. These findings demonstrate the complexity of language and meaning and the need for a more sophisticated understanding of language use in communication skills and related training, as well as associated research.

Hysterectomy is commonly performed but there is scant evidence concerning appropriate follow-up by vaginal vault cytology testing. This observational, retrospective cohort study, using routinely collected data, linked women’s entire cervical screening histories with their operation details and subsequent vault cytology test results, to establish: Which women are having hysterectomies? What was the indication? Which were followed-up? How did they differ from those who were not? 6,141 women underwent hysterectomy; an incidence of 23/10,000 women/pa. 11.61% had malignancy, 3% had CIN and 82.9% had benign disease. Median age was 48years, women were of greater deprivation and different ethnicity from the background population. Post-operatively 1,016 (16.5%) had vault cytology testing. Those having CIN at total hysterectomy should have vault cytology but only 63% had any, of these less than 10% had it according to protocol. Many factors were associated with having vault cytology (younger, less deprived, non-benign diagnosis and abnormal index cytology) but few clinically meaningful. Only 2.9% of vault cytology tests were abnormal. Efforts to identify and eradicate inappropriate use of vault tests should swiftly lead to savings. Although national guidelines are targeting the right women, it is recommended that all vaginal vault cytology should be undertaken in secondary care hereafter.

The objective of this thesis was to identify statistical issues that are commonly associated with evaluations of services for older people with a view to establishing the most appropriate methods of addressing them. This goal was achieved in two stages. In the first stage, a comprehensive literature review of studies that have reported such evaluations on populations of older people in the UK was conducted. The second stage involved demonstrating approaches for dealing with these issues on a dataset drawn from largest evaluation of intermediate care done and published in the UK to date. The approaches were adapted from the studies reported in the literature review and where appropriate, from other sources. This thesis identified a number of statistical issues including those associated with distributional characteristics of variables, missing data and the need to predict utility outcome measures from non-utility ones. Robust approaches of dealing with these problems were demonstrated. The results obtained underlined the importance of avoiding erroneous results and conclusions by applying methods with a sound theoretical background.

The aim of this longitudinal, qualitative PhD was to explore the commissioning and implementation of early intervention services for first episode psychosis across a number of sites in England. Methods: After a literature review of policy, implementation, and empirical RCT and cohort studies, 147 semi-structured interviews and six focus groups involving 35 people from different managerial and operational levels of the health service were undertaken between February 2004 and March 2009. May’s Normalization Process Theory was used as the underpinning conceptual framework and data were analysed using the Framework Analytical Approach. Results: the main findings were the importance of partnership working, influenced positively by the role of a facilitator; challenges which arose when commissioning mental health services, alleviated by the involvement of senior managers acting in a mentor role and the ‘work’ undertaken, from the perspective of Normalization Process Theory. A new service model, called the ‘trailblazer’ early intervention service was identified, which is not accounted for within Normalization Process Theory. Conclusion: further work is needed to define the characteristics and qualities of the mentoring role of senior managers and the facilitator and explore how best to adapt and extend Normalization Process Theory to incorporate the new ‘trailblazer’ service model.

High throughput analytical methods based on UPLC-APCI-HRMS and/or UPLC-ESI-HRMS were developed for the multi-residue analysis of pharmaceuticals, personal care products (PPCPs), brominated flame retardants (BFRs) and their degradation/transformation products. The PPCPs method was successfully applied to analysis of freshwater samples from Egypt. Target PPCPs were ubiquitous in the Egyptian aquatic environment and displayed relatively high concentrations in an effluent sample from a hospital wastewater treatment plant. The BFRs method was applied to screen for legacy BFRs, novel BFRs and their potential degradation/transformation products in simulated landfill leachate samples. In vitro bioassays were developed to study for the first time the metabolism of the novel BFRs TBECH by human liver microsomes and EH-TBB and FM550 by human skin S9 fractions. TBECH was metabolised by hepatic CYP450-mediated enzymes to produce a complex mixture of hydroxylated, debrominated and α-oxidation metabolites. EH-TBB and TPhP (in the FM550 mixture) underwent biotransformation by carboxylesterases in human skin S9 fractions. Kinetic modelling of the studied hepatic and dermal human biotransformation reactions revealed that exposure to multiple chemicals significantly influences the metabolic rates of target compounds. In vitro – in vivo extrapolations were also modelled to investigate the xenobiotic clearance capacities of human liver and skin.

This thesis is a contribution to the literature and debate on health inequalities and in particular on health care delivery to ethnic minority women and children. Its argument is that when discussing the causes of health inequalities of ethnic minorities, a perspective which focuses solely on the gender, ethnicity, or class of the ethnic minority is inadequate. It is argued that health outcomes, service delivery and experience of patients is shaped by the way gender,ethnicity and class intermesh. The specific context of the research is the organisation, delivery and experience of formal and informal health care to Negev Bedouin Arab mothers and their infants during and after childbirth in hospital and during the first two months post partum. Methodologically a combination of qualtitative and quantitative data have been collected over a period of four years. The quantitative data are from an epidemiological infant feeding study which was carried out from 1981-83 and which the researcher coordinated. A subsample of 412 women and their infants in this study were interviewed after delivery, during their stay in hospital and subsequently at home between 40-50 days after birth. The qualitative data was gathered in 1984 by observation and unstructured interviewing with Bedouin Arab women both in the hospital setting and in two sub tribes, one of which was living in a neighbourhood of a planned urban settlement and the other was living in an encampment. The mothers and grandmothers interviewed during the fieldwork were women known to the researcher from fieldwork undertaken 12 years previously in the Negev. This thesis explores the way in which the quantitative and qualitative data complement each other. In Part One there are three introductory chapters. Chapter 1 explores the literature on gender, ethnicity and class relations both in general and in relation to health inequalities. Chapter 2 sets out the gender, ethnicity and class relations of Negev Bedouin Arab society and Israeli society in general and in the delivery of health care. Chapter 3 sets out the methodology both theoretically and empirically. Part Two is comprised of Chapters 4 and 5 which deal with hospital care to mothers and infants at childbirth and post partum. Part Three focuses on the informal health care setting of the home. Chapter 6 deals with the care given to mothers in the home during the first 40 days. Chapters 7 and 8 explore the health of the infants in terms of their growth and development and how this is related to mother's infant feeding options and their socio economic environment. The way in which gender, ethnicity and class relations intermesh in Israeli and Bedouin Arab society influences both the living conditions and the health outcomes of the infants. Chapter 9 sets out the conclusions which are subdivided in to those which are pertinent to the theoretical debate on gender, ethnicity and class relations and health inequalities, those which are methodological, and those which are pertinent to enhancing health service delivery in this setting.