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This qualitative research was about determining management, team coordination, and optimizing service delivery at primal health clinics that could be streamlined. The primary aim of the research is about the use of the total quality management (TQM) approach as the most appropriate contemporary instrument that could strengthen the operations at Primal Health Clinics. A brief background of TQM was demonstrated to shed more light on how it could be used to improve the realization of this objective. Also, the concept of (TQM) had to lead to the streamlining of the operations before demonstrating various methods that had been adopted to enhance the collection of data. The data were collected by using semi-structured interviews of 22 participants and 22 focus groups consisting of members of the management team. This action research cycle (ARC) used the qualitative method, and data analysis was conducted using the template analysis through NVivo Coding Software. It was determined that TQM was the perfect remedy for strengthening management. In fact, it was found to be an imperative tool that could be used to strengthen the quality of service delivered in Primal Health Clinics. Its practical application had the potential to enhance teamwork, improve the healthcare providers' competence, and reduce incompetence. Therefore, Primal Health Clinics was encouraged to put this management strategy into practice if they wanted to streamline their operations.

There have been a few attempts to address different understandings of quality management systems in healthcare organisations. Nevertheless, there are still misconceptions about how the matter of quality management systems can be linked to practice to ensure the establishment of a holistic quality system. In general hospitals, although the quality related practices are universally rooted on the international standardisations such as ISO 9000 and ISO 9001, it is still problematic that standardisations generated by quality control agencies especially in economically developing countries such as Saudi Arabia did not appear to allow better practices to control the service quality in general hospitals. This research is following the pragmatism philosophy. It aims to: assesses and examines the perspectives and opinions of key stakeholders - namely nurses, patients, and middle managers (heads of department) - with the goal of initiating a framework to improve the practices of quality management systems in general hospitals in KSA. The research went into two phases: at the first phase: 252 questionnaires were distributed to nurses, and 237 questionnaires were distributed to patients. While, in the second phase, seven semi-structured interviews were conducted with heads of department in one of the general hospitals under investigation. The findings of the patients' questionnaire demonstrated that patients were satisfied with the information provided to them and the level of communication. However, they showed a lack of satisfaction in relation to staff clinical skills, family involvement, as well as the current level of caring. Conversely, the findings from the nurses' questionnaire showed that nurses claimed to understand the healthcare policy and that their hospitals achieved the required level of QM. Nevertheless, they complained about a lack of education, training, culture of learning and a poor recognition and reward system. the findings from the interviews agreed to a limited extent with and support the questionnaires with three different sets of themes (global, organising, and basic themes), which represent the role of hospital middle management in quality assurance and the important influence of different organisational cultural aspects such as structure, policy, and management style on shaping the role and responsibilities of the management in establishing a culture of quality. In addition, the findings of the interviews helped illuminate the role CBAHI has played in supporting hospitals' mission to set a QMS that responds to patients' needs. The outcome of the interviews revealed that although CBAHI is promoted in general hospitals' QMS related practices such as patient record systems, CBAHI has so far failed to establish a culture of quality where quality practices can be secured. The implications of approaching the aim are varied: firstly, better understanding to the future steps the decision and policy makers should take to improve the clarity of the concept of QMS. In addition, for the successful implementation of QMS, the hospital management requires assuring that quality of care for patients is secured. Second, the research has implications on training and education of the nurses. The outcomes of the patients' questionnaire suggest that staff did not meet patients' expectations regarding not only the level of care, but also the level of clinical skills (practice). In fact, on some occasions in the questionnaire, several nurses demonstrated a lack of understanding of CBAHI standardizations. This suggests that the research should have implications on the development of CBAHI and its standardisation This research is undertaken principally due to a paucity of research that examines quality management systems and practices in the Saudi's general hospital context. This, paired with significant changes within the health context in Saudi Arabia, meant that an opportunity existed to develop the practices of quality management through examining the perspectives of different stakeholders. Understanding the practices of quality management systems and the barriers as well as the challenges that hinder their implementation and use in general hospitals will help set guidelines to improve the practices of quality management system in the future of general hospitals in Saudi This research has contributed to the knowledge theoretically through addressing the issues and perceptions of different stakeholders, especially in Saudi Arabia, as the King intends to pursue his Vision 2030 where quality and equality is at the core, which will have a considerable impact on the development of quality management system practices in Saudi. In addition, it proposes new additions to the research Onion model utilised to master this research which is considered as another angle of contribution to the theory of research in nursing. Into practice, the findings of this research and the initiated framework are hoped to lead to better engagement and communication with the stakeholders at different levels - from top management to end users - to enhance the practices of QMS in general hospitals. As the findings illuminated different challenges including a lack of professional training, and a lack of understanding of both the culture of quality and culture of patient safety. The framework, thus, suggests a new net of collaborations and involvement of accreditation agencies such as CBAHI and MoH to build a holistic quality culture where everyone in the hospital should be engaged in developing the policy of quality and equality that support the implementation of QMS and its practices. The implication of such collaboration should lead to bettering the commitment of the nurses and middle managers to standardisations developed by CBAHI.

Purpose - Development of a multi-dimensional framework for detecting and understand workarounds within a healthcare environment. Workarounds are defined as informal work processes sometimes deemed illegitimate, which are used when formal work processes are unable to be carried out. Workaround can be either positive or detrimental; this study investigated both for the purpose of legitimising the positives workarounds. Development - A multi-disciplinary approach (Informatics, Psychology, Linguistics, Anthropology, Philosophy and Sociology) was used towards the developed of the framework. The Framework consisted of multiple components such as a typology matrix rooted in the theory of Workarounds (Alter, 2014); Work Systems Framework (Alter, 2013); Hall and Trager's (1953) matrix for Analysis of Culture, The Seven Circumstances (Robertson, 1946), and lastly individual; group work process and cognitional norms were used as a unit of analysis for an embedded and holistic understanding of the Distributed Cognitions within an organisation. Research Context - Healthcare domain within a GP Practice (NHS Wales) and Moorefield's Eye Hospital (NHS England) Design/Methodology/Approach - Design Science was used for its ability to allow for sequential abstraction or incorporation of pivotal changes to be made towards the development of the framework (artefact). Design Science also allowed for the research to progress from a knowledge base to building and testing of the artefact within the appropriate designated environment (primary and secondary NHS healthcare setting). A qualitative semi-structured interview and participant observation was used as a method of collecting data. Demographic for Primary Care - 1 practice manager; 1 receptionist; 2 nurses and 1 IT Assistant/Nurse. Demographic for Secondary Care - 1 professor; 4 consultants; 3 nurses; 3 technicians and 3 IT staff members Findings - The research found that, workarounds were rife within most organisations in relation to work processes, information systems and technology and were undetectable without the application of a qualitative means of measure. The findings from the healthcare environment showed that the qualitative analytical data had the ability to aid the current KPI's, which were found to be heavily invested in the usage of quantitative numerical data, therefore giving meaning and motive to the existing performance metric. Contribution - A unique multi-dimensional framework was developed for an embedded situational level of understanding, prior to administering change within any domain and organisation. The multi-dimensional framework was also developed to align with any existing KPIs and good practice of an organisation. Key Words - Workarounds, Multi-Dimensional Framework, Matrix, Typology, Healthcare, Norms Analysis, Distributed Cognitions.

The focus of this thesis is related to the interactions that occur between people collaborating under conditions of mandate and how these interactions are managed, in a health, social care and public health context in England. In adopting a constructivist approach to Grounded Theory (Charmaz, 2006) the basic social process of managing conflict was constructed which is a substantive theory grounded in the data. The substantive grounded theory was developed from the interviews and observations of thirty mandated collaborating members of a North East Health and Wellbeing Board, as they collaborated under conditions of mandate for the organising and provision of local care. The constant comparison analysis of the data revealed that when collaboratives in a health, social care and public health context are mandated, essential elements of the process are omitted and this allows conflict as a multifaceted issue to manifest within the interactions between individuals. Conflict in relation to this study was conceptualised as being located in, interacting identities, democratising the decision-making practices and coping with the traditions of others. Conflict for these participants developed as a result of health and social care professionals and democratically elected members, being mandated to collaborate for the integration of local care. Decision-making practises that had traditionally been left to the professional members of this group. The participants in this study were analysed as managing conflict through the three conceptual domains of: interacting orientations, interacting positions and interacting strategies. These findings represent the first study of mandated collaboration at the micro-sociological level which explores the interactions between people who collaborate under conditions of mandate.

The role of collaboration is becoming progressively more important to achieve innovation in an environment that is continually experiencing rapid technological changes as well as changing modes of knowledge production such as in the digital healthcare sector. However, little attention has been paid to understanding underlying inter-organisational collaboration mechanisms among diverse organisational types such as firms, universities, public research institutes, and hospitals in this sector. More specifically, this thesis examines why these organisations in the Korean digital healthcare sector establish inter-organisational collaborations, how different collaborative structures are established, and what effects these different collaborative structures have on innovative performance. In order to address these issues, this thesis proposes and verifies a novel conceptual framework based on three theoretical approaches (i.e. the national innovation system, transaction cost economics, and the resource- based view) in explaining strategic motives in the establishment of different collaborative structures categorised by focal organisational type. Mixed methods analysis, based on data regarding information on inter-organisational R&D collaborations, strategic motives in establishing the collaborations, and their respective innovative performance collected by a combination of desk-based research, a survey, and interviews, is employed. This thesis makes an interesting empirical contributions by finding different patterns in R&D productivity levels when one breaks down collaborative structures from the perspective of the type of focal organisations, whilst the productivity levels of R&D collaboration projects are generally lower than those of non-collaboration R&D projects in all aspects of R&D performance. We also confirm that each type of focal organisations is largely influenced by distinctive motives, although the strategic motive 'to access complementary capabilities or resources' relating to the resource-based viewperspective has a primary effect on all focal organisations in developing collaborative structures. Additionally, the thesis provides detailed information concerning how strategic motives affect focal organisations in choosing a particular type of collaborating partners.

Background: Theoretical evidence on multitasking warns against the use of high-powered incentives when healthcare providers may substitute effort away from non-targeted tasks. However, incentives may also have wider benefits when targeted and non-targeted tasks share commonalities in production. Evaluations of quality incentive schemes often overlook these potential spillover effects. I aimed to address this limitation by developing the existing empirical evidence on the spillover effects of quality incentive schemes. Methods: I first reviewed 37 empirical studies that had evaluated the spillover effects of 24 different quality incentive schemes. The findings from this review informed the design of three case studies. In each case study, I used a different empirical method to evaluate the between-patient spillover effect of a quality incentive scheme. The first two studies evaluated the Best Practice Tariff scheme, using (i) an interrupted time series model and (ii) an alternative model of effort substitution. The third study evaluated the spillover effect of the Advancing Quality scheme using a triple difference-in-differences model. Results: The interrupted time series and effort substitution models both identified positive spillover effects of the Best Practice Tariff scheme on the daycase rate of non-targeted patients in an incentivised surgical area. However, the interpretation of these models differed. The interrupted time series model identified an initial increase in the non-targeted daycase rate of 1.0 percentage points (95%CI, 0.5 to 1.6). In contrast, the effort substitution model identified that an increase in the targeted daycase rate of one percentage point was associated with an increase in the non-targeted daycase rate of 0.09 percentage points (95%CI, -0.02 to 0.19), relative to the underlying association in the before period. In addition, the triple difference-in-differences model also identified variations in the spillover effect between different non-targeted patients. Estimates from the model suggest that the Advancing Quality scheme increased the mortality rate of non-targeted patients that were treated by a non-exposed physician by 0.38 percentage points (95%CI, 0.06 to 0.70) but had an no harmful effect on patients treated by an exposed physician, in the long-term period. Discussion: Further research is needed on the mechanisms through which spillover effects occur. Evidence from the thesis suggests that patients benefitted from being treated by a consultant that was more exposed to patients with a targeted condition. Identifying when spillover effects may be positive has the potential to increase the benefits of future incentive schemes.

The UK is undergoing changes in the demographics and epidemiology of the population. To tackle this, successive UK governments have introduced policies focused on transforming health and social care from its traditional forms into integrated care systems. Previous research has demonstrated that people are essential in the transformation process which is often complex and requires structural, practical, and cultural change. Despite this focus, there has been a lack of frontline research on the real-time experiences of practitioners tasked with making integration real from the outset. This study attempts to address this gap. It presents a faithful representation of the experiences of two teams, one from health, one from social work, as they moved through the initial stages of integration. The study uses an adapted institutional ethnographic approach (Smith, 2005), which involved observing two teams as they came together to form an integrated neighbourhood team over a nine-month period. The use of this approach ensured that the reporting of the team's experience was from their perspectives and considered the wider external factors that influenced those experiences. The analysis of the findings identifies several key factors in how teams experience integration that could influence future policy. These areas included: the imperative of a local narrative for integration; the place of hope and hopefulness in uniting teams; the importance of 'Bottom-up' action; the imperative of joint leadership. The process of integration was not a linear one but one where teams move through a process of converging and separating from each other. Based on the findings a framework has been developed to assist organisations in the development of integrated teams.

Innovation in United Kingdom (UK) healthcare has in the last decade been driven forward through national policy and the development of a national innovation infrastructure, underpinned by an imperative to change. An increasing number of National Health Service (NHS) provider units, the NHS trusts, are making ‘innovation’ part of their strategies; however, a paucity of published theory, guidance, or information within the sector means how and why a trust should invest in and develop their innovation strategies is not well understood. In these highly complex, dynamic organisations providing 24-hour healthcare delivery, assimilation of innovation into core NHS business and realisation of the desired impact appears dangerously slow for the needs of the sector. Indeed, acceptability by individual healthcare staff within these systems of innovation as part of their role, at best appears ad hoc. This presents significant challenges for those who lead these organisations and those who work within them with specific responsibilities for innovation. This case study research explores this holistically and in-depth to gain a deep understanding of how innovation is understood and presents a theoretical model of how NHS trusts might function as innovative organisations. The case is an NHS Trust, the unit of healthcare delivery within the English National Health Service (NHS), contextualised with its organisational boundaries as a ‘mesosystem’, with individual ‘actors’ embedded within, identified as working within ‘microsystems’. In many ways the case can be seen as typical, yet as a case, also unique, both in terms of the temporal component explored and the emic perspective taken. The researcher in this study is a senior leader within the NHS Trust with a responsibility to lead the innovation strategy, she and her colleagues in other NHS trusts struggle with these issues on a daily basis. Theory from outside the United Kingdom (UK) healthcare context was used to explore the antecedents to an innovative organisation, including the need for strategy, the role of leadership, the creation of a supportive innovation environment, and the value proposition innovation might bring to this complex mesosystem. Data from multiple sources was collected over a one year period, six months after the implementation of an organisation innovation strategy within the NHS Trust. A critical realist perspective informed the data analysis and triangulation process, to give a rich description of the case, prior to using an abduction process to build on the current theory. A model that seeks to explain how a healthcare organisation might function as an innovative organisation was created that will be of direct use to the case, as it continues to develop its innovation strategy. This will be disseminated to a wider audience to support the development of NHS innovation theory and thus provide a useful resource to support other NHS trusts develop as innovative organisations.

Background: The importance of management capacity in the health sector has been increasingly recognised. The World Health Organization (WHO) (2008) has claimed that limited ‘management capacity’ in low-income countries is one of the main obstacles towards achieving goals. Afghanistan is identified as one of those countries (WHO 2018a). To achieve sustainability, the management and leadership capacity need improvement. Aim: to explore the perceptions of directors and senior employees about the factors that affect the management capacity, leadership and employee performance in the MoPH, Afghanistan. Methods: A mixed-methods case-study was carried out in 30 directorates of the MoPH, Afghanistan to explore capacity. Qualitative data were analysed thematically using NVivo, while quantitative data were analysed using descriptive statistics. Both followed by the analytic technique of explanation building using theoretical propositions. Results: The hiring of directors in the MoPH was found to be affected by political influence. Many directors introduced to the system by politicians did not appear to have the capability to manage well. This set of conditions resulted in a reported lack of support for their employees and the absence of a healthy work environment. This is compounded by a resource shortage. It is evident that a strategic approach to capacity building is not in place with employees attending uncoordinated and often irrelevant training. Employees believe they are not treated consistently and fairly in all respects and this is further compounded by overly complex administrative systems. The socio-cultural influence is affecting transparency, accountability and increases the potential for corruption. Overall the findings suggest that management capacity is weak. Conclusions: This study reveals management capacity in the MoPH needs a significant overhaul. The government should address political and socio-cultural influence, to allow the appointment of more competent and diverse people.

The rapid changing life pace and the increasing work challenges are constantly raising the demands placed on employees. This flags the importance of promoting employees’ health and wellbeing in their work environments to deal with challenges that organisations currently face towards building healthier workplaces that support the mental and physical health of working staff. National Health Service (NHS) is one of the top organisations facing increasing challenges that affect staffs’ mental health and wellbeing. In addition to budget shortage and financial challenges, staff may now be paying the cost of an industrial design heritage, which values functionality and standardisation over humanitarian philanthropic design. This is reflected in the status of primary healthcare infrastructure, which is now providing mass NHS services within an inefficient spatial environment and relatively poor workplace quality. Considering the important role that primary healthcare employees play in contemporary life, and realising the challenges they face, this research project develops a set of design recommendations that help with achieving a psychologically supportive working environment for primary healthcare staff in the UK. The research identifies fifteen psychologically supportive stimuli [PSDS] that affect mental health and wellbeing of staff in primary healthcare premises. Adopting a realistic approach, this qualitative doctorate project employs Evidence-Based Design, as a methodological guiding framework. The research is composed of three main stages: The first phase is a primary formulation of hypostatical theory, which delineates and evaluates the primary potential environmental stimuli that affect users’ wellbeing, through the inductive analysis of extensive multi-disciplinary literature review of three main different disciplines, namely: psychology, medicine and architecture. This is followed by two stages of two separate rounds of interviews. The outcomes from the three stages are then contrasted for triangulation for further data validation. The data validation process employs two methods: the selective attention analysis and focus group (three focus groups were conducted). The research defines the associated stressors related to the current physical work environment of primary healthcare in the UK and studies how staff recognise, perceive and describe their physical working environment. The research identifies fifteen PSDS: spatial layout, ergonomics, privacy, furniture, safety & infection control, nature, views, light, colours, artwork, finishing materials & textures, noises & sounds, shapes & patterns, natural ventilation & thermal comfort, and water. The concluded stimuli are categorised under two groups: functional and sensorial. Based on the analysis of the interviews, these stimuli are re-defined and explained from two schematic perspectives: the healing environment schemas and working environment schemas. Finally, this research argues that good healthcare services cannot be managed without considering healthcare professionals’ wellness; factors such as job stress and fatigue are directly related to their physical environment, which may negatively affect both the staff’s physical and psychological wellbeing, consequently affecting the quality of healthcare service delivery. The research outcomes help decision-makers, designers, architects and developers to better understand and consider the needs of primary healthcare providers and guide the development of healthier primary care environments to support the staff wellbeing within their workplace.

Knowledge transfer in organizations has been a topic of great interest to many researchers in recent years. Most research studies related to knowledge transfer have investigated the different aspects of organizational culture and how they influence the process of knowledge transfer. However, there has been a lack of studies that examine the relationship between organizational culture and knowledge transfer in health care organizations in general and in developing countries such as Saudi Arabia in particular. This research study is driven by the need to close the gap in the literature by examining the relationship between organizational culture and knowledge transfer in the health care sector in Saudi Arabia. The aim of this research is to investigate the impact of organizational culture on the transfer of knowledge in health care. Studies in this area have taken a holistic approach to identify the factors that impact knowledge transfer. The present study takes a more focused approach, where the cultural factors that impact the transfer of knowledge are identified and explored through the lens of a health care organization. This research is set within the context of health care in Saudi Arabia, two contexts which have not been considered together in previous studies. The aim of the study was achieved by conducting a case study in a health care organization. The research methodology includes both positivist and interpretivist approaches, utilizing a mixed research approach in which qualitative and quantitative research approaches were implemented. Research data were collected using self-administered online questionnaires and semi-structured interviews. The findings from the questionnaires were later compared with the findings from the interviews. The research concludes that the culture of an organization has both a facilitating and an impeding effect on knowledge transfer in the context of a health care organization. One finding suggests that organizational management and communication are amongst the main factors that have this facilitating and impeding impacts on the transfer of knowledge. Second, meeting the needs of customers and patients is revealed to have the most significant impact on organizational culture in health care. The research concludes that a culture that is supportive of knowledge transfer depends on having both internal and external motivational factors within the organization. The research outcomes have academic implications, since the research findings can be compared with other Western culture research findings, and practical implications for knowledge transfer practices and communication strategies in health care organizations.

This thesis explores the role of the voluntary sector in the delivery of an NHS Multispecialty Community Provider (MCP) pilot project in the area of Erewash, England. It draws on engaged research, informed by ethnographic and action research traditions through which a broad range of data were gathered in order to present a detailed picture of the project in practice. In doing so it contributes both to the academic literature and to the work of practitioners and policy makers. Firstly, it identifies the tensions inherent in the voluntary sector’s role as ‘transmission belt’ organisations, providing empirical evidence of this role in practice and building on Albareda’s (2018) original conception. In addition, it suggests the pressure to work in this way risks damaging the sector’s relationship with both service users and communities. Secondly, the thesis explores the ways that trust, power, and control interact in collaborative contexts, utilising Bachman’s (2001) notion of different ‘traditions’ to suggest that the voluntary and public sectors reflect different ways of working that are interactions of ‘personal’ and ‘system’ trust and power. These different traditions surface tensions that make collaboration difficult. Thirdly, the thesis identifies the complex leadership dynamics at play in collaborative contexts and the dominance of NHS hierarchical aspects, particularly in relation to clinical professionalism. Despite this, the thesis builds on Huxham and Vangen’s (2000a) notion of ‘making things happen’ to identify the positive and proactive leadership role the voluntary sector can enact in practice. However, it cautions that, as both directive and facilitative forms of leadership are needed in collaborative contexts, an increased focus on public sector-initiated collaborations could paradoxically make the sector less collaborative. The thesis offers suggestions for both policy and practice, as well as identifying potential ways to take the research forward in the future.

The six countries of the Gulf Cooperation Council (GCC) - Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates - stand today at a critical juncture in their modern history due to several coinciding socioeconomic and geopolitical challenges. These challenges could be detrimental to the future of the region or be reframed as an opportunity for improving loco-regional governance and adopting normative policy reforms, the latter being a premise in this thesis. The GCC healthcare systems are as well facing major challenges starting from financing pressures and old governance structure and functions to a sharp increase in chronic disease rates and an increasingly aging population with the consequent rise in demand for care and social services. Despite several strategic plans suggested by respective ministries of health to develop and modernise the governance and provisions of care, these plans fell short of delivering successful reforms and improved systems and therefore have under-delivered in terms of health output and outcomes. One effective option to address these new challenges is to adopt an integrative and coordinated strategy that places the well-being of GCC citizens at the core of the health system. Because GCC countries share relatively similar social and epidemiological determinants and have established a Council which is one of the most homogeneous cross-national cooperation organisations in the world and has some jurisdiction in health policymaking, this thesis focuses on coordinating cross-national policies that would enable GCC governments to tackle together the social and healthcare challenges they are facing. This thesis has been thought, planned and conducted in a way to bring an innovative response to the local challenges, through two principal actions: 1. The creation of an independent regional body that enacts health policies, norms and regulations, with a clear objective to work toward a unified and coordinated health market in the GCC. Such institution may install a committee to monitor and evaluate the implementation of New Public Management (NPM)/post-NPM measures in the member states; and 2. Placing the human-being at the central of the health system, through both strongly investing in the development of human resources capacities and transforming the local citizenry from passive to active consumerism of services. Because the spread of chronic diseases is imposing heavy socioeconomic burden and causing more than half of deaths despite being a youthful population, the major health risk for GCC citizens comes from their own lifestyle choices. Thus, consumerism is a key aspect of our approach. This thesis provides two levels of originality: first, there is no ink shed in the literature on NPM principles applied to health systems in any of the GCC countries and second the thesis focuses on suggesting practical policy and governance lessons that the GCC countries can adopt to advance loco-regional health system reforms in light of normative NPM-like recommendations. New Public Administration concepts that many other governments borrowed few decades ago from private sector management and adopted under what is known as NPM principles were successful to certain extent in some countries and circumstances and less successful in other countries and needed to be revisited or revamped to effectively introduce concepts such as performance measurement, accountability, quality, transparency, and customer-focused government (in what is known as post-NPM).

One of the priority areas of the UK healthcare system is urgent and emergency care, especially accident and emergency departments (A&E departments). Currently, there is much interest in studying the unintended consequences of the current UK healthcare performance system. Simulation modelling has been proved to be a useful tool for modelling different aspects of the healthcare systems, particularly those related to the performance of A&E departments. Most of the available literature on modelling A&E departments focus on supporting operational decision-making and planning in specific healthcare units to study particular problems such as staff scheduling, resource utilisation, and waiting time issues. That is, most simulation studies focus on analysing how different configurations of healthcare systems affect their performance. However, to our knowledge, few simulation studies focus on explaining how human behaviour affects the performance of the system, and very few have studied how, in turn, performance targets set for A&E departments affect human behaviour in healthcare systems. Some aspects of human behaviour have been incorporated within existing simulation models, though with limitations. In fact, most studies have aimed to study patients’ behaviour, and few have included some aspects of the behaviour of clinical staff. Here we consider how to model clinician behaviour in relation to the performance of A&E departments. This thesis presents an exploratory study of the use of agent-based modelling and simulation (ABMS) and discrete event simulation (DES) to demonstrate how to model clinician behaviour within an A&E department and how that behaviour is related to waiting time performance. Clinical behaviour, incorporated in the simulation models developed here, employs a framework called PECS that assumes that behaviour is influenced by Physical (P), Emotional (E), Cognitive (C) and Social (S) factors. A discussion of the advantages and limitations of the use of ABMS and DES to model such behaviour is included. The findings of this research demonstrate that ABMS is well suited to simulate human behaviour in an A&E department. However, it is not explicitly designed to model processes of complex operational and queue-based systems such as accident and emergency departments. In addition, this research work also demonstrates that DES is an adequate tool for modelling A&E’s processes and patient flows, that can, in fact, incorporate different aspects of human behaviour. Furthermore, the process of modelling human behaviour in DES is complex because, though most DES software allows the representation of reactive behaviour, they make it difficult to model other types of human behaviour The main contributions of this thesis are: 1) a comparison and evaluation of how suitable ABMS and DES are for modelling clinical behaviour, 2) an approach to model the relationship between human behaviour and waiting time performance, considering four aspects of human behaviour (physical, emotional, cognitive and social).

The Patients’ Rights Act (Scotland) 2018 requires that Health Boards in Scotland encourage, monitor and learn from patient feedback. A range of mechanisms are used by healthcare organisations to capture and monitor the quality of care and services they provide, and to stimulate improvement where required. Historically these have been a mix of paper-based methods and face-to-face mechanisms. In recent years these traditional methods are increasingly being augmented by spontaneous sharing through social networking tools like Facebook and Twitter, and through dedicated patient feedback websites like Care Opinion. There is little published evidence regarding the legitimacy of capturing and interpreting patient feedback using social media. This research explores senior healthcare managers’ attitudes to and acceptance of online patient feedback, and its potential to inform improvements to health and care services. It considers the suitability of social media for monitoring patient experience and considers the main barriers to using this information to inform changes to healthcare services. Interviews were conducted with 18 senior clinical and managerial staff from three National Health Service (NHS) Boards in Scotland in order to build an in-depth understanding of their attitudes and experiences regarding the use of social media patient feedback for improvement to health and care services. A process of Framework Analysis was used to identify the key issues, concepts and themes expressed by interview participants. The results of this study show contrasting views on the usefulness and value of patient feedback. Participants highlighted the importance of understanding and accepting the patient perspective on their healthcare experience, whilst others questioned patients’ ability to judge the quality of their own care. The emotional impact of both positive and negative patient feedback on healthcare professionals was a key issue for participants. The findings from this study show that senior healthcare managers’ views on the legitimacy of patient feedback through social media are influenced by a number of factors, these include apprehension around the anonymous nature of social media patient feedback; the impact of age and IT skills; the risk to organisational and professional reputation: and concern about the loss of face-to-face communication with patients. The findings from this research study have a number of implications for the development of healthcare policy regarding patient feedback and experience, as well as for healthcare organisations in trying to maximise the benefit and impact of this information.

This research maps team types within a tertiary teaching hospital in Oman and deepens our understanding of the factors influencing KS in cross-professional teams with a focus on tacit knowledge. It maps the intersections between cross-professional teamwork and tacit knowledge, aiming to reconcile practice and evidence. A qualitatively driven exploratory multi-method design using a constructivist interpretivist approach. The research analysed 36 documents, 26 semi-structured interviews and 7 hybrid focus groups (HFGs) using participant-led creative exercises, the latter creating a non-traditional methodological approach to eliciting rich data. The data were integrated, and a thematic analysis applied to present a holistic exploration of the phenomena under study. This study contributes to understanding the factors affecting KS within crossprofessional teams in Oman. Tensions around team membership and KS between departments created unease for KS behaviours, but patient-centred care (PCC) was considered a unifying factor for teamwork and KS at every level. The use of HFGs allowed for the co-production of visual artefacts mapping KS and teamwork, creating rich data. These could be adapted for further research.

The shift in focus from dyadic interactions to many-to-many interactions is a crucial aspect of Service Dominant Logic (SDL) in that it places great emphasis on collaborative processes engaging multiple actors. Collaborative working is being increasingly championed in the healthcare sector as the move from hierarchical to network operational structures continues apace. The General Practitioner (GP) federation model exemplifies one service network emergent in this sector. Empirical understanding of these service networks is absent in extant literature. The aim of the study is to critically analyse, through the lens of SDL, the GP federation service network emerging within England’s primary healthcare sector. A multi-methods qualitative research approach (participant observations, semi-structured interviews, document analysis and netnographic data) is employed to examine four distinct GP federations (service networks) operating in England. Literature, and empirical data, explore the effectiveness of SDL in terms of enhancing understanding of value co-creation in service networks. The transferability of established principles of business and social networks to service networks. How different structural elements and characteristics of service networks impact their effectiveness of working at scale. And how examining service networks from a service systems perspective that incorporates micro (individual GP practice), meso (the structural operationalisation of the federation) and macro (wider ecosystem including NHS and Government) levels uncover previously unrecognised opportunities and barriers to effective healthcare performance. Findings contribute to our understanding of SDL, illustrating the value of SDL as a lens for examining the intricacies of a complex service network. They demonstrate how perceived value changes over time and is a function of changes at macro, meso and micro levels. They add agility and flexibility to characteristics of effective service networks. They argue that not all models of collaborative working fully realise the commonly proffered benefits attached to this model. A new collaborative network model is proposed which includes sharing risk as a hitherto unrecognised potential benefit of network working. Theoretical contributions include a retesting of SDL, an application of existing network principles in a novel way, an extension to knowledge linked to collaborative working at scale and a unique application of service concepts and models to examine GP federations. Multiple contributions to the practical implications of working at scale emerge, collectively of importance to future healthcare policy.

In recent times, the impact of globalization has led to the occurrence of threats to global health from diseases of animal and environmental origin. The latter events have led to recommendations by medical educators that Interprofessional Education (IPE) programs that include the principles of One Health (OH) should form part of the curricula of medical and veterinary programs, to equip graduates to effectively collaborate towards diminishing these threats. The transdisciplinary concept of OH provides a framework that engenders collaboration between professionals at the crossover of animal, human and environmental health. This study evaluates the implications of developing IPE that includes the principles of OH at the institution at which this research was conducted. A sequential explanatory Mixed Methods Research approach was used to achieve the aims of this study which sought to attain the following: 1) to explore the readiness of Doctor of Medicine (MD) and Doctor of Veterinary Medicine (DVM ) students who have no prior IPE experience for IPE that incorporates the principles of OH; (2) to explore the effects of prior IPE and OH exposure on the readiness of Master of Public Health (MPH) students for IPE incorporating OH; (3) to explore the perspectives of the faculty and administrators on the opportunities and challenges for developing IPE that incorporates OH for the core MD and DVM programmes and (4) use the information gleaned in this study to inform the development of IPE that promotes the concept of OH at this institution. A survey was used that included a validated scale to explore the differences in readiness between groups of students across the disciplines of the health professions. Two open-ended questions were added to the survey that revealed the students’ knowledge about the relevance of One Health to practice. Faculty focus groups and an interview with one of the senior administrators of the Medical school were used to obtain their perspectives on developing interprofessional education and enhancing familiarity with OH among students. The analysis of the survey data indicated comparative differences in readiness for interprofessional education across the programs. A number of themes emerged from evaluating the student responses to OH that showed a clear omission of various components of definitions of the concept across the programs. Five key themes emerged from the faculty focus groups and interview that provided perspectives for informing the development of IPE that includes OH at this institution. These themes included the accreditation requirements for the programs and the expected role that interprofessional learning held within the traditional culture of each discipline. The study concludes by providing recommendations for curricula and leadership changes as well as a vision for executing the institutional claim for supporting the philosophy of OH. Underpinned by theory, the discussion Chapter utilizes various theoretical lenses for evaluating this research. This research also contributes to widening the discourse on the development of IPE that includes OH in four ways. One by contributing original insight into the factors that influence the readiness of students across four disciplines for IPE and providing an explanation of these findings using the lenses of various theoretical frameworks. Secondly, although the literature reveals that others have identified gaps pertaining to IPE and OH content in the curricula of the MD and DVM programs, this research presents a focused study that provides insight into the specificity of these gaps. The latter is accomplished through comparisons that are made in comparing the differences in the students’ definitions of OH and its relevance to practice across the programs. The student responses about OH revealed specific gaps in the students’ knowledge about OH pertaining to the following: the impacts of global warming resulting from climate change, on human and animal health; the effects of foodborne diseases of animal origin on human health; the impact of socio-cultural and environmental factors on the occurrence of zoonoses with implications for human and animal health; the role of the human-animal bond on human mental health and the implications of antimicrobial resistance for public health. This research also contributes to broader discussions pertaining to the development of IPE and OH by including students within the dual degree MPH program that demonstrate how gaps in the curriculum of the MD and DVM programs pertaining to IPE and OH can be bridged. Finally, this research provides a lens into the opinions of the faculty and administrators across four disciplines for informing the development of IPE that makes students more familiar with OH.

This thesis focuses on the short-term informal learning from the restructuring experience of twenty four senior leaders from three Canadian healthcare organizations who led restructuring in their organizations. This study investigated the leaders' learning through a critical realist case study research approach. It used Pawson and Tilley's (1997) Context-Mechanisms-Outcomes (CMO) framework to analyze their learning by describing the context of the learning, inferring mechanisms that can plausibly explain their learning, and describing the learning outcomes that these inferred mechanisms produced. This research's departure point is the ongoing issue and debate about how formal leadership learning only contributes marginally to leadership emergence and development. In practice, organizations are complaining that they are not seeing acceptable returns in the heavy investments they have made in leadership development programs. On their own side, leadership scholars, having noticed this contribution gap, are calling for more research that may potentially contribute more to leadership learning. Therefore it is valuable to focus research on other sources - as processes or models - that have the potential to contribute more to leadership development. One such area for investigation is understanding how leaders learn informally in the short-term given time pressures occasioned by fast-moving organizational change demands. While previous research identified that learning informally from the experience of activities that they are engaged with is a natural way for leaders to learn, focus on this had remained on the learning that occurs over a long period of time. As insufficient research attention has been given to this area of how short-term informal leadership learning can occur, this research undertook this research to contribute to knowledge in this underserved area of leadership development. This research found that leaders can learn in the short-term and that a model that involves the processes of attention grabbing, rapid reaction, and meaning making can explain how the learning occurs.

Interprofessional education (IPE) has been proposed as a method of creating a collaborative practice ready workforce in healthcare. Postulated benefits of the technique include improving communication between professional groups, which in turn should help to prevent serious untoward events and ultimately improve patient outcomes. Critics of the method have cited poorly designed IPE as a method of reinforcing physician power, and argued there is a paucity of data linking undergraduate IPE to tangible benefits in a patient-facing setting. Simulation has been increasingly used as a method for delivery of IPE, with positive outcomes cited by students and educators alike. Virtual Patients and avatars have been recently used as a delivery method for healthcare education, but there is a paucity of data regarding their use in IPE. Simulation is not a panacea for IPE, many simulations focus on the acute phase of care naturally excluding healthcare professions who are not involved in those situations. Findings from acute simulations may not apply to sub-acute scenarios. Method A sub-acute real-time virtual patient simulation was designed then delivered to educators (n=6) and undergraduate students (n=33) from the professions of medicine, nursing, pharmacy and physiotherapy. Qualitative data was gathered according to a constructivist paradigm using unstructured observation of in-simulation behaviour, focus groups and semi-structured interviews. Results Data was analysed according to Braun and Clarke’s method of thematic analysis. Five themes were identified: technology, education, collaboration, intrinsic behaviours and stereotyping. The simulation was educationally successful with participants citing improved recognition of the skills of other professional groups, and improved physiological and pharmacological knowledge. The real-time aspect of the simulation improved clinical reasoning and forced students to make prescribing decisions, which was cited as beneficial for future practice. The sub-acute nature of the simulation resulted in participants hyper-observing their VP to the detriment of patient care. Good levels of collaboration, team working and appropriate communication were facilitated but students were observed to subconsciously selfstereotype. Conclusions Sub-acute real-time virtual patient simulation appears to be a valid method of enabling students to learn with and from one another. It conveys benefit over traditional educational methods such as classroom-based, problem-based and experiential learning as students are given full responsibility for patient care with little supervision. Self-stereotyping amongst students suggests that students convey stereotypical messages about their own profession to others. This may aid team-building in the undergraduate setting, but if these stereotypical views are transferred to advanced practice, there may be detrimental consequences for team formation and patient care.

The emergence of design and systems development have arisen as legitimate tools for facilitating innovative practices in the delivery of care within public services. Development mechanisms deriving from design led thinking and their associated methodologies have evidently been adopted to construct services that fulfill the interest of public health outcomes. Moreover, the innovations are being generated in response to multi-faceted factors necessitating the need to generate new solutions to improve health outcomes. These factors range from changing, and increasingly complex health needs of the current local population; to advances in medical science; and of the development trends emerging in medical technologies further enhancing potential in health outcomes. The research is conducted to answer key questions regarding both relevance and effective impact, surrounding the adoption of design-led thinking and processes in developing health services within the National Healthcare Service in Wales. The research focus and scope of this investigation encompasses the development processes that are integral to creating innovative services. These processes consist of a combination of tools and principles used by stakeholders with the aim of improving the delivery of health related outcomes. The research has sought to address its core questions by implementing a thematic interpretive analysis, to qualitatively extrapolate how live engagement with design processes among relevant stakeholders facilitate innovative interventions. The relevance and effectiveness by which design processes seek to generate ideas against a set criterion is therefore sought through the interpreted narrative of transcribed data from participant stakeholders. From the analytical narrative, the research aims to establish an original framework that would help stakeholders make sense of the developmental means by which innovative services emerge and can concurrently be evaluated for their appositeness to a design exercise.

Human resource management (HRM) policies and their effective implementation are expected to influence the attitude and behaviour of health workers favourably in providing effective health services to the people. However, within the Indian public health system, it is unclear which HRM policies are implemented effectively and how these influence health workers, especially at district level. This study aimed to explore how HRM policies and practices affect health workers in the Indian public health system. The state of Odisha was purposively selected. Four relevant HRM functions were examined: 1) posting and transfer, 2) in-service training (IST), 3) supervision and review and 4) performance appraisal (PA). Documents including human resources (HR) policies and plans were reviewed to identify intended HRM practices. In-depth interviews of policy makers, managers and health workers were conducted. Using the framework developed by Purcell and Hutchinson, (2007), we identified the relevant intended practices, the practices as reported by the managers and the health workers and their effect on the attitudes and behaviour of health workers. Qualitative data analysis used a 'framework approach'. An in-depth analysis of four HRM functions within the overall human resource management system, as operated at district level within Odisha, has shown that although there may be a weak positive effect on the attitudes and behaviour of public sector health workers, there remain many missed opportunities. Although the design of the majority of HRM systems is logical to achieve the objectives, there are problems in their implementation. The major issues are that either HRM sub-systems are not being operated as designed - with some elements totally missing; or the sub-system is inadequately implemented. Implementation is affected by three major factors: 1) insufficient autonomy of district and facility level managers, 2) lack of resources and skills of the managers and 3) contextual factors including geography, gender and sector reforms. In addition to the inadequate implementation of the HRM system, there are issues in the way the systems are organised and operated, leading to the limited effect of HRM on the attitudes and behaviour of health workers. For instance, the HRM sub-systems are being implemented in isolation, with no connection between the sub-systems of all HRM functions and different 'system owners' at state and district level. With no overall coordination and significant oversights including the monitoring of the system as a whole, opportunities to make this system more efficient are missed. However, the findings from this study provide a very useful starting point for improving the four HRM functions of posting and transfer, in-service training, supervision and review and performance appraisal. Considering these together should help to promote the view of HRM as an overall system, with co-ordinated sub-systems. Therefore, the study concludes that HRM systems can be made more effective to ensure that there is an effective health workforce to deliver the required health care services, and in turn, to contribute to the achievement of the goal of Universal Health Coverage.

The focus for this research is health management in German general practitioners' surgeries. In Germany, there are over 50,000 general practitioners' surgeries with over 150,000 physician's assistants as employees. One of the main objectives of health management is the reduction of absent days due to ill health and it is important to know, which activities can be identified to reach this objective. The overall aim of this research is to develop a concept to support stakeholders in promoting health supporting activities which facilitate personal health potentials and help improve the productivity of the general practitioners' surgeries. The basis for the development of this concept was a systematic literature review, which indicated that health management in general could be improved by health promoting activities. However, the findings from the literature review reveal gaps in general practitioners' surgeries health promotion practices. This research aims to improve the knowledge in health management at general practitioners' surgeries in Germany with a focus on activities promoting the employees' health potentials. The success of the proposed activities essentially depends on the acceptance by the employees. Therefore, a questionnaire about "health management" for employees of general practitioners' surgeries has been developed which used the health-promoting measures found in the literature review. The findings of these questionnaires provide quantitative data (N=194) on which of the health promoting activities are preferred by the employees. The findings give an insight into personal preferences for health-promoting activities from the employee's point of view. The findings of the employee survey were used as indicator for the acceptance of activities; the results of the systematic literature review were used as indicator for the effectiveness. As a third indicator, the costs of the discussed activities have been incorporated into the concept. These three indicators form the basis for a multi-criteria decision analysis. Results were used to build a score for generating a priority list with ten effective activities promoting personal health potentials. The measures with the highest preferences are vaccines (94%), healthy food at work (67%), and training at home (61%). Robustness of the results was tested by means of a sensitivity analysis. Vaccination is widely ranked first in the priority list. This is of importance as the employees of general practitioner's surgeries are exposed to substantial risk of infection. Three different strategies for implementing this concept into health management in general practitioners' surgeries were developed. The main contribution to knowledge is seen in the contribution to the methodology. It shows how different perspectives of different stakeholders can be used in a systematic (and thus in a participatory, interaction-oriented and fair) decision-making process for health management that can be applied in other decision-making situations (e.g. hygiene or emergency management). As a theoretical contribution, the bridging of the implementation gap with the developed priority concept and its integration in an operational HRM model for German practitioners' surgeries with the psychological contract as core are discussed.

The demand for healthcare services are rising as the world’s population is increasing, and on average, people are living longer. As a result, healthcare services are becoming more complex to organise and expensive to provide. Researchers in the field are arguing that the current centralised model of healthcare provision cannot address challenges relating to service cost, quality and availability and there is a need to decentralise it. To decentralise, virtual collaboration systems where healthcare organisers, providers and receivers can work together and share resources across time and space are seen as the future of healthcare. Literatures suggest that a modelling framework specific to healthcare virtual collaboration is yet to be developed and there are unaddressed challenges relating to the organisation and management aspects of healthcare virtual collaboration. In this thesis, Virtual Breeding Environment (VBE) and Virtual Organisation (VO) concepts are used as theoretical bases to answer research questions relating to modelling, organising and managing virtual collaboration for healthcare. To contribute to the modelling aspect of virtual collaboration in healthcare and address organisational and managerial challenges of healthcare virtual collaboration the first objective of the thesis is to develop a modelling framework to enable system developers model healthcare virtual collaboration in terms of participants and services classification, representation and descriptions. The second objective is to develop a framework based on concepts developed in the modelling framework, to be used as guide to develop systems for organising and managing healthcare virtual collaborations. To achieve the objectives, a deductive research approach is used to develop theoretical frameworks first, and later implement and evaluate the frameworks. For evaluation purpose, Technology Acceptance Model (TAM) is modified three times by adding new constructs. The extended TAMs are used as theoretical evaluation frameworks to test the acceptability of the technologies developed in this thesis. For each extension, a set of hypotheses are defined to be tested by prospective target users. Survey questionnaire is used as a data collection method, and Structural Equation Modelling (SEM) technique is used to analyse the collected data statistically in AMOS software. The first contribution of this thesis is a Healthcare Virtual Breeding Environment Modelling Framework (HC-VBE-M-F) which consists of a service and participant classification mechanism, a domain specific modelling language and a service orchestration description language. The frame work is implemented as a Java application and has been tested for acceptance by system developers. The second contribution is a Healthcare Virtual Breeding Environment Framework (HC-VBE-F) which is based on the first framework. The framework consists of a conceptual description, a member selection mechanism, a service level agreement creation and management mechanism and a provider verification and validation mechanism. The Framework is implemented as a mobile application and it is evaluated by healthcare requesters and providers for acceptance. The evaluation results show that the frameworks are both acceptable by prospective users and their intensions to use systems developed based on the two developed frameworks are positive and validated empirically. The achievements of this thesis are the developed mechanisms and frameworks that together facilitate the modelling and development of healthcare virtual collaboration systems based on VBE and VO concepts.

Employees’ turnover has always been the main concern and interest of both academics and practitioners in the healthcare sector. Also, both leadership styles and organisational culture as the main contributors to employees’ intention to leave have always been the central focus of most scholars in different disciplines including healthcare and organisational studies. Although, there are numerous studies that have investigated the impact of both leadership styles and organisational culture on employees’ intention to leave, almost all of this research has only explored the direct relationships between these variables. As a result there is limited and inadequate attention on the indirect relationships among these variables through other major factors such as job satisfaction, organisational commitment and perceived organisational support. Therefore, this study argues that there is an absence of a comprehensive conceptual framework in this area that has explored both direct and indirect relationships among these variables. As a result, the main purpose of this study is to provide a comprehensive conceptual framework that enables researchers to investigate the mediating impact of job satisfaction, organisational commitment, perceived organisational support on the relationship between leadership styles and organisational culture with the intention to leave in public healthcare in Saudi Arabia. In the first instance and in order to achieve this study’s aim and objectives, a systematic literature review was carried out that helped and enabled the researcher to develop a conceptual framework that clearly shows these relationships. After developing a conceptual framework and hypotheses related to the relationships, a questionnaire was designed based on the existing literature in these areas and was distributed among 850 employees working in one public hospital in Saudi Arabia. Out of 850 questionnaires distributed 354 usable questionnaires were returned which provided around 40 percent response rate. The results of this study were interesting and in some respects unexpected in some areas. The findings show that transactional leadership style has no direct or indirect relationship with the intention to leave which was surprising and requires further investigation. Furthermore, job satisfaction does not act as a mediator on the relationship between transformational leadership style and intention to leave which was also unexpected and requires further investigation. On the other hand, the results of this study confirm the importance of both transformational leadership style and organisational culture on the intention to leave among expatriates in the public sector as well as the major influence of job satisfaction, organisational commitment and perceived organisational support on these relationships. This study makes several major contributions both from an academic and practitioners’ point of view. The most important contribution of this study lies in the roots of this study with the presentation of a conceptual framework that shows both direct and indirect relationships among all variables explored. Furthermore, this study also contributes to the growing literature in the area of leadership-culture-intention to leave in public healthcare systems in developing countries.

Using a Constructivist methodology, combining elements of Fourth Generation Evaluation and Grounded Theory (Guba and Lincoln, 1989; Charmaz, 2014), this study explored the impact over time of the Delivering Better Care Leadership Programme, to better understand the factors that enabled or hindered subsequent changes. The study involved three Phases and data were collected longitudinally, primarily using interviews with a range of stakeholders. The study was underpinned by the 'Senses Framework' and 'enriched environments' (Nolan et al., 2006; Brown, 2005), and resulted in the development of the Five Cs' substantive theory comprising: Context, Catalyst, Chronology, Conditions and Consequences. This theory, when used in conjunction with the Senses Framework, illuminates experiences and subsequent Consequences of participants, their teams and the wider organisation over time, and highlights the Conditions needed to create and sustain positive Consequences for participants and the wider Context. The importance of relationships emerged as being paramount. In order to create the Conditions, necessary for enriched environments, a number of enabling factors were identified, including support from colleagues, the promotion of autonomy, intrinsic motivation and drive, and opportunities for continual learning and development. On the basis of this study, the promotion of 'relationship-centred leadership' is suggested as a way forward for future initiatives. Implications for on-going leadership development programmes are considered, particularly in the challenging and complex landscape of the National Health Service (NHS), as are the contribution that the study makes to advancing knowledge. Methodologically, the study also argues for an expansion of the EA Matrix via the addition of two further dimensions: Evaluate and Embed Action. The study concludes that the Five C's theory, allied with Senses Framework, provides a facilitation mechanism to foster relationship-centred leadership, which has the potential to further promote a compassionate, collective leadership culture, so vital for the NHS at this time.

In this thesis I develop a new, wider and richer understanding of wellbeing, through developing a process of reflective practice, with healthcare professionals within their challenging work culture. As a healthcare chaplain, having witnessed poor staff morale, I conducted a critical examination of NHS wellbeing reports and strategies, which revealed an understanding of staff wellbeing that ironically follows simply a health model. Challenging this, I argue for a broader interpretation of wellbeing that, in addition to focusing on health, is more holistic, relational and contextual. I develop reflective practice to nurture this, the use of which extends in healthcare beyond education and professional development. In my action research, knowledge was generated through ethnographic participation and observation, over a year, reflecting as chaplain with eight teams of healthcare professionals. This used my simple and memorable HELP Wellbeing Reflection Cycle (building on Kolb's (1984) model of experiential learning) that combines reflection on work and personal development. My project also responds to Rolfe's call (2014) for greater use in healthcare of Schön's (1980) "reflection-in-action". Building on these works, I develop reflection for healthcare professionals to nurture their wellbeing. My encouragement of the participants to self-facilitate their own reflective groups, when familiar with this method of reflection, is also a contribution to reflective practice, healthcare and the chaplain's role. Thematic data analysis emerged from the reflexive field notes of our shared experience as co-reflective practitioners. The themes include healthcare professionals making the human connection between themselves and with their patients. They also value the space to reflect together, realising their desire for team support and a shared goal, as well as job satisfaction in this demanding culture. These themes, I argue, are consistent with the broader definitions of wellbeing, giving them the opportunity to be both a healthcare professional and human. Further data analysis also reveals consistency with wider wellbeing interpretations (including personal wellbeing measurements and data from the Office for National Statistics (2014, 2015)). I develop the role of chaplain as the healthcare professionals' co-reflector, sharing their reflective space as a pastoral encounter and a source for learning. This combines the images of "empty handed" (Swift, 2009) "welcoming guest" and "mutual hospitality" (Walton, M., 2012). I offer to national healthcare the wider understanding of wellbeing, and the value of creating provision for reflective space to nurture it, in the care of healthcare professionals. This research offers the potential for exciting further developments in a wider constituency both in and beyond healthcare.

The study seeks to provide a deep and holistic understanding of management accounting's (MA) role in supporting organisational performance in England's community health service. Its main purposes are to illustrate the effectiveness of MA in one community health trust and how this is shaped by a set of internal, external, technical and behavioural factors. Drawing on the contingency theory of MA and the related literature, a framework was developed to investigate the conditions (contingencies) of this context and its possible influence on MA's roles, and to explore why MA is practised as it is. The chosen research method was the interpretive case study. During an intensive field study lasting four months, data was collected about one community health trust by means of interviews, observations and documentary review. The qualitative content analysis of the collected data provided insights into how the processes and outcomes of MA are embedded in both the organisational and environmental contexts, revealing that MA's effectiveness is influenced not only by contextual and environmental factors but also by the organisation's other (e.g. cultural and administrative) controls. The influence of the context on MA was investigated by adopting the contingency theory of MA. As the core of the performance management system, MA in the Trust is conceptualised by both environmental and organisational factors, with the result that it is impacted by multiple contingencies which require it to meet different, sometimes conflicting, demands. This limits the role it is able to play to mainly managerial (the budgetary control system is used mainly to ensure the efficient use of departmental resources) rather than strategic or operational. In terms of its operational role, MA in the Trust is tailored to meet external rather than internal demands, leaving clinicians dissatisfied with the information provided. The results suggest that MA could play a more useful role in the Trust with the introduction of practices such as patient-level information and costing systems (PLICS), though this is dependent on contextual and behavioural factors being taken into account, for example by providing appropriate training and encouraging dialogue and collaboration between clinicians and finance managers. The findings highlight the significant role clinical directors can play in closing the gap between these two groups. They also suggest that the multiple demands of trusts are better served by adopting a more flexible budget than by abandoning the budget altogether. In terms of MA's strategic contribution, the findings indicate that the Trust engages in strategy formulation but pays little attention to strategy execution; a range of factors, such as efficiency targets, the contract between the Trust and the commissioners, and rising demand, force managers to focus their attention on short-term performance at the expense of strategy execution. However, while MA appears to make little or no contribution to encouraging strategic behaviour (there being no link between the Trust's operations and its strategy), the findings do show that management accountants (MAs) contribute significantly to the strategic decision-making process. The findings suggest that a full application of the BSC, underpinned by a strategy map, would enhance managers' understanding of their role within the broader strategic picture. The study adds to our knowledge of MA by developing an understanding of MA's particular meaning and significance within the context of NHS community trusts. It shows how MA is both shaped by and shapes this context and thus whether particular MA practices are more or less appropriate for an organisation. The study's main contribution is its proposal of a theoretical framework that features a set of MA contingencies that are specific to NHS community trusts. It provides empirical evidence of the roles played by MA in these trusts and how these roles are influenced by a complex network of political, social and economic conditions, some of which work in opposition to each other. These conditions appear to be the key to understanding and explaining the process and outcome of MA in the NHS community trusts.

This thesis explored the influence of leadership incivility upon employees, with the aim of understanding individual experiences and developing organisational interventions. The research was undertaken within an acute NHS Trust setting, where through the author's professional work, the issue of lack of confidence in dealing with uncivil leadership became apparent. Recent research has explored incivility within different workplaces, but studies within the clinical setting are limited, and incivility within the Allied Health Professionals (AHPs), including Physiotherapy, is a current literature gap. A qualitative exploration of uncivil leadership was undertaken within the NHS Trust, and template analysis used to analyse data from semi structured interviews (N=20) conducted within the Physiotherapy department. The findings were presented and discussed in relation to 6 key themes, of "What it feels like to work with these leaders", "Hierarchy", "Why they behave that way", "Patient care", "Workplace culture and culture of leadership" and "Challenging the behaviours" (study 1). These themes informed the basis and design of an organisational intervention to give AHPs increased confidence in managing situations with uncivil behaviour. The intervention examined different strategies and coping techniques, ranging from directly challenging the uncivil individual, to learning to live with the behaviour through various techniques. A quasi-experimental study (study 2) consisted of pre and post measurements among AHPs in the NHS Trust. Participants completed a survey prior to the intervention (T1) and then after the intervention workshop (T2), split into an experimental group (n=50) and a control group (n=23). Measures of confidence (self-efficacy), Resilience (CD-RISC) were analysed using two-way mixed ANOVA'S. Measures of confidence in having a challenging conversation across different groups in the workplace, and in two different situations were analysed with paired t-tests. The intervention was successful and levels of confidence and resilience in having a challenging conversation significantly increased after the intervention. The results also demonstrated a significant increase in the confidence of the participants in having challenging conversations, across the groups and within different situations, so when the uncivil behaviour was directed at themselves or their team. Overall, the research programme contributes an evidence base for interventions to develop confidence and resilience in challenging uncivil behaviour of those in senior leadership positions.

Saudi law, which is based on Sharia, considers healthcare provision a government obligation. Despite this obligation, and Sharia scholars'opinion against privatisation, the new 2030 Vision will privatise Saudi healthcare. This thesis argues that Sharia scholars have defined privatisation too narrowly, considering only one arrangement and neglecting other privatisation models which can be identified as Sharia compliant. The thesis will consider the basis for state provision of healthcare in Sharia law, define Sharia compliance in the context of healthcare, and highlight the limitations of Sharia scholarship on privatisation. This thesis argues that some healthcare privatisation models such as outsourcing and financial privatisation are Sharia compliant. The thesis also considers how in conditions of need, such as financial crises, some forms of privatisation may be considered exceptionally compliant with Sharia in order to ensure the Sharia obligations are maintained. This thesis engages with Sharia scholarship on Takaful, an Islamic joint guarantee system, specifically the Saudi Cooperative Health Insurance for Foreign Workers. Understanding Takaful showcases how some models of privatisation could be arranged and adopted in a Sharia compliant manner.

The aim of this study is to develop a framework that can be adopted to help improve the participation of SMEs in public procurement. This research was carried out using a critical review of the relevant literature, analysis of data from a survey of SME owners/managers, development of a framework through the constructive research approach, a preliminary validation process and finally, the modification of the framework. First, six key policy measures being adopted to facilitate SMEs in public procurement in the UK were identified from the literature and then evaluated through a cross-sectional survey amongst SMEs competing for public contracts within National Health Service (NHS) trusts across the North West of England. The findings suggest that most SMEs have awareness and a marginally positive attitude towards policy measures, but evidence from the study also indicates that SME participation in public procurement is far from improving. Furthermore, the research discovered some issues and concerns raised by SMEs about the policy measures, which have been addressed and considered towards the development of the proposed framework to improve SME participation in public procurement. Therefore, it is concluded from the findings of this research that, while the policy measures being implemented in the UK are necessary, they do exhibit some limitation, which makes them inadequate to effectively address the issues of SMEs under-representation in public procurement markets. Consequently, a framework was developed based on data collected from the survey and findings from the literature review, to provide broader view of the approaches that might help to improve the participation of SMEs in public procurement. The proposed framework contends that collective actions from diverse stakeholders such as the government, public buyers, policy makers, large business and small businesses themselves, are needed to improve SME participation. Finally, the proposed framework has been tested (preliminarily) through a focus group discussion and found to be feasible and useful.

The dominant concept of leadership among academics and practitioners foregrounds individual leaders and views leadership as a 'thing' that can be discovered. However, there is growing scholarly consensus that we need to challenge the assumptions that underpin traditional leadership theories and engage more effectively with the lived experience of leadership. This thesis responds to the call to consider leadership from different perspectives by applying the lens of process philosophy to leadership-as-practice (LAP), an emergent stream of research that has the potential to deepen our understanding of the dynamic nature of leadership as it is accomplished in everyday activities. To extend the existing understanding of LAP grounded in a process ontology, this thesis brings together two complementary Pragmatist informed theoretical perspectives: the performative theory of organizational communication developed by communicative constitution of organization (CCO) scholars; and John Dewey's theory of Inquiry. The concept of leadership-as-communicative-practice (LACP) proposes that leadership emerges in response to ambiguity and uncertainty and is a social and material process that transforms situations. This transformative change is accomplished through the complex entanglement of conversation and written texts. To explore LACP empirically, a nine-month immersive study was undertaken in a Scottish Health and Social Care Partnership. Through attending designated 'leadership' meetings, two issues emerged that were causing tension within the organization and necessitating leadership. These two situations were then shadowed as they unfolded. The emergent leadership movements within each situation were analysed using two co-productive lenses: Inquiry and co-orientation. Analysing turns in conversations suggested that co-orientation occurred across multiple timeframes, was characterized by dissent as well as consensus, and enabled the talking out of issues, relational dynamics and the discovery of new insights into the situation. Moreover, the findings highlighted the contribution of documents in carrying the almost imperceptible movements generated through co-orientation through time and space to transform situations. The study not only adds to the theoretical and empirical understanding of processual LAP, but also provides new insights into the challenges of studying leadership as an unfolding phenomenon. Specifically, shadowing situations is offered as an extension to the organizational shadowing literature that engages with the need for more mobile methods. LACP provides an alternative to the dominant leadership concept within organizations and lays the foundation for new approaches to developing leadership that attend to the processual, communicative dynamics of leadership practice.

The public sector, particularly healthcare organisations are under ever increasing pressure to do more with less. This coupled with the need to keep up to the constant technological changes and ever increasing abundance of information has led to many public sector organisations adopting Business Intelligence (BI) in order to leverage business value and improve decision-making. However, many organisations such as the National Health Service (NHS) continue to fail in their Information Technology (IT) related initiatives. While the rise of BI and its growing influence in organisations has attracted much academic attention, this has largely been from architectural, design and technological perspectives, whilst little is known about how BI is used by various organisational actors to reach decisions, nor much is understood regarding its resulting impact on organisational power dynamics. Thus, there remains an under researched area of discussion in the literature from the perspective of BI users. While studies report how BI can impact organisational effectiveness, facilitate data driven decision making and supposedly overcome intuitive decision making, the extent to which BI impacts and alters power dynamics between organisational actors across the organisation has received little attention. Accordingly, this research adopts a qualitative case study approach to explore power resulting from BI use within a large NHS trust by conducting 30 semi-structured interviews consisting of operational managers and BI analysts. Through taking a human-centric approach, this research uncovers how BI is altering power dynamics between organisational actors, whereby BI analysts are becoming increasingly influential as a result of their analytical skills. It was found that operational managers are becoming more reliant upon data analysts, resulting in the analysts having more and more influence. However, this research finds it is only when the analysts supplement their technical skill-set with their institutional knowledge, that they have the ability to influence and enact power within the organisational settings. The research also offers insights into the contestations and conflicts which arise from the use of BI, between operational managers and analysts as well as between in-house analysts, based in the operation setting and the centralised analysts, operating across the entire trust. Accordingly, this research empirically validates a BI Power Enactment Framework and proposes the BI Power Matrix, which may assist policy makers in identifying determining key factors which are contributory to the success or failure of technological initiatives.

The objective of this dissertation is to explore the meanings of knowledge as understood by senior medical staff in the UK's National Health Service. It asks the question: 'What does it mean to know something?' The assumption is that an exploration of these meanings will help in designing systems to manage such knowledge. This is because the meaning of knowledge in the literature is contested and the models for its management are extremely variable, to the extent that it is proving challenging to establish knowledge management as an academic discipline or credible business tool. Twelve in-depth interviews were completed and analysed using a constructivist grounded theory approach. Six main categories were constructed. These are: finding motivating factors to pursue knowledge; interacting with knowledge sources; undergoing a process of knowledge acquisition; practising skills; seeking peers' views; and, finally, building confidence as knowledge. Confidence was selected as the core category and the backbone of the constructed theory. The constructed theory argues that confidence is an important, integral aspect of our knowledge. One knows something if one thinks confidently that one knows it. Someone who understands a subject very well but lacks confidence simply does not know that subject. On the other hand, people can be overconfident or possess completely unjustified, misplaced confidence in situations where they lack understanding or ability. According to the emergent theory, these individuals are still knowledgeable, albeit in an incorrect or negative way. The emergent theory provides a new understanding of the concept of knowledge: knowledge as a type of emotion, i.e. confidence. This differs from the current understanding of knowledge, which views it as either objective information that requires cognitive processing or as human behaviour that influences practice. According to the emergent theory, knowledge is not necessarily a logical mental process nor purposeful human behaviour, but a fallible emotion, which can be harder to measure, observe or control than the two former phenomena. Confidence is an essential feature of knowledge and this thesis concludes by proposing a tool for confidence management within the NHS.

This research primarily investigated the Clinical Commissioning Groups (CCGs) in the English NHS to identify factors influencing effective decision-making as perceived by General Practitioners (GPs) with formal roles in CCGs. A study by the British Medical Association (BMA) (2014a) revealed that GPs at practice level felt that CCGs were developing policies that restrict efficient delivery of health care. As such, I developed a hypothesised conceptual model demonstrating factors at play in the decision-making process, which I tested using Partial Least Squares Structural Equation Modelling (PLSSEM). Alongside, informed by the conceptual model, was the qualitative strand, with the data that I analysed under interpretative phenomenological analysis (IPA). Quantitative and qualitative data were collected simultaneously through a survey using a questionnaire in a convergent parallel mixed methods design, underpinned by a philosophical position of pragmatism. Data was collected in 2017. Research sample consists of 73 GPs in the UK. The hypothesis testing results show that GP Proportion has a significant and positive effect on Decision-making Process Effectiveness. Similarly, the effect of GP Influence has been found to be significant and positive on Satisfaction. In contrast, the effect of GP Influence on Decision-making Process Effectiveness has been found to be insignificant. This result is also observed regarding the effect of GP Influence on Member Practice Wishes Met. Five key themes were identified from the qualitative data analysis – namely, (1) Financial, focused on decisions influenced by financial concerns, (2) Bureaucracy, centred on decisions influenced by the bureaucratic hierarchy, (3) Clinical, to do with decisions that were perceived as having clinical implications, (4) Workplace culture, focused on behavioural patterns affecting decision-making within the organisation, and (5) CCG role, based on the way the role of CCGs was understood by member practices and the way that engagement of member practices was achieved by the respective CCGs. The results contribute to theory and practice. Regarding practice, notwithstanding the intended autonomy for the CCGs, which was aimed at improving patient care by aligning health care commissioning decisions with local needs, structure alone appears not enough to deliver effectiveness, as perceived by GPs. The proportion of GPs was found to be a relevant factor, while leadership and local CCG level culture, coupled with communication and governance, are also important. Finance was found to be significant, with many concerns about CCG policies attributed to this factor. On contribution to theory, the general observation is that the CCGs appear to be moving from professional to bureaucratic organisational model (Mintzberg 1979), thereby threatening the purported autonomy. This study also revealed new information on the formal roles that GPs occupy in CCGs, as previous research showed limited awareness in this regard (Checkland et al. 2016). Information gathered on committee memberships and the positions GPs occupy highlights the complexity and diversity of GP roles in CCGs.

China is currently facing a serious conundrum in terms of healthcare availability and equity (which is characterized by the uneven distribution of medical resources among urban and rural areas, and a widening gap in medical service standards among different regions). This has resulted in limited accesses to and high costs of healthcare services for residences in less developed areas. In view of these issues, China has planned to launch an initiative called 'Inclusive Healthcare' to improve the level of medical services in less developed areas. To provide such inclusive healthcare services, we propose a new business model with dual-components and develop a technical framework for supporting such an initiative. The proposed business model consists of two parts. The first part is market-oriented and for-profit, serving as a fund-raising mechanism for the inclusive healthcare services. The second part is charitable in nature and is responsible for developing and managing the operations platform for inclusive healthcare services. From the perspective of governance and funding, we illustrate the key drivers in the implementation of the inclusive healthcare services, followed by an analysis of the new business model based on four elements of the business model proposed by Johnson et al. (2008). These elements include customer value proposition, key resources, key processes, and profit formula. In the discussion on customer value proposition, we focus on how the dual-component business model creates value, and how each participant profits from the new business model. In the discussion on key resources, we focus on the important roles of technologies such as the Internet and artificial intelligence (AI) for implementing the inclusive healthcare service systems. In the discussion on key processes, rather than considering how investors in the market-oriented part manage the healthcare service system, we emphasize the business processes of the charitable part and the positive capital inflow from the market-oriented part to the charitable part. In the discussion on profit formula, we emphasize how the coupled business model generates profit, right from the interface between the market-oriented part and the charitable part. Finally, building on the coupled dual business model for inclusive healthcare services, we provide specific recommendations on the development and implementation of the initiative. To help put the proposed model into practice, we use the case study approach to study the critical success factors for implementing inclusive healthcare services in remote and less developed areas of China. By reviewing the literature on critical success factors for public-private partnerships (PPP) and healthcare services projects, we summarize the possible critical success factors for implementing the 'inclusive healthcare services'. Then, through interviews with two government officials, one investment company executive, four hospital leaders, eight doctors and twenty patients, we identify six critical success factors which are: medical infrastructure, technology, funding, government support, external environment, and organization planning and operations. In this thesis, we also propose a technical framework for implementing inclusive healthcare service systems based on cloud computing and artificial intelligence technologies. At the core of this framework is an integrated architecture using multi-sources of medical data. The architecture is in line with the diagnostic logic of evidence-based medicine, and it is implementable using the theory of evidence-based reasoning. It can make diagnoses by fusing various types of medical data from multiple sources. Furthermore, we construct a cloud system for inclusive healthcare services to support the proposed framework, which comprises three layers: infrastructure, platform service, and platform application. The infrastructure layer provides basic services for the cloud system to collect and compile basic medical data. The platform service layer integrates cloud storage, cloud computing and application development platforms in order to respond to data processing requests and application development requirements. The application layer is intended for doctors and other users. It includes a human-computer interface, a comprehensive medical record processing system, and a comprehensive medical image processing system. Finally, using multimodality brain tumour imaging as an example, we develop a multimodal brain tumour medical imaging diagnostic methodology, based on evidence fusion theory. Experiments show the effectiveness of the evidence fusion technology in the proposed technical framework.

The aim of this PhD study was to gain greater understanding of staff experience of being well led within a NHS Hospital Trust rated 'well led' by the Care Quality Commission (CQC), to better understand the potential contribution leaders could make to improve quality of patient care. A qualitative case study method was utilised to explore staff experiences in the 'well led' Trust. A theoretical framework was developed to underpin the methodological process, incorporating components of learning organisational theory (Argyris 1995 & Senge 1990) and an interpretive grounded theory approach was applied (Charmaz 2006). Four main themes were identified: • A sense of 'family', particularly a focus on shared values and behaviours that prioritised both patient and staff wellbeing. • A strong preference for a distributed leadership model that was balanced against a need for a hierarchical model. • A learning approach was balanced against a robust commitment to sanction behaviours outside the values of the organisation. • A clear ambition to build resilience and embed these values to sustain the 'well led' approach in the face of significant financial pressures and work force challenges. Many of the principles of learning organisation theory, identified by Argyris (1992) & Senge (1990), were visible across all four themes. However, there were also some important differences. In particular, there were challenges related to the organisational requirement to balance strategies to both promote staff commitment, as well as compliance. Furthermore, there were similar challenges linking parallel, but disparate models of distributed and hierarchical leadership. The findings identified both the features of a well led NHS Trust and also some challenges. These new insights contribute to our current understanding of 'well led' Trusts, which can be used to improve Trust level leadership more broadly in the NHS, and also provide a framework for further research in this area.

Purpose - Despite the fact that research in readiness is growing, there are gaps in the context of enacting readiness within healthcare. Adopting the complex adaptive systems theory, this thesis aimed to extend the theoretical understanding of the concept of organisational readiness for innovation in the context of healthcare. It examined the meanings and the processes involved in achieving and maintaining a state of readiness for innovation in the UK public healthcare services sector from the perspective of its senior leaders. Methodological approach - The thesis included three studies. First, a narrative systematic review was conducted across different bibliographic databases to explore the associated meanings and factors influencing organisational readiness for innovation. The search revealed that there were different meanings and processes associated with the development, implementation and sustainability of the construct. These included the stage vs. the process-based debate, the various disagreements amongst theorists on the multifaceted nature of the construct and its impact (i.e. behavioral, psychological and structural), and its relation to organisational change. This led to the adoption of a qualitative research method to further investigate the topic in the context of UK public healthcare services. Twenty semi-structured individual interviews in total were conducted. The data were collected in two phases. The first phase consisted of a total of ten senior managers working in NHS organisations. This first phase investigated from an internal point of view how organisational readiness for innovation was successfully managed within the National Health Service (NHS) - it explored meanings, discrepancies between organisational change management and innovation, and identified contextual (pre) conditions and processes of how leadership may influence readiness for innovation, its enactment and sustainability. In the second phase, a total of ten semi-structured personal interviews were conducted with senior management representatives from the Academic Health Science Networks groups. This second phase provided information on the perspective and role of an external facilitator's organisation in supporting and sustaining an innovation 'ready' culture in the NHS. Conducting the study in two phases allowed the researcher to see the level and reasons for alignment in the senior management's views from different organisational perspectives - internal and external. Summary of results - A significant distinction was found in the senior managers' opinion regarding the definition of innovation and organisational change. Successful innovation management was described as a much more complex and intricate process than organisational change management. Readiness was perceived as an iterative process of interaction between different stakeholders, their new ideas and the environment to enable innovation development and service improvement. Participants acknowledged that readiness for innovation was driven by collective engagement and intrinsic motivation from members of the NHS organisation. The findings presented, among others, some unique key contextual factors enabling organisational readiness for innovation which include: free spaces, communities of practice, and five types of leadership style: systems leadership, collective leadership, distributed leadership, lateral leadership, and transformational leadership. Conclusions - The study generated new understanding about the theoretical distinction of innovation from organisational change. It provided new rationale about the meaning of organisational readiness for innovation based on views from those managing the process internally and externally in the NHS. The study recommended a conceptual framework enabling scholars, practitioners, senior managers, and policy makers to understand the actions required in order to prepare the NHS for the long-term success, adaptability, and the sustainability of organisational innovations in healthcare services.

Problem definition: Healthcare is a professional field, which most individuals will encounter at some point in their life, directly or indirectly. In the UK, healthcare organisations are facing significant challenges, including financial pressures, shortages in staffing levels, and changes in the way healthcare is delivered. In addition, patient demand for such healthcare systems has been increasing dramatically year on year, in part, due to societal changes towards unhealthier lifestyles. Consequently, amid such adversities, it is important to understand how these issues are affecting both the providers and receivers of healthcare. Therefore, the current study will explore how healthcare professionals' job satisfaction relates to, and affects, the quality of care staff are able to provide. Unlike the multitude of healthcare research which tends to focus solely on clinical staff - defined here as those who are directly involved in patient care (Department of Health, 2016), the current study will also include staff in non-clinical roles in order to obtain a greater appreciation of the multi-disciplinary aspect of healthcare provision. The main areas under investigation in this study are, understanding the factors which influence healthcare professionals' job satisfaction, determining if there are differences between clinical and non-clinical staff, and to understand the relationship between job satisfaction and quality of care. Literature: Job satisfaction and quality of care are the two principle concepts being explored throughout this thesis. An extensive review of the literature was carried out in order to establish existing knowledge concerning the individual constructs, as well as how they are related. The review allowed specific gaps to be identified. One crucial area highlighted, was that the links between job satisfaction and quality of care were significantly absent from the literature. Whilst some connections were evident, the holistic exploration as to how various components interlink appeared to be missing. Instead, analogous links were investigated from other sectors, such as job satisfaction and performance. Accordingly, the literature review chapters included general studies, as well as research based specifically in the healthcare domain. Method: Due to the relationship between job satisfaction and quality of care being somewhat neglected throughout existing research, the novelty of including a broad participant group, and the critical realist perspective of the researcher; qualitative semi-structured interviews were conducted. The interviews were conducted in two phases, 12 in the first phase and 15 in the second. Participants were recruited from a range of organisations throughout the UK and included a diversity of roles. In particular, an important objective of the study was to ensure that the selection of participants included both clinical and non-clinical staff. Once transcribed, the interviews produced a large amount of data (301 pages), which were analysed using thematic coding. Findings: A number of aspects relating to healthcare professionals' job satisfaction at work emerged. The key factors included helping patients, teamwork, social network, cognitive aspects, demand and resources, as well as staff management. For the second key area of study, a comparison was made between clinical and non-clinical healthcare staff. In terms of the broad factors that arose, many appeared to affect participants irrespective of whether their roles were classed as clinical or non-clinical. That said, the manner in which these factors influence staff was nuanced. The overarching aim of the study was to explore the relationship between healthcare professionals' job satisfaction and quality of care. Based on the analysis of the interviews it was suggested that this relationship is reciprocal. Specifically, satisfied employees are more likely to provide a higher level of care, however being able to deliver quality of care also impacts on healthcare professionals' job satisfaction. Contribution: The study contributes to the job satisfaction literature by identifying several factors which appear to influence a wide range of healthcare professionals' job satisfaction. Based on the data analysis, it has been suggested that the antecedents to job satisfaction can be categorised into three main areas: 1) universal factors, 2) individualistic factors, and 3) job specific factors. The overwhelming consensus across all staff regardless of job setting or role was that the primary factor influencing their job satisfaction was 'helping patients'. The current study suggested that when outcomes of the care or service delivered are more immediate and have a greater impact, this has a greater affect on healthcare professionals' job satisfaction than occasions where gradual changes to a patient occur over time. The study also provided a theoretical contribution by exploring the novel interrelationship between healthcare professionals' job satisfaction and the quality of care an individual is able to provide. The relationship was determined as reciprocal, however, key factors influencing both of these concepts also emerged, these were: staff shortages and time to care. These concerns were found to be prominent across both clinical and non-clinical staff roles. The thesis also contributes to practice through several recommendations and suggestions which aim to improve both healthcare professionals' job satisfaction and the quality of care they are able to deliver.

Treating people in a safe environment, including protecting them from avoidable harm, and improving the quality of both care and leadership are the top priorities for the NHS since the tragedies and high profile cases of recent years (Berwick, 2013; Francis, 2013; Keogh, 2013). My research describes the value of an action-based approach to research and learning in North West London (NWL) NHS organisations, in response to the challenges and recommendations of the Berwick review (2013). This proposed that the NHS should become a system in which leaders create and support capability for continual learning and improvement. The research is in the form of a first-person inquiry (into my life as the researcher – Reason & Torbet, 2001) and a second-person inquiry (with others, into issues of mutual concern – Reason & Bradbury, 2008) including learning and sharing with others beyond NWL. This thesis illustrates my experience – as a practitioner inquirer with lived personal experience of being a patient receiving critical care and in active collaboration with other co-inquirers (NWL practitioners and patient representatives) – of working in the complex system that is the NHS: a collective, human, living organism that is non-linear, unpredictable, dynamic and networked over multiple organizational boundaries. My doctoral research has made a contribution to academic literature and professional practice by evidencing what it takes to operate through relational leadership in the NHS. I offer my view from the inside, capturing the emotional rollercoaster of anxiety, excitement, struggle, messiness and warmth involved and describing the dynamics we experienced. It includes exploration of the less obvious thread that connects race, voice and power to leadership practices, which was a critical part of my personal leadership experience. My doctoral research demonstrates that nurturing effective use of the voice and power of practitioners and patients not only improves patient safety at an individual level, but also promotes the safety of the wider healthcare system. It does this through enhancing a self-reflective approach in leadership practices and thereby fostering sustainable cultural change.

This thesis explores the impact of financial incentives on non-profit organisations delivering outcomes-based contracts in UK public services to understand how they affect intra-organisational behaviour and the motivation of staff members. These issues are examined in comparative case studies of two non-profit organisations delivering public services through a Social Impact Bond (SIB), an outcomes-based payment for results (PbR) contract. In a SIB, government purchasers collaborate with private investors or social investors (seeking a blend of financial return and social value) to fund interventions tackling social problems. The SIBs generated direct financial incentives to the organisation and indirect financial incentives for managers and front line staff. This thesis examines the impact of these incentives on organisational, team, and staff behaviour at the managerial and front-line level. This analysis draws on economic theory about the agency relationship, incentives, and non-profit organisations to understand the impact of these direct and indirect incentives on the behaviour of providers delivering outcomes-based contracts. The research examines the applicability of theories of intrinsic motivation crowding from the economics and social psychology literature to understand the impact of indirect financial incentives on the staff's intrinsic motivation. The analysis of the SIB contracts identified the potential for unintended consequences and suboptimal allocations of resources. The strategic importance senior leadership placed on direct financial incentives influenced how team managers organised staff structure and service delivery. Front line staff understood and prioritised the preferences of their team managers in their choices to apply a client- or outcomes-centred approach to the client group. Incentives 'crowded in' intrinsic motivation for staff that supported the outcomes targets and had autonomy over their work. This study argues that the highly-geared incentives in these outcomes-based contracts had complex effects on public services delivery.

Participants from the four health regions were invited to participate in a study which focused on Leading Health Information Management in Jamaica. The purpose of this convergent-parallel mixed-methods study was to understand their views concerning how leadership was practiced in HIM, and the policies and procedures that guided the HIM practice. The interview results corroborated those of the survey and revealed a hybrid of leadership practices in HIM in Jamaica. The results highlighted a number of issues regarding leadership in the HIM practice; recruitment, retention, succession planning among HIM practitioners; and the policies and procedures guiding the practice. The results suggested that HIM practitioners, policy makers and academic leaders will need to work synergistically to address the issues raised and to revise the policies and procedures to reflect current practice. The results also suggested a need for more in-depth studies into HIM practices through the lens of leadership;and the introduction of leadership and professional development programmes to build the capacity of HIM leaders and to enhance the HIM practice.

Regarding the failures of Mid Staffordshire NHS Foundation Trust between 2005 and 2009, Sir Robert Francis QC commented to the then Secretary of State for Health 'that above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement of managerial and leadership responsibilities' (The Francis Report, 2013, p. 9). This was a criticism directly laid at the feet of those NHS leaders and managers who were charged with caring for vulnerable families and friends during that time. Understanding how leaders and managers are developed within the NHS is of a notable concern, especially if we wish not to see the likes of what occurred at Stafford Hospital again. Even after significant investment in NHS management training, Lake (2016) of the NHS Leadership Academy suggests that there are still vague barriers which prevent a culture of effective leadership development from embedding itself within the NHS workforce. This view is supported by others including Ahmed et al. (2015), West et al. (2015) and Tull (2018). It can be reasonably asserted that this unclear picture starts with a need to explore the recent experiences of NHS staff who have been participants on NHS leadership and management development (LMD) trainings. The primary aims of this thesis were 1) to explore how NHS LMD training participants experience their training and 2) to examine potential barriers which impacted upon the LMD participant's learning within their NHS workplace. With a focus on the need to understand the experiences of NHS LMD participants, a qualitative methodology was proposed as a suitable research method (Creswell, 2017). Thus, a retrospective, cohort sample of nine recent (within the past 10 years) NHS LMD participants partook in nine; 40-60-minute individually recorded then transcribed, semi-structured interviews. Recognising Alvesson and Deetz (2000) concept of 'interpretative repertoire' (2000, p. 166) and Mabey's (2013) recognition of the neglected organisational and leadership development discourses; an Interpretative Phenomenological Analysis (IPA) (Smith et al. 2009) and a modified Critical Discourse Analysis (CDA) (Fairclough, 2003; 2013) were chosen as multi-methods of analysis to be applied to the same nine transcribed interview transcripts. Findings revealed 1) some LMD interventions and participant opinions regarding LMD's role within the NHS workplace are more appreciated and supported in the literature then others 2) NHS LMD as a discourse and social practice is inherently vulnerable to manipulation and the agendas of others due to a range of influences and vested interests involved within the field 3) overall NHS LMD trainings are well liked and appreciated by participants. This thesis concludes with a series of recommendations, which can be summarised as 1) that increased integration, collaboration and closer working relationships between the NHS LMD training providers, the NHS LMD participant and the NHS workplace may enhance the LMD experience for all involved 2) the use of both IPA and CDA in exploring organisational and LMD related issues is a novel and informative approach, which should be encouraged to address a notable deficit of research approaches and practices within this field.

The Researcher has been employed as a manager in a private healthcare firm for many years. The advancement of technologies and abundance of social media platforms have led to innovative marketing methods for businesses in an era of continuous pressure to cut cost for long term sustainability. However, healthcare organisations still rely heavily on traditional and costly marketing methods for their businesses. The research seeks to investigate how private Healthcare Organisations are using social media and its platforms as marketing tools in the UK. The research objectives are: • To critically evaluate how organisations are utilising SM as marketing tools. • To critically examine the use of SM platforms as potential marketing tools across healthcare organisations. • To evaluate the effective use of Social Media as marketing tools in healthcare organisations. • To explore the challenges and barriers of using SM and its platforms as a potential marketing tool across healthcare organisations in the UK. • To make recommendations for formulating a Social Media Marketing Strategy that managers and marketers could use to market their organisations in the healthcare industry effectively. Through literature reviews and empirical methods; an extensive search was performed to establish and understand the main subject areas within healthcare marketing and social media. The research uncovered the gaps in the subject area to answer the research question and objectives. A conceptual framework was created using combined elements from the literature review: preferred SM platforms, effective use of SM and challenges and barriers need to be considered when using SM for Healthcare Organisations. By identifying the philosophical positions for the research objectives, the research design was developed and decided to use a combination of quantitative and qualitative methods to collect data. Having looked at the various methods to collect data, it was agreed that a case study strategy approach would be most suited to address the research objectives. The researcher uses a case study strategy and through Observation, and Semi-structured interviews to collect the research data. As a result of the findings, the recommendations that have been made are: 1) Use Linked In, Twitter and Facebook for SM marketing in healthcare organisations. 2) Determine resource needs, focus on 2 or 3 platforms if new to SM marketing. 3) Know their audiences and target them accordingly. 4) Design SM activities for long term strategies to include content strategy and frequency of post. 5) Determine and agree on company policy for content clearance. 6) Participate in and listen to customers' online conversation. 7) Encourage and use sponsor adverts to reach their target customers. 8) Encourage posts with a combination of texts and photographs. The combined results from the research methods are: Linked In, Twitter and Facebook are the most used and preferred platforms in Healthcare Organisations. The effective use of SM and its platforms are: share and communicate healthcare-related information, marketing, monitoring and creating brand awareness, recruitment activities, Building trust, customer relationship, viability, creating good brand identity, good images and communicate better with customers, interactive communication and monitor their competitors. The challenges and barriers identified for using SM marketing practices during this study were : Negative comments, Lack of knowledge and understanding, Budget/cost, Lack of focus, lack of time and resource, Lack of engagement, culture and age, personal preference, return on investment, Privacy, confidentiality and ethical and target. Finally, a new conceptual framework was developed to reflect the research findings. The research contributed to the development of UK based research and literature within the field of promoting the use of social media for marketing healthcare organisations. It would allow the marketing strategies for healthcare Organisations to be up-to-date, efficient and cost-effective; similar to the USA and other advanced nations.

Extant literature has called for contextual studies on performance management to maximise its effectiveness. Following this call is a study of performance management that considers the practice, its system and context. Scholar also presents that performance management researches conducted in less developed countries’ context loosely align their studies with a theoretical framework or use none within the study. This exploratory research study built upon Ferreira and Otley's (2009) framework as the theoretical underpinning to guide the research to address these problems and achieve its aim. This research aims to investigate performance management within the Nigerian public health sector. An interpretivist philosophy and abductive reasoning were the methodological choices employed while using a case study strategy. Data collected for this research include 40 semi-structured interviews and a document review across two Federal Hospitals in Nigeria. Thematic analysis was adopted to examine the data collected for this study using NVivo 11. The findings identified issues (such as union, godfather, organisational needs) that affect performance management. These issues elaborate the third level (contextual factors and culture) in Ferreira and Otley’s framework and pervade the organisational, sectoral and national level. Again, the findings also identified the informal activities (such as mentoring encouragement) used by managers in the study context. The findings further suggested that actors of performance management interpret the phenomenon as continuous and integrated and the practice within the context is at multi-level - departmental and organisational. The implication of the findings reinforces the significance of including the performance management practice, its system and context to fully again in-depth or insight into the contextual understanding of PM across different context. The originality of this study is the conceptualisation of performance management within the Nigeran Public Health Sector building upon Ferreira and Otley (2009). The contribution to knowledge includes the elaboration of the outer level in Ferreira and Otley’s framework with the identification of the v contextual factors challenging performance management within the Nigerian public health sector. The development of knowledge on performance management within the Nigerian public health sector is another contribution as there is a dearth in research studies. Again, the study contributes to the on-going debate by scholars on the relevance of understanding performance management within its context in order to maximise its effectiveness. The practical implication for hospitals managers is the awareness of the factors affecting performance management, which consequently will maximise its effectiveness within the Nigerian public health sector. Further studies on performance management should investigate and identify contextual factors and how these would affect its effectiveness within the different contexts.

The core aim of this study was to determine the factors that influence Emiratis’ choices for healthcare careers as well as propose viable initiatives through which the number of Emiratis pursuing healthcare careers can be increased. In this regard, the research sought to meet three research objectives: (i) to identify the factors that influence Emiratis’ choices for healthcare careers; (ii) to investigate the key challenges encountered by healthcare workers in the UAE; and (iii) to propose viable initiatives through which the number of Emiratis pursuing healthcare careers can be increased. The above-stated research aim was guided by the worrying low number of health workers, particularly doctors and nurses, of UAE origin (UAE nationals account for less than 10% and 20% of the country’s physicians and nurses workforce (Ibrahim et al., 2016; Informa, 2016). Besides the above identified research problem, there was a major literature gap concerning what generally impacts people’s choices for healthcare careers and more so in the Arab/Muslims setting. In particular, my interest to investigate what influences Emiratis career decision-making, specifically for healthcare professions, was in this thesis cultivated out of the conviction that the current theories of career choice are too broad and they are based on findings made in studies carried out in non-Islamic/Arabic religious and cultural settings such as the UAE. As a result, I considered their applicability in the UAE context questionable. For the set research objectives to be met, a qualitative research approach was used based on grounded theory principles. In this case, a sample of 36 respondents was purposefully selected, and it comprised of high school students, college medical and nursing students, nurses and doctors, healthcare administrators, as well as officials from the UAE Ministry of health and that of education. The intended data was primarily collected through in-depth interviews and it was analysed using the constant comparative data analysis method. In this case, the data collection and analysis exercises took place simultaneously. With respect to the aspect of factors that influence Emiratis’ choices for healthcare careers, an emergent theory of healthcare career choice was developed, which identifies and explains the several factors that influence Emiratis’ choices for healthcare careers. From the emergent theory, Emiratis’ choices for healthcare careers are influenced by numerous factors that fall under six substantive categories: parental and family influences, personal interest and passion, role models, gender, cultural, and religious factors. Nevertheless, personal interest and passion, as well as parental and family influences have the greatest impact on the Emiratis’ choices for healthcare careers. Low remuneration, lack of benefits (allowances and bonuses), high workload and long working hours, inadequate specialisation and training opportunities in the country, insufficient access to training, as well as poor organisational climate were also found to be the main challenges encountered by UAE healthcare workers. As a result, based on the findings and conclusions derived in this study concerning the challenges encountered by healthcare workers in the UAE, the emergent theory of factors influencing Emiratis’ choices for healthcare careers, as well as the recommendations made by the respondents, the current crisis of low number of healthcare workers of UAE origin may be solved through two main techniques. The techniques include: one, sensitising Emiratis about healthcare careers through outreach programs and any other initiative that can be effective in reaching out to the locals. The second technique may involve addressing the challenges facing the UAE healthcare sector, mainly the issues of poor remuneration, overworking, lack of training facilities, and poor working conditions. This thesis has three core contributions to the previously existing empirical and theoretical literature. The first and the main contribution of this study is that it has enriched the available literature concerning the factors influencing people's choices for careers, specifically in the healthcare context. The second core contribution of this study can be attributed to the research method or approach used in this study. As discussed later in this thesis, employing a grounded theory approach gave room for the introduction of new insights about the research topic since the researcher was open to new ideas based on the primary data collected from the field. The third contribution of this study is the development of a model or framework that clearly explains what influences Emiratis’ choices for healthcare careers and how. The model can be applied in other Arab-dominated countries such as in the Middle East, though there is a need for testing the theory developed in this study using a quantitative or a hybrid of quantitative and qualitative research approach as explained later in this study.

The Healthcare Quality Strategy for NHS Scotland, relates its overall vision of healthcare quality to six dimensions of care as: Safe, Efficient, Effective, Equitable, Timely and Patient Centred. Patient Centred Care also underpins many subsequent policies such as the management of Long Term Conditions (Scottish Government, 2008) and the Chief Medical Officers Realistic Medicine report (Barlow, et al., 2015) Leadership styles and associated policies and procedures are often assumed to inhibit or encourage the delivery of quality Patient Centred Care and the NHS invests millions of pounds per year in Leadership training. At a clinical team and management level there are behaviours and initiatives that can arguably have positive and negative impacts on the ability of individual practitioners to provide quality Patient Centred Care. However there have been no attempts to empirically test the association between (good) Leadership and quality Patient Centred Care. Without any evidence of such a relationship, NHS investment of substantial resources may be misguided. Additionally, much of the focus of research in both Leadership and Patient Centred Care has focused on medical practitioners and nurses. There is little research that focuses on the impact of allied health professionals' (a term describing 12 differing health care professional groups representing over 130,000 clinicians throughout the United Kingdom) practice on the quality of person centred care and how this is affected by Leadership structures and styles. This study aimed to explore whether there is a direct or indirect link between (transformational) Leadership and achieving the delivery of high quality Patient Centred Care (PCC) in allied health professional (AHP) practice. Aim The aim of this thesis was to explore whether it was possible to empirically demonstrate a relationship between Leadership (good or bad) and Patient Centred Care, and to do this in relation to Allied Health Professional practice. Research questions I. Is there a relationship between Transformational Leadership and Patient Centred Care in AHP practice? II. How do AHP’s conceptualise Leadership and its impact on their ability to deliver PCC? III. Do local contexts influence the ability of leaders to support Patient Centred Care? Study one Study one was designed to answer research question one: exploring the relationship between transformational Leadership and Patient Centred Care using survey design. Two groups of Allied Health Professionals were selected to take part in the study: Podiatrists and Dieticians. Clinical team leaders from across 12 Podiatry teams and 12 Dietetic teams completed a survey composed of measures of transformational Leadership and self-monitoring. Clinicians from these teams were also be asked to complete questionnaires on their perception of their clinical leaders’ transformational Leadership skills. This allowed comparison of self-assessed Leadership and team assessed Leadership. Clinicians were also asked to collect patient experience measures from 30 of their patients. Study Two Study Two was designed to answer research questions 2 and 3: how do AHPs conceptualise Leadership and how do they view the link between Leadership and their ability to deliver Patient Centred Care; and how might local context impact on professional Leadership and therefore its potential to enable or inhibit Patient Centred Care. In depth interviews were conducted with clinicians and clinical team leaders to explore the barriers and facilitators to effective Leadership, teamwork and the provision of quality care. Interviews were conducted with 21 Podiatrists and 12 Dieticians and analysed using a framework analysis approach. Results I. Is there a relationship between Patient Centred Care and transformational Leadership in AHP practice? The theory that there is a link between transformational Leadership and Patient Centred Care was confirmed. A significant relationship was discovered for the dietetics group linking Transformational Leadership with patient centred quality of care measures. There was also a relationship in the podiatry group that was suggestive of a relationship. II. How do AHP’s conceptualise Leadership and its impact on their ability to deliver PCC? AHP’s in both groups had broadly similar conceptualisations of Leadership and both groups played down the role of Leadership in the delivery of Patient Centred Care. A far more salient factor in achieving the delivery of high quality Patient Centred Care for the AHP’s interviewed was professional autonomy. III. Do local contexts influence the ability of leaders to support Patient Centred Care? A number of contextual issues related to both Patient Centred Care and Leadership were identified from the qualitative analysis. These were centred on systemic factors, relating to management and bureaucracy, and individual factors, such as relationships within teams. In Podiatry a major shift in the context of care was ongoing during the study, namely a greater emphasis on encouraging patients to self-care. This affected the relationships between patients and Podiatrists, and Podiatrists and managers, in a way that Podiatrists felt it negatively impacted on their ability to provide quality Patient Centred Care. Conclusion A weak relationship was observed between Transformational Leadership styles and the delivery of Patient Centred Care in two Allied Health Professional groups. Professional autonomy was identified as being more likely to facilitate delivery of person centred care. Organisational issues and intervening policy directives can impact on the delivery of Patient Centred Care, regardless of Leadership. Recommendations Further work exploring the link between Leadership and Patient Centred Care is required. The concept of professional autonomy should be fostered within Leadership programs to enhance delivery of Patient Centred Care. The impact of individual policies, such as moves towards more self-care, on quality criteria need to be more fully considered. Whilst such policies may make care more efficient, there may be negative consequences for other quality care criteria, such as Patient Centred Care.

Management of long term conditions is seen as one of the greatest challenges facing the English National Health Service currently (House of Commons Select Committee, 2014). One of the proposed solutions for this growing crisis is to support patients to manage their conditions themselves, thereby reducing hospital visits and lowering costs to the NHS overall (NHS England, 2013). Self-management necessarily involves the patient having some level of knowledge regarding their condition. In addition, there is a commitment within healthcare for patients to be involved in decision making regarding their healthcare needs with the mantra "no decision about me without me" (Department of Health, 2010) as well as development of the 'expert patient' agenda within healthcare (NHS Choices, 2014). In order for knowledge to be shared between health care professionals, patients and carers, knowledge boundaries must be managed within the process of knowledge sharing. This ethnographic study takes as it starting point, literature concerned with knowledge boundaries specifically, but highlights how current understanding of these boundaries is limited in some ways. In particular, issues of power and choice within the management of knowledge boundaries are inadequately explored within this body of literature which limits its applicability to contexts such as healthcare, in which power dynamics are endemic. In addition, the concepts of identity and expertise are implicated in issues of power and therefore this study seeks to explore the relationships between power, identity, expertise and knowledge in order to better understand the nature of knowledge boundaries and the dynamics of their management. This study found that issues of power were fundamentally implicated in knowledge sharing and the management of knowledge boundaries. Knowledge boundaries were found to be not only sites of struggle over knowledge, but also sites of struggle for control more generally. Whilst knowledge and power have long been associated, this study found that this relationship was complex and greater knowledge did not necessarily confer greater power on the social actor. Despite being evident in the rhetoric of healthcare, as a basis for power, expertise was redundant as more embedded social discourses remained prevalent. It is proposed that bases of social power are hierarchical in some respects as power based on one foundation can be rendered ineffective if faced with opposing power exerted by another social actor based on an alternative and more efficacious basis. This study emphasises the pervasive nature of embedded power dynamics within healthcare which concurrently facilitate conventional knowledge sharing processes and impede the development of new processes which would encourage the increased involvement of patients.

Background: International agencies such as the World Health Organisation have highlighted the potential of digital information and communications technologies to strengthen health systems, which are underpinned by the 'building blocks' of information, human resources, finances, commodities, leadership and governance, and service delivery. In high income countries, evidence of the positive impacts of 'eHealth' innovations on the cost-effectiveness of healthcare is growing and many governments are now providing incentives for their adoption. In contrast, the use of eHealth in developing countries has remained low and efforts to introduce these new approaches have experienced high failure rates. There is even scepticism regarding the feasibility of eHealth in low-resource settings, which may be hindered by high costs, indeterminate returns on investment, technical problems and socio-organisational barriers. More research is needed to document both the value of eHealth for strengthening resource-limited health systems and the challenges involved in their implementation and adoption, so that insights from such research may be used to inform future initiatives. While many studies of eHealth for patient care in low- and middle-income countries (LMIC) are taking place, evidence of its role in improving administrative processes such as financial management is lacking, despite the importance of 'good governance' (transparency and accountability) for ensuring strong and resilient health systems. The overall objective of this PhD was to elucidate the enablers, inhibitors and outcomes characterising the implementation and adoption of a modular eHealth system in a group of healthcare facilities in rural Malawi. The system included both clinical and billing modules. The specific objectives were (i) to understand the socio-technical, organisational and change management factors facilitating or hindering the implementation and adoption of the eHealth system, (ii) to assess the quality of data captured by the eHealth system compared with conventional paper-based records, and (iii) to understand how information within the eHealth system was used for service delivery, reporting and financial management. A further aim was to contribute to the corpus of mixed-methods case studies exploring eHealth system implementation processes and outcomes (including data quality) in LMIC. As described in the following chapters, the research also gave rise to unanticipated and serendipitous findings, which led to new lines of enquiry and influenced the theoretical perspectives from which the analysis drew.

Research in judgement and decision-making has identified numerous ways in which human decisions are likely to be biased, deviating systematically from the behaviour one would expect if humans were fully rational 'Econs', maximizing their utility with perfect self-control. Suboptimal decision-making as a result of these biases imposes large costs on individuals and society. In this thesis I investigate experimentally how decision-making can be improved, focusing on the health domain, where errors ultimately become a matter of life and death. Chapter 1: Providing feedback has been shown to be an effective way to change behaviour across several domains, including energy use and the workplace. However, there is little evidence on the effect of providing feedback in high stakes environments, where people make risky decisions with potentially catastrophic losses. In the first chapter I conduct a field experiment that provides feedback and information in such a context - emergency healthcare. Understanding the drivers of patients' decision-making relating to their demand for healthcare services and how they can be directed to the most appropriate services at any given time is a challenge for health systems across many countries. This trial aimed to reduce avoidable Emergency Department (A&E) attendances by sending a personal feedback letter to people who recently attended an Emergency Department but whose health concerns could have been dealt with elsewhere. Patients were randomly allocated to either receive a follow-up letter with information on alternatives to A&E or no letter (usual care). Overall, I do not find a statistically significant difference between the re-attendance rates of patients who did and did not receive the letters. However, the effect of the intervention interacted significantly with patient age, especially in men. I develop a conceptual framework that explores possible explanations for these heterogeneous effects. Chapter 2: Policy interventions drawing on insights from behavioural sciences are increasingly popular and have been successfully applied across a number of different policy areas. However, little attention has been paid to the extent to which the effects of repeated behavioural interventions are sustained over time. In the second chapter I study this question through a natural field experiment in the English National Health Service (NHS). The intervention consists of changing the salience of waiting time on the clinicians' e-Referral Service (ERS) interface. Waiting longer can negatively affect patients' health gains from receiving treatment, so referring patients to services with shorter waiting times can be of benefit. I find, through a stepped wedge trial, that putting a simple alert against services with high waiting times leads to a 35 percent reduction in the share of referrals to these services. The effect of the intervention is sustained over time and does not vary with prior referral habits. A small, low-cost intervention increasing the salience of waiting time to clinicians has a powerful and sustained effect on the choices of their patients. Chapter 3: Behavioural attitudes toward risk and time, as well as behavioural biases such as present bias, are thought to be important drivers of unhealthy lifestyle choices. While the first two chapters of this thesis take behavioural biases as given, the third chapter makes a first attempt at exploring the possibility of training the mind to alter these attitudes and biases, in particular relating to health-related behaviours, using a randomized controlled experiment. The intervention we consider is a well-known psychological technique called "mindfulness", which is believed to improve self-control and reduce stress. We conduct an experiment with 139 participants, around half of whom receive a four-week mindfulness training, while the other half are asked to watch a four-week series of historical documentaries. We find strong evidence that mindfulness training reduces perceived stress, but only weak evidence of its impact on behavioural traits and health-related behaviours. We do not see that engagement with mindfulness training is correlated with behavioural characteristics such as impulsiveness and impatience. Our findings have significant implications for a new domain of research on training the mind to alter behavioural traits and biases that play important roles in lifestyle.