PhD Project

Many healthcare service delivery improvements are unsuccessful, yet there is an incomplete understanding of why many improvement initiatives fail. Despite a complex healthcare context, traditional biomedical paradigm approaches to improve healthcare persist; focusing on if interventions work rather than how and why. The influence of patients on the adoption, implementation and assimilation process is also often neglected. This thesis is based on introduction of a new mobile service, delivering osteoporosis services to remote, rural and island communities in Scotland. Similar services had been introduced elsewhere in the UK with variable success.

This study aimed to develop an empirical ‘real time’ integrated study of this complex, emerging cross boundary service to understand if, how and why mobile bone density scanning services work. A comparative case study design examined the adoption, implementation and assimilation of mobile DXA services across diverse contexts in the UK; three ‘real-time’ and three retrospective cases studies. An individual programme ‘theory’ was developed and tested, and evidence used to inform ongoing service development in ‘real-time’ cases. Mixed quantitative and qualitative methods were employed, alongside an action research informed dual implementer/evaluator role in real-time cases.

Findings suggest mobile DXA services offer an effective service delivery model. A complex interplay of contextual factors at multiple levels determined success adoption, implementation and assimilation of services. Place mattered; the ‘right kind of rurality’, policy and organisational context. People and effort mattered in terms of leadership, networks, individual and team capabilities and learning relationships and impact of improvement on professional working practices. A complex interplay between clinician and patient ‘mindlines’ contributed to a collective, iteratively developed ‘knowledge in practice.’ Patients were not simply passive recipients of services, but instead they made informed decisions based on their own set of ‘mindlines.’

Findings have also affirmed and extended existing conceptual frameworks and theory on service implementation as well as conceptualisations of the role of context in healthcare service delivery. It has also revealed the value of upskilling clinicians in health services research methodology.

Impact: Results from this study have been used to support mobile DXA service sustainability longer term within Scotland and work is ongoing to apply contemporaneous ‘real- time’ evaluation of healthcare service development to a range of other complex, common services.

Supervision: Professor Lorna McKee, Dr Alison Black and Professor David Reid


Rosemary Hollick;




Hollick, RJ, Black, AJ, McKee, L & Reid, DM.  A mobile DXA scanning service for an island community: Addressing geographical inequalities in access to care. Osteoporos Int (2014): 25 (Suppl 6): S694-695

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