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The aim of this thesis was to progress our understanding of clavicle nonunion and the ability to accurately predict fracture healing in order to improve the current management of these injuries. Although only one in seven fractures go onto nonunion, these are challenging to predict. It is unclear if the recent widespread increase in the use of acute plate fixation for displaced fractures is justified on current evidence. It is unknown whether the early accurate prediction of fractures at high risk of nonunion is advantageous. Currently the perceived risk of nonunion is largely based on factors available at time of injury alone. The evaluation of clinical recovery following non-operative management and the novel use of ultrasound may advance our ability to accurately predict fracture healing for these injuries. The cost-effectiveness of acute clavicle plate fixation versus non-operative treatment was estimated from randomized controlled trial data that had been previously published. This was completed prior to the start of this thesis and the author was not involved in the original trial. A large retrospective review of clavicle fracture fixations was undertaken to determine whether delayed clavicle fixation has an increased risk of complications compared to acute operative management. A prospective study of displaced midshaft fractures was carried out over a two-year period to determine the influence of functional recovery on the ability to predict fracture healing. The influence of clavicle fracture management on the early functional recovery was evaluated with data from a randomized controlled trial and second prospective cohort. Finally, the novel use of ultrasound to detect early callus formation and determine whether this allows accurate prediction of fracture healing was evaluated for a cohort of clavicle and tibia fractures. The estimated cost per quality-of-life adjusted year of acute plate fixation over non-operative treatment is £480,309.41/QALY. For a threshold of £20,000/QALY the benefit of acute fixation would need to be present for 24 years to be cost-effective over conservative treatment. Linear regression analysis identified nonunion as the only factor to negatively influence the SF-6D at 12-months (p<0.001). A ten-year cohort of 259 clavicle plate fixations found failed primary surgery requiring revision fixation occurred in 7.7% of all patients. Smoking (p<0.001), presence of a post-operative infection (<0.001), increasing age (p=0.018), and greater time delay from injury to surgery (p=0.015) was identified as significant independent predictors on regression analysis. Receiver operating curve analysis (ROC) revealed that surgery beyond 96 days from injury has an increased rate of major complications and revision surgery. Using a matched case cohort of cases before (n=67) and after the 'safe window' (n=77), the risk of post-operative infection increased (Odds ratio (OR) 7.7, p=0.028), fixation failure (OR 3.8, p=0.017) and revision surgery (OR 4.8 p=0.004). A delay to operative fixation beyond 3 months following injury would appear to be associated with an increased risk of major operative complications and revision surgery. A large prospective cohort of 200 patients managed non-operatively with a displaced midshaft clavicle fracture were recruited. Regression modelling found a QuickDASH ≥40 (p=0.001), no callus on radiograph (p=0.004) and fracture movement on examination (p=0.001) were significant predictors of nonunion. If none were present the predicted nonunion risk was 3%, found in 40% of the cohort. Conversely if two or more of the predictors were present, found in 23.5% of the cohort, the predicted nonunion risk was 60%. The delayed assessment nonunion model appeared to have superior accuracy when compared to the estimation of nonunion at time of injury alone healing on ROC curve analysis (Area Under Curve analysis; 87.3% vs 64.8% respectively). Data from a randomized controlled trial was used to compare 86 patients who underwent operative fixation against 76 patients that united with non-operative treatment. The recovery of normal shoulder function, as defined by a DASH score within the predicted 95% confidence interval for each respective patient was similar between each group at six-weeks (operative 26.7% vs non-operative 25.0%, p=0.80), three-months (52.3% vs 44.2%, p=0.77) and six-months post-injury (86.0% vs 90.8%, p=0.35). The mean DASH score and return to work was also comparable at each time point. Regression analysis found no specific patient, injury or fracture predictor was associated with an early return of function following non-operative management at six or twelve weeks. From a pilot study of twenty clavicle fractures, six-week sonographic bridging callus appeared to be the most accurate, and repeatable, predictor of fracture healing with a strong agreement on intra class correlation (ICC) between four reviewers (ICC 0.82, 95% confidence interval 0.68-0.91). In a large prospective study of 112 patients, sonographic bridging callus was detected in 62.5% (n=70/112) of the cohort at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n=69/70). If absent, nonunion developed in 40.5% of cases (n=17/42). The sensitivity to predict union with sonographic bridging callus at six weeks was 73.4% and the specificity was 94.4%. Three-dimensional fracture reconstruction can be created using multiple ultrasound images in order to evaluate the presence of bridging callus. This imaging modality has the potential to enhance the usability and accuracy of identification of fracture healing at an early stage following injury. Nonunion following a displaced midshaft clavicle fractures accounts for the majority of poor functional recovery and impaired quality of life over the first-year post-injury. Prediction of clavicle fracture healing at six weeks following injury maybe a safe and effective strategy to identify patients at greatest risk of nonunion. The use of functional recovery enables a more accurate estimation of nonunion risk compared to conventional prediction at time of injury alone. The use of ultrasound may further refine our ability to predict fracture healing.

When Tony Blair's New Labour administration took control in 1997, it sought to establish a programme of organizational, performance, and democratic reform. Initially badged as the modernizing government programme, it was later developed in the Best Value regime for local government, which imposed a centrally-controlled performance regime on all local authorities. This was characterized by a managerialist regime of external inspections, league tables, and reliance on extensive performance management, overseen by the Audit Commission. One of the first acts of the 2010 Coalition government was to dismantle this regime, along with announcing the abolition of the Audit Commission. This research sought to examine the legacy of the 1997-2010 performance regime on six English local authority case studies, identified via a deviant case analysis. An examination of the literature developed a conceptual model of seven dimensions of reform, and the research used an exploratory approach to examine the legacy of the performance regimes through a range of qualitative interviews and focus groups. The inductive analysis of interview data found that financial austerity dominated the local government environment, and the impacts of these cuts were felt across the entire group of case studies. These savings requirements had effectively broken the expectation of continuous improvement explicit in the Best Value duty what we refer to here as the death of improvement . Authorities were reducing staffing, which resulted in the loss of expertise and skills. They were also scaling back many universal services through managed decline , and deregulation of performance regimes was stimulating divergent responses to performance management arrangements, as well as influencing the relationship between politicians and performance management, and central performance staff and departmental staff. There were challenges raised around the residual inspections, largely restricted to social care and education, and how these interacted with central performance team models. The discussion develops a three-part model of performance as a system of governance , which integrates three key areas of theoretical and empirical development: performance management frameworks, accountability, and value for money. This allows four main contributions to knowledge: The concept of public value for money , Further development of our understanding of multiple forms of accountability A new model of performance management zones that articulates different roles for performance management at points within the organization A categorisation of the main changes in reform paradigms It concludes that understanding the values underpinning public sector reforms through a range of interpretive lenses is essential to fully comprehending the impact of reforms at three levels: conceptualization, operationalization, and implementation. The legacy of Comprehensive Performance Assessment and Comprehensive Area Assessment can be seen in the increased capacity and capability of local authorities to engage with performance management, and data and evidence-driven policy making. Yet, these capabilities may not have prepared authorities sufficiently for the demands of significant budget cuts driven by the post-2010 political environment.

This thesis empirically investigates how well the Nigerian National Petroleum Corporation (NNPC) ensures value for money (VfM) in its exploitation of Nigeria’s oil resources. This focus on VfM distinguishes the study from other researches carried out on the performance of national oil companies (NOCs) where the common approach in the literature has been to assess performance using the metrics applicable to private oil companies. The rationale for the new approach is that the NNPC is a quasi-public sector organisation and thus its performance should be measured in the same way as that of public sector bodies and state owned enterprises (SOEs). Informed opinions on NNPC’s management roles in Nigeria’s oil and gas upstream sector were sought from a range of relevant experts in twelve stakeholder groups involved in oil and gas upstream operations. Data were collected through the use of questionnaire and interview surveys, and further subjected to statistical analysis to determine and assess significant differences in views between respondent groups. The empirical results obtained from the questionnaires were used to draw a conclusion on the hypotheses formulated for the study. Furthermore, the findings of the interview survey were used to validate the conclusions drawn. The study revealed that the NNPC was perceived to be deficient in keeping its mandate of adding value to Nigeria’s hydrocarbon resources. In specific terms, the respondents were of the view that NNPC has not been able to ensure VfM in its operations because of defects in its organisational structure, administrative system, and accountability. External factors such as political interference, instability and an inappropriate legal framework against which NNPC operates have also been perceived to impede the corporation’s performance. The main conclusions were: firstly, it is argued that the use of conventional private sector metrics to evaluate the performance of NOCs makes it difficult to form an appropriate view on their performance. Secondly, NOCs with numerous conflicting roles as is the case with NNPC are unlikely to achieve satisfactory performance. Thirdly, the NNPC lacks the capability required to ensure multinational oil companies’ (MOC) conformity with operational provisions and best practice. Finally, the thesis concludes that establishing a standardised performance/benchmarking framework is an essential requirement to ensure value addition, VfM and accountability in Nigeria’s oil and gas operations.

The process of determining outputs and outcomes plays a key role in the setting of global targets, in defining national sector policy and strategic plans and in ensuring a continuous, safe supply of affordable water. Each of these actions, are integrally linked by aggregated data sets generated through an effective monitoring and evaluation (M&E) process. This thesis examines the various components of M&E across three case studies: Global, Kenya and Uganda, including aspects such as whether roles and responsibilities are realistically assigned and whether there is a recurring set of core indicators being monitored and reported. The research has also sought to establish an evidence base of the associated costs and efficacy of use of M&E. Through purposive and snowball sampling, fieldwork was undertaken across the case studies with 85 key stakeholders. Programme, national and global level data sets were collected through structured literature reviews, document and data archive reviews, key informant and semi-structured interviews. Qualitative and quantitative data analysis methods were applied. The results demonstrate that despite having a recurring global goal and associated target, the number and variety of indicators reported against has grown over time and at each level. In turn this is placing a burden on already resource constrained countries. Regardless of the various principles of harmonization and alignment, countries are still required to manage internally and externally driven parallel systems. Whilst the research suggests the costs of M&E are escalating, the full extent of this increase remains unknown as does the extent of efficacy of use of M&E. Despite evidence that country-led M&E processes are at some level achieving their objectives, with the continuing complexities of the sector particularly around the accompanying aid architecture, M&E is not currently ‘fit for purpose’ for use in the WASH sector and is unlikely to be providing value for money.

Value can be defined as quality in relation to cost. The relationship between these two dimensions, in the context of a building's design, has to be properly understood if building owners (clients) are to be confident of achieving value for money in the outcome. This thesis proposes a cost-quality modelling technique that evaluates the cost and quality dimensions of early design options, enabling the relationship between them to be explored. The research has revealed problems associated with current practice in terms of early cost advice and the modelling techniques used for providing that advice. Inadequate consideration of the quality dimension was highlighted as a significant cause, due to its perceived elusiveness and complexity. The findings of the research, however, suggest that quality is amenable to a systematic treatment with respect to its representation and measurement. Results of a survey revealed that quality parameters, which are meaningful and necessary for early design generation and evaluation, are not as diverse as first believed. The results also revealed that quality can be examined and expressed in terms of its key contributing parameters. These findings, amongst others, have provided the basis for the development of a framework for quality benchmarks. A cost-quality modelling technique is proposed, based on the integration of the framework for quality benchmarks, a multi-criteria decision-making technique, and graphical and statistical methods. The proposed modelling technique has been applied to example building projects in order to test its sufficiency. Results show that the technique is able to guide the client and design team towards an improved solution in terms of cost and quality.

This research project provides novel tools and applications of techniques to better understand and utilize Construction Manager-at-Risk (CMR) project delivery in the context of public university capital projects by evaluating CMR project delivery in comparison to Design-Bid-Build (DBB) project delivery to understand and quantify the value of owner-driven scope growth in achieving critical success factors. Machine learning algorithms were used to support construction research and analysis, modeling cost and schedule growth using a sample of 37 CMR and 74 DBB projects, and accurately imputing missing data values in a sample of 67 CMR and 99 DBB projects. In-depth analysis of design and preconstruction services contracts illustrates the importance of synchronizing contractual language governing the duties, responsibilities, and obligations of collaboration and cooperation between the designer and general contractor. Analysis of project performance metrics demonstrated that traditional cost and schedule growth metrics may not accurately describe CMR projects in this market segment and a novel metric to evaluate design fee efficiency in developing scope changes was developed to assess the quality of project team integration. Results were validated by data envelopment which included a survey of public university capital projects staff, a content analysis of 44 CMR procurement documents not previously included in the research, and case studies of three database projects which appeared to have performed poorly but were considered as successful projects to their owners and end users. Finally, a method of quantifying the value for money from using CMR over DBB is proposed that accounts for collaborative behavior and improved relationships within the project team. Four best practices synthesized from the research project are proposed as techniques to allow public university owners to maximize the potential benefits of CMR project delivery.

This thesis investigates the accounting and other practices performed as part of trials experienced by interested actors in forming a Public Private Partnership (PPP) scheme. Prompted by the high visibility of PPP schemes and a lack of understanding about the situated roles and effects of accounting and other practices in motivating and appraising such schemes, two practice-oriented research problems are investigated. Firstly, how does an ambition for a PPP scheme form in particular times and places. Secondly, what is the agency of accounting and other appraisal processes in trialling a proposed PPP scheme. Following an introductory section, this thesis proceeds via three papers. The first paper reviews the extant accounting-related literature on PPP schemes along five research themes adapted from Broadbent & Laughlin (1999, 2004), highlighting the literary contributions and future research opportunities in this area. The second and third papers focus on the experiences of interested actors in trialling possibilities for a public housing PPP in the Australian state of New South Wales (NSW), using field-based research. The aim of the second paper is to understand how an ambition for a PPP can become accepted through efforts to ‘envisage value’ for such schemes in particular times and places. The third paper investigates the roles and effects of accounting and other appraisal practices mobilised to translate an ambition for a PPP scheme into an agreement that promises a ‘Value for Money’ (VFM) outcome. Collectively, these papers contribute to extant knowledge about the involvement of accounting and other practices in the performance of ‘value’ in PPP schemes by: (i) illustrating how an ambition for a PPP scheme forms through ‘envisaging value’ (ii) explicating the agency of accounting and other practices in conferring VFM with situated meaning; (iii) contradicting the dominant status attributed to the involvement of accounting calculations in PPP schemes; and (iv) highlighting the various ways in which interested actors can cope with and act in the face of significant uncertainties. Overall, these contributions further our understanding of how proposed PPP schemes are (per)formed through the complex of activities (including accounting) and interests tied to the achievement of such schemes.