General findings indicated practitioners were engaging in a variety of learning as advocated by their regulatory body, and thus meeting their professional and organisational responsibilities. Further investigation presents a tale of contrasts:from the positive experiences of learning which are driven by a commitment to delivering high standards of patient care, to the negative experiences with regards to participation and provision. Participation was hampered by a range of structural and organisational barriers, some of which were identified as being unique to this group. Providing a 'snap-shot' of learning within the NHS at a time of challenge and financial constraints the research questions the underpinning philosophy of lifelong learning policy in promoting inclusivity and prosperity and exposes deficiencies within organisational policy.

Across many countries worldwide, support for patient and public involvement (PPI) in health care has grown significantly over the last two decades. Calls to democratize the health care system have resulted in a system where patients are increasingly involved in the design of medical research and members of the public have been called upon to help make decisions concerning various elements of national, regional, and local health care policy. In some countries, like the UK, laws on the books now mandate that health care institutions meet certain benchmarks in PPI in order to be eligible for national funding. Though many scholars have sought to understand how society can make PPI efforts more "effective," they have largely neglected to provide an overarching justification for involvement in the first place. This thesis seeks to understand whether such a justification exists. I examine two sets of arguments in support of PPI: one that maintains PPI simply improves the quality, relevance, or effectiveness of medical research and health care provision (the outcomes-based argument) and one that appeals to notions of democratic legitimacy and representation. I argue that the outcome-centered argument wrongly presupposes an agreement on which outcomes should be prioritized while the democratic legitimacy argument fails to adequately identify the relationship between PPI and greater transparency, accountability, or reasonability. Since supporters of PPI often use the framework of deliberative democracy as support for the democratic legitimacy argument, I use it as well as a starting point for analysis. In short, though PPI may appeal to certain democratic intuitions, there is little reason to think that in practice it has strengthened bonds of democratic legitimacy. I conclude by suggesting ways in which those core democratic virtues might be strengthened outside the realm of PPI. Despite increased patient involvement, the processes of resource allocation (rationing) in health care remain opaque in many countries. In addition, there exist few mechanisms for individual appeal of an unjust decision, a feature that most deliberative democrats consider essential to a just system of resource allocation. Ultimately, I contend that a greater focus on the processes that facilitate transparency and accountability will better serve citizens and their health care systems.

Introduction and aims A core outcome set (COS) is defined as an agreed standardised set of outcomes that should be measured and reported, as a minimum, in all clinical trials in specific areas of health or health care. Their use allows research to be compared and combined as appropriate, and may ensure that all studies provide usable information. There is currently no accepted gold standard method for COS development and further work was necessary to explore choices about methods, and what the priorities are for guidance and further research in this area. This thesis aimed to investigate what is currently known about COS development, and explore developers’ experiences of developing COS. Methods A systematic review of studies reporting the development of a COS was undertaken, and the methodological techniques used in these studies was described. A mixed methods approach was undertaken to explore COS development, drawing on qualitative interviews with, and an online web-based survey of, COS developers. This thesis used a Triangulation Design to obtain different but complementary data on the same topic for comprehensiveness. Results The systematic review identified 198 published studies that described the development of COS for clinical trials. The systematic review demonstrated variability in the ways that COS had been developed, particularly the methods used and the stakeholders included as participants in the process. Patient participants had infrequently been included in the development of COS (18%). Key aspects of the process were frequently not reported. Eighty-one (48%) developers completed the survey. The majority of survey respondents (73%) felt that there is a need for methodological guidance or research to inform future activity to develop COS. Areas for future guidance or research included: stakeholder involvement, patient involvement in particular; choice of methodology, and consensus formation. 32 interviews were conducted with COS developers (18 with published, and 14 with ongoing, COS projects). Developers found the process of COS development to be a challenging process, in part due to the nature of COS development being an emerging field of research, but also in part to not always considering important methodological details from the outset, for example their choice of methods and stakeholders. There was a variety of influences on developers’ choice of methods, which included the previous literature on COS development, expert advice, developers’ own experience with methods and the resources available to developers. The absence of guidance in COS development, and the prominence of uncertainties, dominated developers’ accounts. Conclusions The work in this thesis has brought COS together in one place for the first time, summarises key characteristics of COS and their development, and provides the first comprehensive account of COS development. It will inform the development of much needed guidance in this area and help to improve COS development methodology. Guidance needs to determine commonalities across different disease areas, and promote awareness of important issues; encourage COS developers to think about their own contexts and circumstances, and enable COS developers to make decisions about methods that best suit their needs and resources. Guidance seems to be needed for all aspects of COS development, but it was particularly felt that guidance around the systematic review process, conduct of Delphi, and conduct of consensus meetings, are high priority.

Background: In the United States inpatient generalist social workers in discharge planning roles work alongside specialist palliative care social workers to care for patients. As a result two social workers may concurrently be involved in the same patient’s care. Previous studies identifying components of effective collaboration, which impacts patient outcomes, care efficiency, professional job satisfaction, and healthcare costs, were conducted with nurses and physicians. The components of effective collaboration for generalist social workers’ interactions with specialist palliative care social workers are unknown. Aim: To explore inpatient generalist social workers’ views of what facilitates or hinders collaboration with specialist palliative care social workers. Methods: Using a grounded theory approach, qualitative interviews with inpatient generalist social workers (n=14) were systematically analysed to develop a theoretical model of generalist social workers’ collaboration with specialist palliative care social workers. Results: The emerging theoretical model of collaboration consists of: 1) trust, which is comprised of a) ability, b) benevolence, and c) integrity, 2) information sharing, and 3) role negotiation. Effective collaboration occurs when all pieces of the model are present. Collaboration is facilitated when generalists’ perceptions of trust are high, pertinent information is communicated in a time-sensitive manner, and a flexible approach to roles is taken. Conclusion: Trust is increased when generalist social workers’ perceive the specialist palliative care social worker has the necessary skills to identify and address patient needs, manage interactions with the multidisciplinary healthcare team, support the generalists’ roles, and adheres to social work professional values. Opportunities for formal and informal communication boost collaboration, along with regular access to the specialist palliative care social worker. At the organisational level effective collaboration is hindered by a lack of clarity regarding roles. Research about specialist palliative care social workers’ perceptions of what facilitates or hinders collaboration with generalist social workers is needed.

This thesis concerns the linking together of the currently distinct teclmiques of pharmacokinetic-pharmacodynamic and health economic modelling. These have limitations, with economic models being empirical and thus hard to extrapolate outside the evidence base where they are constructed, and challenging to implement early in the drug development process. Pharmacokinetic-pharmacodynamic models, by contrast, are mechanistic but produce a limited range of outputs, not generating all the values useful to infonn decision making. Pharmacokinetic-pharmacodynamic-pharmacoeconomic models, by linking these approaches, have the potential to overcome these limitations. The feasibility, validity and applicability of such an approach are assessed through two case studies. The first contains both retrospective and prospective simulations ofrituximab for the treatment of follicular lymphoma. Retrospective analyses allow simulated results to be compared with trial-based data, and show an acceptable degree of concordance between the two methods. The prospective simulation of a trial currently recruiting will enable comparisons with the results of the trial, when these become available. The second and larger case study uses anticoagulation and stroke prophylaxis for patients with atrial fibrillation as an example. The end result is a full, prospective simulation of genotype dosed warfarin compared with both standard clinical dosing and a number of newly available oral anticoagulants. To make such an analysis possible, necessary prerequisite work was undertaken with the construction of a discrete event simulation to extrapolate both trial and simulation results to a lifetime horizon and an indirect comparison of all available treatments, to ensure all possible alternatives are considered in the analysis.

This research investigates stakeholders’ knowledge of, and experience in, public health commissioning of alcohol services in North East England. Public health commissioning has undergone significant transformation during the course of this research. However, health policies and legislation have consistently supported the concept of stakeholder involvement in all stages of the commissioning process. Alcohol is an issue that spans health and wider public health services. On a global level alcohol is the fifth leading cause of morbidity and premature death and is causally linked to over 60 diseases. The growing recognition of both the harmful effects of excessive alcohol consumption, and the rising associated costs have made it a major public health priority in recent years, both internationally and within the UK. The North East has one of the highest prevalence rates for excessive drinking and alcohol related health inequalities. A qualitative case study approach was adopted, focussing on the commissioning of alcohol services in a specific local area. Semi structured interviews and focus groups were used to obtain the perspectives of commissioners, alcohol service providers, general practitioners and alcohol service users. Collectively, all study participants were stakeholders in the commissioning process. However, understanding about what constituted stakeholder involvement was not consistent among participants and often definitions were limited to public and patient consultation. Stakeholder participation was often viewed as an end point rather than a process, the implication being that ‘any involvement was good involvement’. Furthermore, participatory approaches did little to ensure that stakeholder involvement actually influenced planning and decision making. Arnstein’s Ladder of participation was used to examine the extent of stakeholder involvement and a revised ladder is proposed. For many stakeholders, contribution to commissioning decisions seemed to occur at a tokenistic level, resulting in minimal motivation for at least some stakeholders to become involved in the commissioning process.

Disease outbreaks are a constant threat to public health and so effective management of these outbreaks is vital. By using statistical methods, we can better understand how a disease is affecting populations and monitor the progression of diseases over time. This thesis applies and develops statistical methods to studies of vaccine-preventable disease outbreaks in Scotland and aims to aid in the detection and management of outbreaks. For detecting outbreaks, a system was designed for Health Protection Scotland (HPS) to link cases with incomplete genetic typing data to other cases to form potential clusters that may be worthy of further investigation. A novel inuenza strain spread worldwide in 2009 and this work helps in the understanding and monitoring of that outbreak. A key parameter is the reproductive number and this was monitored for pandemic influenza using routinely collected data. Then postcode data was added to develop a spatial model for estimating the rate of spread. For vaccine-preventable diseases, the primary intervention strategy is vaccination but their effectiveness must be assessed. Vaccine effectiveness (VE) was assessed against various clinical outcomes which were associated with influenza to differing extents. Additionally, different methods were employed, including attempts to correct for biases. The main findings of this work have important implications. The system to identify linked TB cases helps to ensure more links between cases are found, preventing further disease spread. The spatial method for estimating reproductive numbers offers improved parameter estimates. The VE study found that estimates differ more by the outcomes it was measured against than by the methods employed. Moreover, estimates found using outcomes with low specificity for influenza can be unreliable. Therefore, the recommendation for future studies is to focus on using outcomes with higher specificity for influenza.

This study explores socio-geographical processes influencing health and wellbeing in deprived Maltese neighbourhoods, contributing new knowledge on how these compare with those reported in research on Anglo-American cultures. This qualitative research obtained data from three deprived neighbourhoods in Malta through in-depth interviews with 31 mothers (of diverse marital status) and their children. Some of these families were followed across a period of time thus obtaining longitudinal data. The research employed a grounded theory approach, and constant comparative approach was used to explore how social processes differed across neighbourhoods. Familial and neighbourhood ties, networks and other aspects of social capital emerge as highly significant, and often beneficial for health and wellbeing. However, divisive processes in these social networks also had negative impacts, less often reported in other research. This thesis emphasises that there is a strong connection between material neighbourhood factors and social relations, as the physical built environment, housing conditions, service provision, welfare benefits, and employment opportunities influence social processes and impact on health and wellbeing in diverse ways. The history of the place, as well as individual life histories, together with a cross-generational and longitudinal approach the significance of the ‘time’ dimension, thus contributing to the complexities of health and wellbeing in neighbourhoods. This study adds to literature on social determinants of health operating in a Maltese, Mediterranean context. It emphasises that there are traditional norms that still determine the health and wellbeing of inhabitants in their neighbourhoods, however, social and economic changes are also transforming these neighbourhoods. It further reveals how individual agency interacts with the social and material environment to affect wellbeing outcomes, albeit within limits on individuals’ power and resources. The findings therefore highlight the importance of a relational approach in order to understand the connection between people, place and health.

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Peoples' participation and empowerment are widely considered as key elements if not pre-requisites for successful and sustainable health development outcomes. To date there is no conclusive and widely accepted definition of participation and no standard tools for its assessment. What does people's participation in health development mean to the stakeholders from the community to the national and international level? Can it be assessed? What is the effectiveness in terms of health development? and what are the factors that can influence the outcomes of a participatory process? An answer to these questions is sought in the case study from the Community Based Nutrition Programme in Kenya. Using a mixed methods design and innovative tools developed and tested in a pilot community, this field study tries to answer these questions. There is no conclusive and congruent definition of participation to be drawn either from the literature or from the field research. The health impact and process can be measured in qualitative and quantitative terms. However, firm inferences on the effect of health outcomes could not be drawn due to a "non-fit" in the two tested communities. Social cohesion leading to community homogeneity, and the role of gatekeepers in both, horizontal and vertical structures, are the factors that appear to mostly influencing health development outcomes. Health managers when planning interventions in any given community need to acquire in depth knowledge of all participating stakeholders, including diversities within and between them, and adopt democratic processes at all stages. 11 The analytical framework used in this study could stimulate further development of effective tools and methods for assessing participation, thereby contributing to the current policy dialogue on health development and poverty reduction. The results will therefore be disseminated to relevant stakeholders at national and international levels, as well as to the academic and donor community.