The concept of best interests lies at the core of my work. 'Best interests' underpins all healthcare decision-making whether orientated to treatment of an individual or which impact on a community. My publications explore the respect accorded to an individual's view of his own best interests in healthcare decision-making, both for contemporary and future decisions and how this may conflict with patient welfare, objectively perceived. They also consider the weight given to different perspectives of those involved in deciding what treatment option is 'best' for a patient lacking capacity and whose view predominates when there is conflict. I have also written on the tension between individual best interests and the wider interests of society. My publications have increasingly moved from describing the meaning and application of 'best interests', particularly with reference to the Mental Capacity Act 2005 (MCA), to focusing on how the legal provisions may be interpreted in practice - a translational approach. I have also explored the role of medical education in equipping doctors of tomorrow to make informed decisions about best interests and how clinical ethics committees may elucidate the meaning, and ensure the proper analysis, of best interests in a process for resolving conflicts in healthcare decision- making. The importance of the assessment of best interests in healthcare decision-making cannot be overstated. Failure to acknowledge and give respect to the views of competent patients or the parents of young children may result in loss of trust in healthcare professionals and disengagement with services. Giving due regard to the values and wishes of adult patients who lack capacity is fundamental to protect and promote the interests of the most vulnerable members of society. However, the mere mantra of 'best interests' belies the complexity of the assessment and its application in practice. Clinicians, parents, family members and the patient himself may have differing interpretations of best interests. The weight given to these perspectives may depend not only on the level of evidence required to adduce these views but also on how far they move away from promoting the basic interests of the patient, such as dignity, freedom from pain and suffering, and life itself. My thinking on this topic has developed through my research and writing, particularly through the qualitative research I have undertaken, and I now come to the view that best interests imposes a normative standard which is interpreted through the subjective lens of the various stakeholders in the decision making process, as Atkins notes, "the problem of trying to capture something unique using tools proper to the general" (Atkins, 2000 p 73). My approach to best interests in healthcare decision-making derives from a wide range of professional experience. After training as a solicitor I took an LLM in law and nearly 20 years ago 3 started teaching at Kingston University on a fractional appointment. I developed an interest in medical law and ethics, and following an MA in Medical Law and Ethics I taught this subject to final year law students at Kingston. Thus my initial emphasis was on the interpretation and development of best interests in case law and statute. My work with The Ethox Centre, University of Oxford focusing on clinical ethics support, enabled me to gain insight in to the role of clinical ethics COmmittees as part of the process of decision-making and as a member of three clinical ethics COmmittees I am able to observe the range of different clinical settings which give rise to challenging issues in best interests. More recently I have been involved with the Institute of Medical Ethics Education Project in developing the core medical undergraduate curriculum in medical ethics and law. If medical students are not confident about their knowledge of key medico-legal and ethical issues then as young doctors they will not feel able to challenge poor practice or promote better patient care "through using legal rules and an understanding of how law relates to and underpins good medical practice" (Preston - Shoot, 2011, P 6). I also teach medical law and ethics at the School of Medicine, King's College London and this gives me first-hand experience of the way both medical students and clinicians approach the tension between respecting patient autonomy and the duty to 'benefit' the patient. Through my qualitative research focusing on practitioners' interpretations of best interests my recent publications on adolescent decision-making (2009) and clinical ethics committees (2010) set the legal analysis in the context of the practice of medicine and methods of resolving divergence in decision-making.

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This is an exploratory case study evaluating the process of TQM implementation in the 23 TQM demonstration sites in the NHS. These sites were set up in 1989 by the Department of Health as centres of excellence for the implementation of TQM. An earlier study' evaluating TQM in the NHS failed to adequately contextualise the reasons for the argument that orthodox TQM has failed in the NHS. Against this background, it became necessary to carry out an extensive reassessment of TQM initiatives in the NHS. The central thrust of the study involves the identification of: i.the differing modes of implementation of TQM across the sites; ii.the difficulties managers were encountering in the implementation of TQM - barriers to the implementation of TQM; iii.the critical key success factors for the successful implementation of TQM in theNHS; and, iv.based on empirical evidence seeks to determine whether a specific model of TQM is required in the NHS. As Francis Bacon noted, 'if anyone wants to understand nature, he has to study nature rather than base their understanding on Aristotle's postulations of nature. This is because Aristotle did not understand nature, his ideas about nature were not empirically determined'2 Hence, to gain a conceptual understanding of TQM, it is necessary to understand 'implementation' and not base understanding on the outmoded ideas of the Gurus, whose philosophies are not grounded in empirical data. Thus, the TQM literature is inundated with TQM models that are based on anecdotal evidence and the personal prescriptions of TQM writers'. This situation has led to a call by a number of writers' for an empirically determined implementation model for TQM; particularly in the healthcare setting. To determine whether such a model is required in the NHS, this exploratory study used a unique combination of qualitative and quantitative data to sample 23 Quality Managers at the 23 TQM sites in order to provide an accurate rendition of the TQM process in the NHS. The study makes a valid contribution to the quality literature, by contending that TQM has not failed in the NHS as earlier suggested by one stud?, but is yet to be tried. Allegations of failure arise from improper implementation, which is itself symptomatic of the lack of a context-specific model for the implementation of TQM in the NHS. The conclusion was reached from a number of perspectives: (1) the critique of current TQM literature which is based on the personal ideas of quality management proponents (Chapter Three). (2) a reconceptualisation of the implementation of TQM. The study suggests that the traditional paradigms of TQM lack adequate contextualisation. They only provide answers for the "what" of TQM in the form of step-by-step approaches, or of TQM as a vehicle for culture change, without providing the practising manager with the 'how' of the implementation process. This apparent limitation, the author suggests, makes TQM orthodoxy inappropriate to deal with the complexities of the NHS (Chapter Four). (3) the study also found that the suggestions in the literature that the barriers to the implementation of TQM have generic applicability across organisations is a misnomer. In most of the hospitals the difficulties that quality managers were facing were specific to the organisational context (Chapter Five). (4) seventeen critical success factors were identified as valid and specific to the NHS. These factors, unlike the 'Ten Critical Success Factors' identified by Black6 are of equal importance for the implementation of TQM and are not categorised on a scale of importance (Chapter Seven). In the final analysis, the study, as a major contribution to knowledge in the quality management field, provides the first empirically determined context specific model for the implementation of TQM in the NHS. The model represents the first problem specific model validated by the experiences of fifteen quality managers in the NHS. It provides an empirical understanding of the 'nature' of the implementation of TQM within the confines of the British National Health Service. In addition, a measurement framework to monitor the progress of TQM at various stages of the implementation process is offered (Chapter Seven).

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