This thesis is an attempt to study the evolution of the idea relating to poverty and disease during the 19th Century. The interest in the welfare of the people and the improvement in public health owe much to the recognition of' the injurious ef'f'ects of want, on the health of the nation. This is why I was interested in following the growth of understanding in this subject. The study of the evolution of this idea naturally involved all investigation into the health and social conditions which inspired it, and allowed society to conceive it. It also entailed a study of the prevalent economic and political trends of thought, and how those trends had influenced the reaction and the response to this idea. Further, it was requisite to ascertain how far the growth of' understanding of the dangers of destitution on the public health had helped in the gradual change in the outlook and attitude toward the problem of poverty.

In the 21st century, medical tourism has emerged as a prosperous industry. Its growth has been fostered by increasing healthcare costs, long waiting lists for nonemergency operations and a lack of service availability in many developed countries. This has resulted in a reverse phenomenon of patients travelling from developed countries to developing ones to seek affordable healthcare and prompt services. Developing countries in particular have established a variety of strategies to benefit from this profitable market. However, the negative implications of the cross-border movement of services have raised concerns. Quality of services and continuity of care for patients are key concerns in source countries, and inequity, in terms of access to services, rising healthcare costs and the ‘internal brain drain’ of healthcare personnel are concerns in destination countries. It is widely believed that there are substantial economic benefits to be gained from medical tourism, but this belief is not based on a firm empirical foundation. Similarly, there is a lack of empirical evidence concerning the impacts on the health systems of destination countries. The divergence of views and overall lack of evidence affords the potential for policy incoherence between trade and health. This study intends to address this gap in the literature through an empirical assessment of both medical tourism and the healthcare profiles of medical tourists. The overall aim of the study is to assess the impact of medical tourism on the Thai economy and domestic private health system. Thailand was selected as a appropriate country for a case study due to its significant medical tourism industry. This study presents the most extensive and detailed research on medical tourism and its effects on the private health system to date, by drawing on 324,906 patient records in the five largest private hospitals in the country. The key findings are that medical tourists in Thailand are non-homogenous. Comparisons present differences between them and non-medical tourists and Thai private patients in terms of demography and service profiles. The majority are likely to be opportunistic tourists, especially patients who use out-patient departments. Furthermore, the actual number of medical tourists is far fewer than is generally suggested, although they and their companions contribute disproportionately to the Thai economy in terms of medical and tourism-related spending. In terms of medical services, there is no difference between the critical aspects of care given to Thai and foreign patients. Hospitals make use of spare capacity to serve the demand of foreigners. However, foreign patients might be partially responsible for a shortage of high calibre doctors in public hospitals. Hence, if it wishes to continue with its “Medical hub” policy, there is an evident need for the Thai government to consider carefully the overall “cost” of this policy.

This study explores the experiences of emergency nurses working in a new Major Trauma Centre in the UK National Health Service, and how reconfiguration of trauma services has affected perceptions and working practices. Methods: Drawing on the principles of focused ethnography, fieldwork was conducted over 5 months in the Emergency Department (ED) of a newly designated Major Trauma Centre in London. It comprised approximately 53 hours of participant observation, and conversations and semi-structured interviews with 31 nurses. Qualitative thematic analysis was conducted of fieldnotes and interview data. Results: The findings reveal a complex picture of the experiences of emergency nurses within the Major Trauma Centre, with interrelated themes emerging. The first gives an account of how major trauma work has led to a perceived increase in the status and profile of the ED. The second theme explores the draw of trauma and how it is viewed as an exciting component of the nurses‘ work. The third looks at the idea of the „decent‟ trauma patient, examining the hierarchy of interest within trauma work, and the final theme explores ED nurses‘ accounts of their task-orientated roles in looking after trauma patients. Conclusion: The study shows how the value placed on the high profile ‗specialist‘ major trauma work pervades the culture of the department and how the protocol-driven nature of this work fits the immediate patient needs but minimises the ability of nurses to negotiate their professional boundaries in a way they are able to in other areas of their practice. Thus major trauma work is an outwardly exciting but ultimately unsatisfying aspect of the ED nurses‘ work. More importantly, the collectively accepted notion of the major trauma patient as the one with technically demanding complex injuries that can only be catered for by a ―Centre of Excellence‖, risks undermining the value placed on the care of other patients in the ED.

This study investigates the history of caesarean section and women's experience of the operation today. There has been no systematic collection of historical data on caesarean section since 1944. This study now constitutes the most comprehensive compilation of the history of the operation to date. It illustrates the development of the medical ethos concerning women as patients and provides the background to the next phase of research: the experience of caesarean section. Previous research on caesarean section has exhaustively analysed the indications for the operation, reasons for the increasing rate and women's perceptions of abdominal delivery. This study differs in eliciting responses from women on a range of issues relating to caesarean birth in order to assess the quality of information given to women in hopital regarding the necessity for caesarean operations and analyse the effects of abdominal birth on women. Women's experiences were examined in a sample of 300 women who had delivered by caesarean section. Significant differences were found in reactions between women who had emergency operations and those whose caesareans were elective. The emergency caesarean women suffered more in all negative measures including increased feelings of pain and depression. Negative sequelae was found to relate to the unexpected nature of emergency operations and the use of general anaesthesia. Subjectively women report that they do not suffer as a result of caesarean birth, yet objectively it is clear that they do. This anomaly is attributed to the unequal relationship between women and doctors. Women feel grateful for the treatment offered by the doctors and therefore do not express dissatisfaction with their care. Recommendations are made suggesting practical ways in which maternity services, in respect of caesarean birth, can be improved.

People can experience feeling vulnerable whenever their health or usual function is compromised and can increase when they enter unfamiliar surroundings, situations or relationships. One’s experience of vulnerability can also be heightened through interaction between the individual and the society within which they live. As such, vulnerability is a dynamic concept that crosses the interface between the self and the social world. It is, therefore, a key concept for professional practice; however this complex, elusive phenomenon is ill defined within the literature. Within studies of vulnerability it is the existential (lived) experience (emic perspective) that is the most silent in comparison to normative perspectives (etic perspective). The Gypsy/Travelling community are often normatively identified by researchers and professionals as a vulnerable group due to increased morbidity and mortality (Goward et al. 2006; Parry et al. 2007) as well as their marginalised status within society (Van Cleemput 2007; McCaffery 2009). But this tells little of the experience of feeling vulnerable by the individuals themselves, and yet without their stories and experiences how can professionals ensure that service developments meet their needs. This research addresses this gap in the evidence base by exploring the lived experience of vulnerability of a Gypsy/Travelling community. The study consisted of two phases (a breadth phase followed by a depth phase), after the work of Todres and Galvin (2005). The breadth phase (Phase 1) consisted of narrative interviews with five Gypsies and Travellers exploring times in their lives when they had felt vulnerable. This identified the following:  A feeling of vulnerability created by the potential or actual lack of physical travelling experience.  Fear of the future and declining physical health.  Being an outsider; this experience of vulnerability contained two similar but distinct variants. o Insider identity o Perception of others outside the Gypsy /Travelling community  Vulnerability connected to the ambiguities of their historical, cultural and geographical identity. Phase 2 explored the experience of vulnerability related to the ambiguities of their historical, cultural and geographical identity by exploring their experience of being part of a cultural group with threatened cultural identity and heritage. The lived experience of this type of vulnerability was described by 15 participants and descriptive phenomenological analysis (Giorgi 2009) identified six constituents of the phenomenon of vulnerability:  Vulnerability due to feeling defined and homogenised in a particular way  Vulnerability of feeling pressurised to conform to live a particular way  Vulnerability of feeling split in one’s identity  Vulnerability due to feeling a loss of one’s heritage  Vulnerability of feeling discriminated, persecuted and threatened  Vulnerability of powerlessness The findings of this study on the lived experience of vulnerability (emic) present a different perspective to vulnerability than what is already known from the literature (etic). This develops the understanding of the concept of vulnerability itself, which can enhance professional skill and knowledge when working with people who may be experiencing feeling vulnerable. In addition, this thesis illuminates a light on experiences of vulnerability of Gypsies and Travellers, largely hidden within society. This new knowledge of their stories can be used to influence policy as well as statutory services (health, education and social care). Lastly, the thesis proposes a new, novel theory to understand vulnerability, referred to as “Etemic”; a fusion between the emic and etic. It argues that it is only through an appreciation of the Etemic that services can be developed to effectively address the needs of individuals within the Gypsy/Travelling community.

Health inequalities - the unfair and avoidable differences in health status between individuals, communities, social groups and populations - have progressively widened and deepened in recent decades, despite access to world~ class healthcare services and public health research in cities such as Glasgow. New ways of thinking about and tackling the problem are therefore constantly being sought One potentially innovative and sustainable response could be the 'social enterprise', a business that works towards social ends, rather than for the maximisation of financial returns for shareholders or investors. In the literature, the role of social enterprise in the context of health has, to date, been limited to exploring their role as an alternative provider of health services. However, by drawing upon a wide theoretical base, particularly the work of Karl Polanyi, the fields of social enterprise and public health are brought together to make the argument that by acting to address one or more aspects of social vulnerability, and achieving the means to do so in some broader trading activity, gains in health and well-being can be realised from any social enterprise, regardless of whether this is explicitly stated as part of their social mission. Following the development of an initial hypothetical model, the results of what is believed to be the first Systematic Review of empirical evidence of the impact of social enterprise~led activity on health outcomes and their social determinants are presented. An empirical phase has also been undertaken, involving interviews with practitioners from a diverse range of social enterprises around the city of Glasgow and employing methods of data analysis and theory building inspired by the critical realist philosophical stance. The study culminates in the construction of an empirically informed conceptual model, which maps plausible causal pathways between engagement with social enterprise-led activity, through to improvements in health and wellbeing. The results of this study are considered to not only encourage a broader and more imaginative consideration of what actually constitutes a public health 'intervention', but also implies that the Third Sector and other 'non-obvious' actors have an important role to play in addressing contemporary and future public health challenges.

Introduction The aim of this study was to generate new knowledge in occupational therapy practice. The study explored the change management process employed to develop integration of health and social care, evaluate the waiting lists, identify the critical success factors and the barriers to successful implementation of integrated practice In NHS Highland. Methods Mixed methods were employed to examine the change process following integration. Staff perceptions have been explored through a survey and participation in semi-structured interviews. Quantitative data was generated in a survey using the Health and Safety Executive Work Related Stress Tool which is valid and reliable. The data was collected at two points in time and was subjected to statistical analysis (n=27 & 26 respectively). Details of the waiting lists were collected from each area at two points during the study. Interviews were undertaken with a purposive selection of occupational therapists (n=lO), five from health and five from the ex-local authority. The data from the interviews were thematically analysed using Interpretive Phenomenological Analysis. Results The superordinate themes identified in this study relate to communication issues and concerns for professional practice. Staff reported their main stressor to be the lack of effective leadership and their relationship with managers. Therapists have identified co-location, and shared learning to be positive factors for integration. Barriers are identified as incompatible computer systems, perceived incompetence, and lack of a shared vision. The waiting list reduced during the study period. This was due to changes in the referral process, which resulted in therapists and other health professionals being able to action services directly from providers, rather than through occupational therapists. Implications for practice Integrated health and social occupational therapy services have the potential to develop effective relationships, reduce duplication and provide co-ordinated services with a single point of access for service users. Staff require to be involved at all stages of the change process in order to implement the integration of health and social care within their locality. The results could have implications for improving the effectiveness of integrated services generally. Summary The results of this study will be used to increase understanding of the barriers and critical success factors to develop effective, collaborative relationships and integration of health and social care occupational therapy provision.

The purpose of this study is to examine how national culture influences the social constructions of health care quality in the Kuwaiti primary care. Kuwait has a well- developed primary care system, offering a wide range of services in practices distributed throughout the nation, throughout the day, and on a walk-in basis. Despite its extended hours, relative comprehensiveness and affordability, the primary care service in Kuwait appears to be poorly received by the public. This study employed a qualitative research methodology to investigate how the elements of the Kuwaiti national culture shape the social constructions of health care quality. The study proposal was reviewed by the research ethics committees of the University of Surrey and KIMS, and a favourable ethical opinion was obtained. Participant information sheet were given to potential participants and consent obtained before data collection. Semi-structured interviews were conducted with 42 participants from various stakeholder groups. Data analysis identified three themes that represent the experiences of the various stakeholders’ relating to their social constructions of health care quality in primary care: (1) meanings of health, (2) attitudes towards primary care service, and (3) access to primary care. Within the identified themes, a number of sub-themes were identified, including: (a) the meaning of health, (b) responsibility for one’s health, (c) tensions in doctor-patient communication, (d) doctors feeling ‘undervalued’, (e) gender issues, (f) cultural suitability of primary care, (g) primary care work environment, (h) disproportionate distribution, (i) waiting times, and (j) institutional discrimination. The study found that the high-power distance element of national culture impacts the social constructions of health care quality. Perceptions of power differentials across social groups seem to contribute considerably to the social construction of health care quality. The contribution of this study is towards the body of knowledge on the cultural competence of health care provision in high-power distance cultures.

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This study explores the perceptions of Directors of Nursing from NHS acute Trusts in England, on caring practices. The aspiration of the NHS is to deliver good care to patients and their families. The NHS constitution states that the ‘NHS is there to improve health and wellbeing, and it touches our lives at times of basic human need, when care and compassion are what matter most’ (DH 2013:2). However, recent inquiries into poor care have created a searching debate regarding standards of nursing care, leadership, culture and practice. Directors of Nursing play a significant role in influencing care, as they are charged with responsibilities relating to providing assurance of standards of care within NHS Trusts. However, little is known about the perceptions of Directors of Nursing in NHS acute Trusts, on caring practices. The study aimed to construct a grounded theory of the perceptions of Directors of Nursing from NHS acute Trusts, on caring practices. The study also sought to understand the social, political, professional and organisational challenges facing Directors of Nursing. Twelve Directors of Nursing from NHS acute Trusts in England were interviewed between July 2013 and January 2014 using semi-structured questions. A constructivist grounded theory approach was adopted to support the co-construction of the theory by exploring how the participants construct their worlds or reality. Through the co-construction approach a theory of ‘Directors of Nursing Perceptions on Caring: Post Francis Paradoxes’ revealed that the participants are working within a paradoxical NHS system in response to findings from the Mid Staffordshire NHS Foundation Trust inquiry. The theory is supported by three categories of: ‘trusting my senses’; ‘avoiding becoming collateral damage’; and ‘being in a different place’. The three paradoxes that emerged were: the need to produce reliable high-quality assurance about standards of care in the NHS which detracted from and impacted on the Directors of Nursing roles in supporting internal assurances processes. Secondly, external monitoring standards did not capture the ‘real’ warning signals of care failings as intended. Thirdly, the reliance on intuitive skills to give assurances of caring practices was considered necessary to support the demanding monitoring and assurance processes. This study captures a challenge, as perceived by Directors of Nursing, regarding how external regulatory demands can be accommodated alongside the internal organisational requirements to lead the improvement agenda of patient care standards. Directors of Nursing need then to balance the competing priorities in their roles whilst supporting and leading a nursing workforce to deliver ethical caring practices. Recommendations are made for research, education and practice.