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This thesis investigates the establishment and operation of NHS Primary Care patient and public involvement forums and explores whether they were able to meet expectations, and fulfil their intended regulatory roles. PPI Forums, established in 2003, and now disbanded, were intended to strengthen the relationship between patient and public involvement and service improvement. This expectation of functional value was matched by a concern to also strengthen democratic process in local health policy making. To cover both lines of interest, the 'performance' of the Forums is examined in terms of their constitution, composition and mode of operation. The work is topical given the governments continuing emphasis and commitment to a patient-centred National Health Service. The character of eight PPI forum groups in Kent is described using both survey and comparative case study approach. The survey was used to elicit basic demographic information about Forum members and to achieve access for subsequent inquiry. Lay forum members, related support organisation personnel, CPPIH managers and Primary Care professionals were all interviewed to assess their experiences, beliefs and attitudes. Further data on the operation of the Forums was also gathered through observation and documentary sources. The study concludes that the PPI forums only had limited success. This was due to many factors, including budget constraints, confusing structures and poor recruitment processes. There were also limitations in their roles as 'representatives' of their local communities and in working relationships with NHS professionals and their organisations. The thesis ends by drawing lessons for groups, networks and policy makers to ensure that the experiences of lay volunteers who participate in future regulatory patient and public involvement initiatives are fully considered, understood, and embedded within local NHS policy systems.

In the UK, healthcare resources are scarce and insufficient to meet all claims on them. Such scarcity has to be managed. Economics provides a set of principles for managing scarcity. However, economic methods have had limited impact on managing scarcity in healthcare decision-making. This thesis argues that economics must fit alongside the pragmatic necessities of everyday decision-making. The focus of this research was to work within an NHS organisation to consider how decision-making was organised and explore the potential for using health economics, using programme budgeting and marginal analysis (PBMA) as a vehicle to study how health economics can be informed by, and inform, the management of scarce resources in the 'real world'. The research was conducted using a participatory action research (PAR) framework to study PBMA in three phases: before, during, and after its introduction into the organisation. Qualitative interview, observation, and focus groups methods were used to examine the organisational context prior to the implementation of PBMA, record the implementation of PBMA, and reflect on the implementation of PBMA. Through thematic qualitative analyses of these data sources, this thesis presents a rich description of the decision-making context and the inherent constraints; an account of how PBMA was applied; and the challenges of implementing PBMA. These findings indicate that economics provides a set of principles for managing scarcity that are embedded in the discourses surrounding PCT commissioning. However, these principles are rarely borne out in the decision-making processes. Both strengths and weaknesses in the PBMA method, and barriers and facilitators in the application of PBMA were identified. More research is needed to integrate PBMA into the organisational culture, something that may come with further iterations of the PAR framework.

Background; Long term conditions have been identified as causing increased demand on health services and there is much debate about how this demand can be managed. Formalsed lay-led self-care programmes are being introduced into the health systems of many industrialised countries as part of top-down policy initiatives that empower patients to manage their chronic condition. Self-care support in England is being introduced in the form of the Expert Patients Programme (EPP). This thesis aimed to examine the extent to which traditional outcome measures (e.g. self-efficacy, health service utilisation) captured the experiences of people taking part in a self-management programme.

This study examines the relationship between orthopaedic and podiatric surgeons which has formed since the NHS reforms of the 1990s facilitated the establishment of podiatric surgery as a mainstream health-care service. Relations between these two disciplines are considered against the traditional background of dominance of health-care by the medical profession. The study seeks to understand the resistance shown towards podiatric surgery by orthopaedic surgeons and to determine if there is a willingness among orthopaedic and podiatric surgeons, respectively, to develop a more satisfactory working relationship. Two methods of data collection were employed to gather information on the views of orthopaedic surgeons on podiatric surgery. Firstly, questionnaires were sent to all Fellows of the British Orthopaedic Association with the intention to collect a breadth of data. In this way a total population was contacted by means of the survey. Secondly, personal interviews were undertaken with fifty orthopaedic surgeons who indicated a willingness to take part in their questionnaire responses. These interviews were designed to add richness and depth to the data gathered from the questionnaires. All podiatric surgeons in the UK were also sent questionnaires in order to investigate their professional experiences with, and their attitudes towards, orthopaedic surgeons. Once again, a total population was surveyed. A range of attitudes towards podiatric surgery was found among orthopaedic surgeons but significant opposition was identified. Reasons for this opposition are multi-factorial and complex. Overall, there appears to be an imperative to maintain control and, therefore, medical dominance over a competing occupation. For some orthopaedic surgeons, this control is perceived as necessary if the prestige and status of orthopaedic surgeons are to be protected. For others, collaboration with podiatric surgeons is a possibility although many orthopaedic surgeons have reservations about a formal union which often result from a lack of understanding about many aspects of podiatric surgery. Podiatric surgeons are generally in favour of developing closer links with orthopaedic surgeons, though they have concerns about a possible loss of autonomy arising from any collaboration. The development of a closer working relationship between orthopaedic and podiatric surgeons could have benefits for health-care but it seems likely that this may only occur on a gradual basis and through negotiations conducted at local levels.

This thesis argues that the assumption of self-regulation, historically claimed and enjoyed by the professions for an efficient promotion of their positional interests, has shaped the moral division of labour in medical practice in colonial and postcolonial Burkina Faso, in a way that has defunctionalised the state's regulatory oversight, but without the professions being able to achieve such claim, thus confirming the sociological assumption according to which the integrative and solidarity functions of the professions, as with regard to the market, depend on the state regulatory oversight, in a context of an equitable institutional design. The professions' claim for self-regulation challenges two classical theories of social action. One of these theories, originating from classical sociology, sees the professions (or occupations) as a development that forms part of the foundation of modern society. These institutions are alternatives to the disintegration of traditional forms of institutional designs. From this perspective, those occupations already organised into occupational groups should be supported to adapt their organisations to the new social order, and those lacking organisation should be obliged to gather into regulated organisations. Conflating any moral distinctions between occupations, this classical sociological theory strongly supported that only a regulated labour market could foster occupational moral behaviour. x The second competing theory, originating from classical economics, sees free labour markets as the ultimate source of moral conduct in the exchange economy. According to this paradigm, deliberate coordination of individual efforts is irrelevant and counterproductive; because the regulator does not know all the circumstances of the complex mechanisms of the markets, and what even the regulator succeeds in bringing about would have been spontaneously better worked, solved' by the internal laws of the market anyway. The professions have subscribed in part to the sociological theory by claiming that only regulations by the professions themselves can result in ethical provision of their services that advance the public interest. No interference of the state is therefore needed. In consequence, they rejected the second rationalisation in terms of the market as opposed to their orientation. The professions' claim cannot be empirically substantiated. The professions consistent inability to accomplish their claim it contexts in which this oversight is lacking has been substantiated. Surprisingly, when the state cannot guarantee the condition which promotes democratic values, the basis of professionalism, the market situation offers a much more effective means for mitigating individuals' trouble, than a regulated situation such as the professions'.

This thesis brings together two distinct bodies of knowledge, the Sociology of the Professions and literature on International Patient Movement, in order to examine the dynamics of contemporary trends in global health care provision. The thesis suggests that the international movement of patients coincides with symbolic changes in the penetration of commercial practices in health care. The role of states and transnational regulatory bodies in promoting trade in health services directly and indirectly accounts for it to a significant extent. Against the backdrop of accentuated commercialisation and marketisation key actors are reconceptualised as market agents who consequently reinforce marketisation and contribute to the creation of a vicious cycle of commercialisation within health care. Within this framework the study seeks to shed light on the role of medical professionals in the emergence of the internationalisation health care, through the case of physicians practicing on a so lo basis in Greece. It is informed about the perspectives and initiatives of medical professionals on the internationalised market through a qualitative research design based on 32 semi-structured interviews with health professionals. The research findings provide evidence that medical professionals play a prominent role in the emergence of transnational health care provision. The results extend the literature on commercialised professionalism (Hanlon, 1998) by showcasing professionals who adopt an entrepreneurial self and explore the business opportunities arising from the international patient movement. Displaying an entrepreneurial spirit they employ marketing techniques to attract foreign patients to their practices; exemplifying a case of contemporary professionalism which may be characterised as enterprising. The omnipresent enterprise culture and the competitive forces forge the emergence of professionalism characterised by lack of disinterestedness (Brint, 1994), individualism , and a strong career focus, as a strategy for adaptation to the changing environment. The effort to perpetuate professional dominance (Freidson, 2006; Larson, 1977) in the emerging internationalised landscape with the subjugation of the new actor, the medical tourism agents, however, gives evidence that elements of continuity and change co-exist and co-shape professionalism (Evetts, 2011).

Medication administration errors (MAEs) in hospitals account for the majority of reported medication-related patient harm in the UK. Research suggests error-prevention strategies should focus on reducing error-producing conditions associated with systems and processes. However, medication administration is complex, and potential systems and process variations exist across the National Health Service (NHS) which present a barrier to prioritising and developing interventions to reduce error. This thesis investigates variations in hospital medication systems and their potential effects on the safety of medication administration. It also includes a systematic review summarising hospital MAE rates and the effects of methodological variations on reported MAE rates. An initial observational study of nurses administering medications on one ward identified several process variations and system factors that may contribute to MAEs, including potential inefficiencies and dose omissions related to medication storage. A novel meta-analysis of the literature revealed an MAE rate of 5.6% of non-intravenous doses. Dose omission was most common, of which 52-67% were because the drug was unavailable. A census of ward-based medication systems in English NHS hospitals identified the extent of inter- and intra-hospital variation, particularly in medication storage and medication safety related processes. A separate observational study documented variations among nurses in how they utilised systems, including the use of ‘temporary’ drug trolley alternatives. An ethnographic study of drug administration in three different hospital medication systems then revealed systems-related factors that both facilitated and hindered medication administration. Overall, the extent of a number of variations in hospital medication systems has been described, including more subtle variations than previously reported. Many variations were associated with both positive and negative effects on the safety of medication administration, which were often affected by situational factors. This emphasises the importance of considering potential unintended consequences of sociotechnical interactions when developing and implementing systems-based interventions to reduce MAEs.