There is a clear need to account for caregiver burden in economic evaluations of healthcare interventions, since omitting it has the potential to produce skewed cost-effectiveness estimates. This is particularly important in palliative care, as interventions in this field are often explicitly intended to help patients’ families and informal caregivers as well as the patients themselves. However, caregiver burden is a complex concept with a number of different dimensions, so valuation can be a challenging task. This paper describes the different dimensions of caregiver burden and provides suggestions as to how those dimensions might be valued for inclusion in economic evaluations. Outcomes are found to be far more complex to value than costs, with considerable controversy over the appropriateness of quality adjusted life years (QALYs) as a unit of outcome both for palliative care and for informal care more generally. The results of a cost-effectiveness analysis of a palliative care intervention are also presented. This analysis was conducted both to demonstrate how to apply the valuation techniques discussed in the first section in practice, and to illustrate how accounting for caregiver burden can significantly affect the estimated cost-effectiveness of palliative care interventions. A simple two-state Markov model was used, with results reported both with and without caregiver burden taken into account. The intervention in question was a multidisciplinary service in southeast London for patients prone to breathlessness. Including both caregiver costs and outcomes in cost-effectiveness calculations was found to reduce the estimated incremental cost-effectiveness ratio (ICER) for the intervention from £103,744 to £26,194 per QALY. Sensitivity analyses revealed substantial uncertainty around these results due to the small sample size in the primary dataset. It is concluded that while accounting for caregiver burden when assessing the cost-effectiveness of palliative care interventions is vital and has the potential to significantly alter ICER estimates, further research on how best to value caregiver outcomes is required, since consensus in this area is necessary to ensure the consistency and comparability of cost-effectiveness estimates.

This study considers pharmacy practice in hyperdiverse, urban communities through the eyes of independent community pharmacists, who are underrepresented figures in anthropological research. Taking the role of the pharmacist as being dynamic and negotiable, this is an investigation into how pharmacists find ways to be relevant in the light of, or even in spite of, a shifting professional remit and the changing landscape of community pharmacy in Great Britain, (where almost 50% of pharmacy contracts are held by just 9 national chains). The study explores 'independence' as it is positioned by the pharmacists; expressed through a rhetorical framework of autonomy, engagement and the bespoke nature of practice, narratively embedded in accounts of urban situations. The research takes an ethnographic approach and was conducted in East and South-East London boroughs combining participant observation and active interviews with pharmacists. All but one of the pharmacists represented in the study were from ethnic minority backgrounds; this reflects a bias typical of urban independent pharmacy. The urban setting presents particular challenges but also particular opportunities and this study demonstrates how pharmacists cope with the constraints and possibilities afforded by their situation. In exploring concepts of professional personhood the study highlights the pharmacists' focus on the importance of autonomy and the creation of distinct professional personas. The significance of engagemen wtith customers is examined through stories of 'acceptance' and developing pharmacy 'communities' alongside the practice of maintaining personal relationships. This reveals the use of cultural capital by the pharmacists, taking advantage of shared cultural heritage and language skills to provide a distinct service offer. The value of providing a 'bespoke' service is investigated through areas of particular significance in differentiating independent pharmacy; 'time' and 'specialism'. The discussion concludes by raising questions about the place of independent pharmacy within the profession and emphasising the contribution independent pharmacists can make to the delivery of care in this setting.

Since 2004, Home Office statistics reveal an increased influx in the number of migrant workers to the United Kingdom, with a corresponding increase in resultant language diversity. Such diversity poses many challenges for health care workers. Studies show that in order to facilitate communication, health care workers commonly use family and friends to interpret. This approach has the potential for several negative consequences which includes amongst others, poor health outcomes, limited access to preventative services, and dissatisfaction. Attempts to improve communication have focused on benefits gained from professional face-to-face interpretation. Subsequently, the use of professional interpreters through telephone access has developed to become an increasingly pragmatic choice amongst health care providers. There is a dearth of research on the use of telephone interpreter services in health care, and this study is the first to explore such use in health visiting. The study employs an action research model to process the introduction to and evaluation of a telephone interpreter service for health visiting. Uniquely, health visitors constitute the first point of contact for many migrant workers with children under five years old when they presented for health care services. Their role requires effective communication to complete accurate health needs assessments, to perform developmental checks and to offer health advice. Locally, health visitors reported several concerns regarding the communication of health care requirements, and consequently, were sufficiently interested to participate in this study.

Background: End-of-life care has become a priority at local, regional and national level and thus creative approaches to evaluating how to successfully implement tools such as the Liverpool Care Pathway (LCP) are required to enable generalist staff to improve care for patients and their families at the end of life. Aims: To determine the processes and underlying influences that facilitate or hinder appropriate implementation of the LCP. Method: The study was an organisational case study using realistic evaluation designed to identify, test and refine programme theories of what will facilitate success. Semi-structured interviews were used to illuminate the differing viewpoints of key stakeholders involved in the implementation of the LCP in one health and social care trust in Northern Ireland. Results from the National Care of the Dying Audit Hospitals pertaining to the organisation provided data on both intended and unintended outcomes. Analysis was guided by the realistic evaluation maxim "what works, for whom, and in what circumstances?" to help explore context-mechanism-outcome patterns. Results: Key resource inputs included facilitation and education for generating tension for change; clarification of goals; visible benefits and communication skills. The key enabling contexts were the priority of LCP implementation; consistent senior management support; appropriate training for facilitators; palliative care team support; presence of LCP link nurses; positive peer influence among medical teams; robust ongoing education and training; and effective multidisciplinary working. Conclusion: This research provided the opportunity to look beyond the question of whether the intervention was successful or not, and to examine the processes involved. Whilst the overall consensus of respondents was that the LCP was a good idea, in practice there were many underlying social, organisational and individual influences that hindered successful implementation and sustainability of the pathway. This research provides transferable lessons for the future implementation of end-of-life care pathways.

As the population ages, the use of information technology and telecommunications in healthcare delivery (often known as Connected Health, telehealth or e-health) has been proposed as a means of providing . patient-centred care to those with chronic conditions. Little research has been conducted into the involvement of community pharmacists in Connected Health delivery. This thesis aimed to investigate the potential role of community pharmacists in the delivery of Connected Health services. A systematic content analysis of print media was performed to explore reporting of Connected Health in UK and US newspapers. A qualitative interview study was conducted with community pharmacists and key stakeholders in Canada and Northern Ireland to gather their views on community pharmacist involvement in Connected Health. Informed by the latter qualitative study, an online questionnaire was distributed to community pharmacists in Northern Ireland to explore their views regarding their potential role in Connected Health. Finally, a feasibility study was carried out, in which community pharmacists sent patients mobile telephone medication reminders and remotely monitored their blood pressure . . Connected Health was positively reported by the print media in the US and the UK. Community pharmacist and key stakeholder interviewees were supportive of community pharmacist involvement in Connected Health, believing it would extend and promote ' their role. However, they had concerns regarding appropriate remuneration. Similar views were obtained from community pharmacist questionnaire respondents. The feasibility study showed that a community pharmacy-based Connected Health programme could be successfully implemented on a small scale. Participants involved were positive about community pharmacist involvement in Connected Health. Community pharmacist involvement in Connected Health has the potential to improve patient outcomes and ease pressure on the health service. However, barriers such as funding and general practitioner acceptance would need to be overcome and a sound evidence base established before routine pharmacist involvement becomes a reality.

This thesis is an exploration of nursing culture in an Intensive Therapy Unit (ITU). In particular, it problematises and explores specific aspects of culture - the notions of ritual and symbolism - in order to understand the meanings underpinning nursing actions in this setting. The contested nature of the term 'ritual' is recognised and extensively elaborated in the review of the literature. Data were generated through the use of ethnography, which entailed participant observation in an ITU over a twelve-month period followed by interviews with fifteen members of the nursing staff; it also included the examination of documentary material present in the field. The findings from the study indicate that whilst nursing work in this ITU was undoubtedly grounded in evidence-based practice, elements of symbolism and ritual were also an integral part of the nurses' work and of their working environment. That is to argue that these two, seemingly contradictory aspects of nursing work, coexisted in this unit. A core component and important theme arising from the findings is that many nursing actions have a dual purpose, one, essentially practical and grounded in science, whilst the second purpose entails responding to various other needs stemming from the nature of nursing work.

No description available.

This thesis examines the government-industry relationship in the regulation of pharmaceutical prices in the UK, through the pharmaceutical price regulation scheme (PPRS). It takes a broadly institutionalist approach to explaining and understanding the design and persistence of this idiosyncratic form of pharmaceutical cost control. Broad factors such as the global nature of the pharmaceutical industry and its industrial importance in the British economy, as well as the conception of the British state's role, the place of parliament in framing regulation and the organisation of the executive all play a part in underpinning the PPRS as a co-operative policy community between government and industry for the control of medicine costs to the NHS. Key to the dynamics of this sector of policy is the interplay between the industrial policy and health policy concerns of government, in a unique relationship in which government is both the primary sponsor and customer of the industry. The thesis develops a theoretical framework and five working hypotheses for the study of three cases of policy development in the PPRS during the 1990s. The empirical research is undertaken through interviews with key players across industry, government and parliament, as well as the analysis of government and industry documents and legislation.

This thesis is an evaluation of practices to control antibiotic prescribing in UK NHS hospitals. Within the past ten years there has been increasing international concern about escalating antibiotic resistance, and the UK has issued several policy documents for pmdent antibiotic prescribing. Chief Pharmacists in 253 UK NHS hospitals were surveyed about the availability and nature of documents to control antibiotic prescribing (formularies, policies and guidelines), and the role of pharmacists and medical microbiologists in monitoring prescribers' compliance with the recommendations of such documents. Although 235 hospitals had at least one document, only 60% had both an antibiotic formulary and guidelines, and only about one-half planned an annual revision of document(s). Pharmacists were reported as mostly checking antibiotic prescribing on every ward whilst medical microbiologists mostly visited selected units only. Response to a similar questionnaire was obtained from the Chief Medical Microbiologists in 131 UK NHS hospitals. Comparisons of the questionnaires indicated areas of apparent disagreement about the roles of pharmacists and medical microbiologists. Eighty three paired-responses received from pharmacists and medical microbiologists in the same hospital revealed poor agreement and awareness about controls. A total of 205 institutional prescribing guidelines were analysed for recommendations for the empirical antibiotic prescribing of Community-Acquired Pneumonia (CAP). Variation was observed in recommendations and agreement with national guidance from the British Thoracic Society (BTS). A questionnaire was subsequently sent to 235 Chief Pharmacists to investigate their awareness of this new guidance from the BTS, and subsequent revision of institutional guidelines. Documents had been revised in only about one-half of hospitals where pharmacists were aware of the new guidance. An audit of empirical antibiotic prescribing practices for CAP was performed at one hospital. Although problems were experienced with retrieval of medical records, diagnostic criteria were poorly recorded, and only 57% of prescribing for non-severe CAP was compliant with institutional guidelines. A survey of clinicians at the same hospital identified that almost one-half used the institutional guidelines and most found them useful. However, areas for improvement concernmg awareness of the guidelines and ease of access were identified. It is important that hospitals are equipped to react to changes in the hospital environment including frequent movement of junior doctors between institutions, the employment of specialist "infectious diseases pharmacists" and the increasing benefits offered by information technology. Recommendations for policy have been suggested.

Background: Medicines that are of poor quality present a challenge to many countries especially the developing countries. Many interventions against medicines counterfeiting are often not evaluated and qualitative fieldwork to find how stakeholders perceive the problem of poor quality medicines is currently lacking. Aims: 1) To conduct a systematic review of the literature; 2) To validate the Mobile Authentication Service (MAS); 3) To explore stakeholder experiences and perceptions of the current situation of medicines counterfeiting and quality of medicines distributed in Nigeria. Methods: 1) A quantitative study involving Short Message Service (SMS) authentication of tagged Glucophage® (metformin) samples, packaging and chemical (Near Infrared spectroscopyand High Performance Liquid Chromatography) analysis of metformin samples, randomly selected from retail outlets in Lagos, Nigeria; 2) A qualitative study involving semi-structured interviews with different stakeholders. Results: The results of the SMS authentication agree with that of packaging and chemical analyses. The Glucophage® samples were significantly different in quality from the generic versions in terms of the concentration of active ingredient with a p value of 0.006. This difference in quality was in favour of the innovator brand, Glucophage® and it is similar to the findings from the qualitative interviews where majority of the participants perceived innovator brands better in quality than their generic versions. Majority of the participants felt that the problem of poor quality medicines in Nigeria is decreasing. Increase in cost of medicines, poor dispensing practices, poor phone network, time constraints, consumer trust in medicine sellers, low level of awareness and complacency by the consumers were identified as factors that may be a barrier to the use of MAS. Conclusion: MAS seem to be successful in helping consumers authenticate their medicines. However, recommendations arising from this study should be adopted to overcome barriers to its use. Substandard medicines may present a greater challenge than medicines counterfeiting and should therefore not be neglected.