This study examines the experiences of men who undertake the care of sick or disabled relatives. The modes of entry into carer careers are discussed, and the actual components of caring are described. The efforts of male informal carers to present themselves as coherent and worthy moral agents are described. Adaptations to caring as manifested in fantasy and daydreaming are examined. The entry into caring is seen to occasion a certain disruption in the continuing self-narratives of the men in the study, which amounts to a thorough threat to identities. The role of narrative in the formation and reformation of the self is discussed. It is argued that caring has disrupted the usual relation to masculinity for male carers, and that this is an important component of narrative disruption. Its restitution is important to successful caring. Certain narrative styles are associated with certain responses to caring, and the relationship between these is adduced and examined. An association between the form of narrative reformation, attitude to masculinity and caring style is identified, and this is correlated with adaptation to, and success in, the caring situation.

This thesis focuses on drug use and control in Britain, and on the previously un-researched period between the late 1920s and the early 1960s. These decades have been described by one Home Office Official as the ‘quiet times’, since it was believed that nonmedical drug use was restricted to a few hundred respectable middle class individuals. Subcultures, inhabited by those whose lives centred on drugs, were thought not to exist. The thesis also engages with the historiography of the British System, named by US liberals to denote the medical approach to addiction in Britain in contrast to America. The research on which this thesis is based, however, including heretofore unexamined archives of the Home Office and the Metropolitan Police, indicates otherwise. It locates what is best understood as subcultural drug use, which, despite important differences, resembled and prefigured the hedonistic drug use of the 1960s. In order to understand subcultural use, one must explore its inception in the 1930s and the surrounding regulatory architecture, consisting of both medical and police functions. Utilising case studies, the thesis traces the interwoven development of two opiate networks, based respectively in Chelsea and London’s West End, the Home Office Drugs Branch, and the Chemist Inspection Officers and broader drugs work of the Metropolitan Police. In addition, it examines the ‘script doctors’ supplying the addict subculture, medical regulators such as the Regional Medical Officers and the General Medical Council, and the attitudes of prominent addiction specialists working on the 1938 Committee on Addiction of the Royal College of Physicians. The thesis conceptualises drugs as symbolic categories standing in for objects of social anxiety or promise, and over which social and cultural conflicts played out. These are illustrated though the tensions between and within the drug control machinery and the nonmedical drug users.

No description available.

Changes in the way health care services are delivered in England have affected the roles and boundaries of healthcare professionals. The agendas of skill mix and inter-disciplinary team work have been facilitated by the migration of services into primary care. There is a growing body of research addressing the effect of healthcare organisation and delivery on the roles and boundaries of doctors and nurses. Very little research has focused on the third largest section of the professional healthcare workforce, allied health professionals. This study investigated the roles and boundaries of allied health professionals working in primary and secondary care contexts. An ethnographic extended case based methodology was adopted. Two case studies were taken from a secondary care organisation, and two from a primary care organisation. Cases were identified in discussion with professional leads from the two organisations. Within the cases both purposeful and convenience sampling approaches were applied. Data were generated through semi-structured interviews, field work and non-participant observations. Analysis consisted of a broadly thematic approach; the emergent themes were presented within the case reports as an interpretive poly-narrative. Structuration theory provided a framework on which to develop a cross case analysis and frame the interpretations overall. The emergent themes highlighted a number of important aspects related to professional roles and boundaries. The primary element shaping the roles and boundaries of allied health professionals was the complexity of the patient. The findings indicated a positive relationship between transparent and structured care and patient centred practice and team work. Finally and of significance was a neglect of rehabilitation within both primary and secondary care. In order to promote inter-professional team work and patient centred practice there needs to be clarity of patient need and focus of service provision. The neglect of rehabilitation will have far reaching implications for the future.

This research explores 15 years of palliative care group work, inspired by the Asclepian healing temples in Ancient Greece, working in and with nature, using imagery, ritual and bodywork. Through Intuitive Inquiry, incorporating hermeneutic, heuristic and transpersonal elements, the research focuses particularly on the nature of the therapeutic space. From archive material and interview data, five broad themes emerged which were considered integral to creating a healing space and environment, and which were inherently interconnected. Separated only for the clarity of discussion, these themes were named as Pilgrimage, Place, Nature, Imagination (the ‘Mundus Imaginalis’) and Presence. From this, the researcher developed a collaborative model for group work in palliative care and considered the potential impact and relevance to education and practice. Collaboration in this sense refers to the potential of shared facilitation, for example between psychotherapists and artists, and also acknowledges the therapeutic collaboration with the environment, particularly nature, and, in the spirit of Asclepius, with ancient wisdom. The research also highlighted the resonance between the methodology and the research focus. The research process itself became a pilgrimage. This dissertation, with the journey forever unfolding, is a resting post along the way.

Introduction A number of UK studies have investigated the role of pharmacists in public health (Blenkinsopp, et al. 2002; Anderson and Blenkinsopp 2003; Agomo 2012a). However, many of these studies have also identified barriers in this public health role (Agomo 2012a; Agomo and Ogunleye 2014). My project aimed to identify strategies, which could enhance the public health role of community pharmacists in the UK. Method My project used a mixed methods approach, involving a content analysis of the UK undergraduate pharmacy curriculum, a descriptive survey of UK community pharmacists and interviews with healthcare practitioners to investigate strategies enhancing the public health role of community pharmacists in the UK. Results The majority of my survey respondents indicated that there was a need for pharmacists to work closely with other healthcare practitioners [93.1%, C.I. ±5.32]; pharmacy students to train with other healthcare students [81.4%, C.I. ±8.21]; students and pharmacists to be provided with advanced experience in public health [86.2%, C.I. ±7.24 and 89.8%, C.I. ±6.32 respectively]; as well as increasing the public health content of the undergraduate pharmacy curriculum [64.8%, C.I. ±9.97]. Respondents from Cardiff were more likely to participate in local authority-run schemes than other respondents (p < .001; η2 = .296). Male respondents were more likely to agree that 'insufficient funding from the government’ was a barrier to the public health role of community pharmacists [p = .011; ρ = -.269]. The findings of my interviews confirmed several aspects of my survey findings, particularly as regards accessibility, encouraging collaboration between pharmacists and other healthcare professionals, and tackling a number of barriers, such as the lack of awareness of the public health skills of pharmacists. There were some indications from my content analysis that the teaching of macro-level public health activities (such as epidemiology, assessment, pharmacovigilance, policy development and assurance at the population-based level) in most UK pharmacy schools was either minimal or lacking. Conclusion There is a need to enhance the public health role of community pharmacists in the UK. This will help make public health services more accessible to the public, reduce healthcare costs and pressures on other healthcare professionals, as well as helping to elevate the image of community pharmacists.

Thousands of in-hospital deaths each year in the UK are potentially preventable, being often preceded by physiological deterioration. The current standard of clinical practice for patient monitoring on general wards is the periodic observation of vital signs by nursing staff. The use of early warning score (EWS) systems should enable a more timely response to, and assessment of, acutely ill patients. The investigations described in this thesis seek to apply principled approaches based on machine learning to the analysis of vital-sign data from patients who are recovering from major surgery. A dataset comprising observational vital-sign data from 407 post-operative patients taking part in a two-phase clinical trial in the Oxford Cancer Centre is introduced. A second independent dataset collected from clinical data obtained from 24,212 patients admitted to the Medical Assessment Unit of a different hospital is used for validation purposes. When applied to post-operative patients, currently-used EWS systems achieve values of Area Under the Receiver-Operating Characteristic curve (AUROC) that range from 0.717 to 0.841 for predicting a composite outcome of death, emergency admission to the Intensive Care Unit, and cardiac arrest within 24 hours. We also demonstrate that the method of recording vital signs on the ward plays a fundamental role in the design and performance of EWS systems. Using the same set of physiological variables, kernel density estimators and support vector machines give equivalent results to those of EWS systems which have been carefully optimised by trial and error. A method for describing the physiological trajectories of post-operative patients is developed using machine learning techniques. We further introduce the concept of variability of vital signs over a 24-hour period, and propose a strategy for incorporating this information into the machine learning models studied. The resulting model leads to an improvement in performance (AUROC = 0.856). An approach based on Gaussian processes is then discussed for exploring and representing patterns of vital-sign time-series data. The approach allows different types of normal physiological trends to be identified in patients recovering from surgery. Knowledge of different patterns among hospitalised patients and their incorporation in monitoring systems improves early-warning scoring systems for the identification of physiological deterioration in specific patient groups.

Non-attendance in the drug service hepatitis C outreach clinic means clients miss essential components of care: being offered lifestyle advice such as limiting their alcohol intake (to prevent further progression of liver disease);a discussion about ways to avoid transmission to others; and referral for hospital treatment, which can be curative. In the absence of much empirical evidence many suggestions have been given for missed appointments by hepatitis C patients. For example, they forget, lead ‘chaotic lifestyles’, the infection is ‘not a priority’ to them and they are ‘hard-to-reach’. This study was undertaken to investigate beneath these ‘surface’ reasons for non-attendance. Thus, a realist approach was taken. The study comprised three phases of theory development and testing that incorporated qualitative telephone interviews with clients followed by a national survey of staff. All 28 clients who participated gave ‘surface’ or ‘prima-facie’ reasons for non-attendance. However, the study revealed hidden underlying factors (mechanisms). These were categorised under the themes: (i) ‘client characteristics’ e.g. ‘priority’ to score drugs and the ‘cost of travel’ (ii) ‘hepatitis C’ e.g. ‘no symptoms’ and fear of treatment ‘side-effects’ (iii) ‘clinic service’ e.g. ‘distance’ to the clinic and difficulty with ‘reimbursement’ of travel expenses. These mechanisms were produced within a complex context of factors including addiction, welfare policy and stigma. They were often played out in different ways and linked to other mechanisms. 41 out of 142 (29%) drug services in England ran a hepatitis C outreach clinic. There was general agreement with clients about reasons for nonattendance. However, there was some discordance, notably difficulty with walking. This study revealed a complex picture for non-attendance in a hepatitis C outreach clinic and makes an original contribution to knowledge about the reasons for missed appointments. This in turn has informed changes to practice which may engage more people into care and treatment for example, arranging scans to be undertaken on the day of clinic appointments.

This thesis examines whether members of the public wish to place greater weight on a unit of health gain for end of life patients (i.e. patients with short life expectancy) than on that for other types of patients. The research question was motivated by a policy introduced in 2009 by the National Institute for Health and Care Excellence (NICE). The policy indicates that under certain circumstances, life-extending end of life treatments may be recommended for use in the National Health Service even if they would not normally be considered a cost-effective use of health care resources. NICE’s policy was justified in part by claims that it reflected the preferences of society, but little evidence was available to support the premise that society favours such an ‘end of life premium’. This thesis helps to fill the gap in the evidence. Four empirical studies were undertaken, each using hypothetical choice exercises to elicit the stated preferences of the UK general public regarding the value of health gains for end of life patients (total n=6,441). A variety of preference elicitation techniques, modes of administration and analytical approaches were used. Results varied across studies, but overall the evidence is not consistent with an end of life premium. Whereas NICE’s end of life policy applies to life-extending treatments, there is some evidence that quality of life improvements are more highly valued than life extensions for end of life patients. The results of all four studies suggest that where a preference for prioritising the treatment of end of life patients does exist, this preference may be driven by concerns about how long the patients have known about their prognosis rather than how long they have left to live per se. End of life-related preferences also appear to be sensitive to framing effects and study design choices.

This thesis discusses the historical association of blood donation with narratives of 'the gift'. It is a history of blood-giving in London between the emergence of the city's first voluntary blood donor panel in 1921 and the establishment of the National Blood Transfusion Service in 1946, and follows the transformation of transfusion therapy from a one-to-one surgical procedure to a standardised complement to a nationalised system of health. Special attention is given to the articulation and cultivation of altruistic ideals. The argument is that the theme of the gift arose simultaneously with a modernised blood transfusion service and its associated technological innovations, in particular the blood bank, which distanced donors and recipients. From this basis, A Genealogy of the Gift uses history to challenge an interpretation of the gift as ' anachronistic', symptomatic of early face-to-face blood transfusion but thoroughly incompatible with technological advances in the manufacturing, storage and distribution of blood products. On the contrary, the gift emerged in processes of expansion that first flourished in World War II and, to a greater extent, remain with us. The opening chapter examines the case of interwar London, where surgical one-to-one transfusions of whole blood were the norm but the morality of giver took precedence over the theme of the gift. Three subsequent chapters consider the shift 'from giver to gift', through the planning of an emergency service in autumn 1939 (Chapter 2) to the development of specialist venues of blood collection (Chapter 3) and the promotion of fictive recipients in connection with 'the gift in the battle line' (Chapter 4). A final chapter questions the legacy of these changes in the planning of a postwar service from 1943 . By confronting the alleged hostility of modern blood supplies to altruism with a story of coincidence and mutual complicity, this thesis makes a claim for the importanc~ of history in understanding the boundaries and potential of gift rhetoric.