In 2008, the Organ Donation Taskforce was asked to consider the impact of introducing an opt-out system for organ donation in the United Kingdom. The Taskforce conducted a thorough investigation, which included information gathering from both the public and experts in the field of healthcare, ethics and law and a thorough appraisal of the countries currently operating an opt-out system. Having reviewed this evidence the ODT conceded that whilst the numbers of organs generated may increase under an opt-out system, conversely, because of the way the system actually works, they felt there was a risk that its introduction may cause a backlash amongst the general public resulting in a decrease in organ donations. They based their concerns around fears that such a system would remove the potential for spontaneous acts of goodwill, denying people the opportunity to give a gift, and may deny the opportunity for individuals to determine whether their organs should be donated, thereby precluding choice and the right to self-determination. This might ultimately compromise public trust in the system. This thesis challenges the assumptions made by the Organ Donation Taskforce in respect of introducing an opt-out system. It casts doubt on their claims about compromising privacy interests and then looks to reconcile the potential issues which may arise under an opt-out system; these are preventing the choice to act altruistically and acting in such a way as to undermine public trust. Both of these may result in policy failure. It will advocate a system which addresses the issues raised by the ODT and acts to provide respect for self-determination; this is a soft opt-out system with a combined registry. Such a system would increase the supply of organs for those in need of a transplant, and remain consistent with a society's values in terms of demonstrating respect for individual choice regarding donation.

Background: Blood donors are required to exceed a minimum haemoglobin level before they donate; those who fail are temporarily deferred from blood donation. In this way, donor health, and that of the recipient (patient), is assured and a drain on blood collection resource is avoided. Knowing what factors contribute to donors failing to reach these levels and whether provision of iron supplements decrease deferral rates would prove beneficial to blood collection agencies. Methods: Two systematic reviews of available literature were conducted after searching on-line databases. The first looked at observational studies of demographic data, donation history and haematological and biological factors that might be associated with deferral from blood donation. The second review studied only randomised controlled trials and was carried out using the protocols and facilities of the Cochrane Collaboration to assess the efficacy and safety of iron supplementation to reduce iron deficiency and/or anaemia. Results: Fifty-five studies met the inclusion criteria for the first review, thirty studies were included in the second. Key findings are: 1. Females show a significantly greater risk (11-fold) of donor low haemoglobin deferral as compared to males. 2. Higher deferral rates were also associated with increasing age, higher ambient temperature, lower body mass, shorter donation interval or being of certain ethnicity. 3. Donor deferral is reduced by taking iron supplements but the evidence is moderate. 4. Those taking iron supplementation are subject to more frequent adverse events. Conclusions: These peer-reviewed and published works help define criteria that should be considered in large scale studies of donor deferral, especially any which attempt to address failure to meet low haemoglobin thresholds. Additionally, although donors may benefit from iron supplementation, the risk of side effects means it is unlikely to be a universal treatment. Together these reviews may help determine suitable donation intervals which decrease risk of donor iron-deficiency.

Rationale for the Study: High quality care is high on the national agenda together with the centrality of clinical nurse leadership to achieve this The issue of the unpopular patient in nursing, as someone nurses do not enjoy caring for, is important, because when it occurs, the prejudice negatively impacts the quality of nursing care. Yet the concept of the unpopular patient has been rarely studied, and the specific experience of clinical nurse leaders, who are said to set the climate and tone of the care setting, has not previously been explored. Aim of the study: To explore the lived experience of clinical nurse leaders leading a team caring for an older patient perceived as unpopular in community nursing settings. Methodology/Methods: A Heideggerian hermeneutic approach was taken. Data was gathered using in-depth semi-structured audio recorded interviews with eleven female clinical nurse leaders. Findings: Five themes which contributed to the whole interpretation; “Knowing the Unpopular Patient”, ”Being Faithful”, ”Betwixt and Between”, ”Joined at the Hip” and ”Growing into Leadership”. The visible meanings of the experience included moral distress and moral courage, and the hidden meaning was the loneliness the clinical nurse leaders seemed to experience when trying to prevent, or address, the development of the older unpopular patient. Implications for practice and research; NHS organisations need to be aware that clinical nurse leaders may feel distressed and lonely as a result of trying to create a culture of quality care and dignity in difficult circumstances. Original contribution to knowledge: The unpopular patient also exists in community nursing settings, and importantly, clinical nurse leaders can experience moral distress and loneliness in response to the attitudes and behaviours of their staff team as the 'wounds of clinical nurse leadership'.

The contribution of over-the-counter (OTC) medicines sales data from pharmacies for public health (PH) has previously attracted interest in the UK. In this study, data for several OTC medicines were utilised to explore their contribution to (a) understand the impact of medicine reclassification or increased regulation on supply and (b) the surveillance of infectious diseases in the community in Wales. Following the reclassification of ophthalmic chloramphenicol (June 2005) an increase in primary care supply (OTC + prescription) of 54% (47,026 units) in eye drops and 29% (15,657 units) in eye ointment were observed (2004 to 2010). Despite this increase the items of eye drops prescribed were similar 12 months before and five years after the reclassification. The impact of regulatory changes concerning the non-prescription sale of opioid-containing analgesics was studied. In the 12 months following September 2009 legislative changes there was a significant fall in sales of codeine- and dihydrocodeinecontaining solid oral dosage forms (p<0.05). Similarly, following the pack size restriction of non-prescription pseudoephedrine and ephedrine products (April 2008), significant (p<0.05) year-on-year reductions in the total weight of pseudoephedrine sold were observed. Sales of non-prescription ophthalmic chloramphenicol were monitored on a small area basis in two areas with known outbreaks of infective conjunctivitis. In both areas sales data did not demonstrate the required sensitivity. When monitoring seasonal influenza, significant positive correlations were observed between cough/cold/flu medicines sales and indicators of influenza activity in Wales. In alignment with the professional standards for PH practice for pharmacy produced by the Royal Pharmaceutical Society, the work undertaken demonstrated a number of potential uses of medicines sales data for PH. Routine data collection, particularly if captured at time/point of sale, would further enhance its usefulness in detecting and tracking PH incidents.

Equity of access to healthcare services is a concept which underpins current UK health policy. However evidence suggests that this is not achieved within community palliative care. Referrals can be tardy or not made at all. Most literature describes inequality in service utilisation, but does not aid understanding of why such inequalities exist. There is little research exploring the processes underpinning referral making rather than the outcomes of referrals such as service utilisation. The aim of this research was to investigate the influences on referral decisions made within community palliative care services. A qualitative case study strategy was chosen as the research approach as it provided a framework for facilitating the incorporation of multiple perspectives in a complex context, in a field where there has been little previous research, and where there is little theory to guide the investigation. Three cases (Primary Care Trusts) were studied. Data collection used multiple methods (interviews, observation and documentary analysis, as well as mapping and profiling the palliative care services provided within the cases) from multiple perspectives (general and specialist palliative care professionals, managers, commissioners and patients). Detailed data analysis followed a framework approach, comparing and contrasting patterns within and across cases with existing and developing theoretical propositions. Two core influences on the way health care professionals made referral decisions were found. First, their perception of their own role in providing palliative care. Autonomous professionals made independent judgements about referrals, influenced by their expertise, workload, the special nature of palliative care and the relationship they developed with patients. Second, their perception about those to whom they may refer. Professionals needed to know about services to refer, and then made a complex judgement about the professionals involved and what they could offer the referrer as well as the patient. These findings indicate that many more factors than an assessment of patients' clinical need affect referrals within community palliative care services. It appears that personal, inter-personal and inter-professional factors have the potential to shape referral practices. It may be that the combination of these factors has an influence on equitable access to community palliative care services. Practitioners could be more explicit about referral or non-referral rationales, and policy makers take account of these complex influences on referrals rather than just mandating change.

The role of community pharmacy (CP) in health promotion has developed over the last decade and a half following the introduction of the new National Health Service (NHS) plan in 2000. CPs have been turned into healthy living centres where individuals can access a variety of services designed to prevent disease and promote health. In 2005, three types of pharmacy service were introduced; essential, advanced and enhanced (currently known as locally commissioned). Enhanced pharmacy services were provided by Primary Care Trusts (PCTs) (until 2010) based on local needs identified by PCTs. In 2010, the Government decided to abolish the PCTs by 1‘"t April 2013; hence, PCTs entered a transition phase between 2010 and April 2013. By February 2011, each PCT was required to publish Pharmaceutical Needs Assessment (PNA) report regarding the provision and need for pharmacy services. The national commissioned vascular and sexual health enhanced pharmacy services in England are Stop Smoking Service (SSS), NHS health check, Emergency Hormonal Contraception (EHC) and chlamydia screening and treatment services. In 2012, the Healthy Living Pharmacy (HLP) scheme, which was piloted in Portsmouth PCT, was expanded to 30 PCTs known as HLP pathfinder PCTs. The aim of this research was to identify the correlation between needs, provision and uptake of vascular and sexual health pharmacy services at a PCT and CP level. It also aimed to investigate whether the provision of those services was cost effective. Finally, it aimed to determine the impact of the introduction of the HLP scheme on the provision and uptake of those services. At a PCT level, the PNA reports were used to identify the CP provision of SSS, EHC service and chlamydia screening service for the financial year 2009/2010. The local need for SSS (prevalence of smoking adults) and EHC services (rates of teenage pregnancy) were obtained from Health Profiles for each PCT. The need for chlamydia screening service (prevalence of positive chlamydia infection) was obtained from the National Chlamydia Service Programme (NCSP). Uptake and cost attributed to provision of those services for the financial year 2009/2010 were obtained from a short questionnaire targeted the public health leads for the related services in PCTs where the provision of services and the needs were identified. Simple cost-effectiveness analyses were performed on CP SSS and CP EHC provision, based on identified uptake and cost. At a CP level, a cross-sectional survey was conducted on 1 249 CPs in 28 PCTs across England in 2013. PCTs were chosen based on provision of SSS, EHC and chlamydia screening service identified in the PNA reports. 7 PCTs out of 28 PCTs were HLP pathfinder PCTs. CPs were allocated to one of five groups based on deprivation. The response rates for SSS, EHC and chlamydia screening surveys were 30% (42/138), 30% (42/139) and 19% (21/111) respectively. Data analysis identified that the need for SSS and EHC services were highly correlated with deprivation, with Spearman's rank correlation coefficients (rho) of 0.76 and 0.83 respectively (both P 0.001). The correlation between deprivation and the need for a chlamydia service was weak (rho = 0.25, P = 0.009). Higher number of CPs per 25 000 population were observed in more deprived PCTs (rho = 0.63, P < 0.001). CP provision (percentage of CPs offering a service out of total CPs in a PCT) of SSS, EHC and chlamydia service did not correlate with needs. The uptake of SSS, EHC and the chlamydia screening service did not correlate with increasing need or deprivation. However, pharmacists in areas of higher need dealt with a greater number of clients in relation to SSS and EHC services to meet their local needs, with rho of 0.4 and P of 0.01 in case of SSS and Pearson's correlation coefficient (R) of 0.36 and P of 0.02 in case of EHC. A cost-effective analysis of CP SSS provision found it to be cost effective when compared to no intervention based on NHS perceptive and the incremental cost per Quality Adjusted Life Year (QALY) gained. was £1 511. Similarly, the CP EHC service was also found to be cost effective with an NHS saving of £689 per unintended pregnancy prevented. The response rate for the CP survey was 19.3% (241/1 249). No significant differences were identified in terms of provision or uptake of SSS, EHC, chlamydia screening and NHS health check services between CPs with different deprivation neighbourhoods. 18.5% (31/168) of the respondent community pharmacists were working in HLPs. The uptake of SSS through HLPs (median = 6) was higher than that through non-HLPs (median = 4; P = 0.02)._Playing a more active role in health promotion was cited as the main driver for pharmacists to adopt an HLP scheme. Respondent pharmacists indicated that the introduction of an HLP scheme had improved public awareness of vascular and sexual health services available in CPs and they suggested the use of social media websites to further improve public awareness. Lack of time and the provision of similar services via other providers were considered the main barriers. Local Authorities should increase the provision of vascular and sexual health pharmacy services to meet the needs of their localities. They should use the latest technology to improve public awareness regarding availability of those services in CPs.

Declining resources are a global phenomenon. One of the consequences has been the reorganization of health care provision in different countries. Doctor shortages and scarcity of resources particularly in developing countries like Cameroon have resulted in nurses providing frontline care to patients and taking on roles traditionally performed by doctors in developed economies, such as diagnosing and prescribing. However, little is known about the exact role of nurses, the process of providing care, how key stakeholders influence the nurse’s role and the consequences of this role of nurses on the various parties concerned in the context of Cameroon. An empirical study was conducted with (n= 42) key stakeholders; (government representatives, doctors, nursing managers, nurses and patients). Semi-structured taped-recorded interviews were carried out on a one-to-one basis to explore the perceptions of multiple key stakeholders of the role of nurses in diagnosing and prescribing. Interviews were transcribed and data analysed using framework analysis. Nurses are the first point of contact for patients in Cameroon in all health care settings and most have a far greater role in diagnosing and prescribing than their counterparts in developed economies. However their involvement was found to vary significantly depending on a number of factors, including: the organisational context, the type of facility (whether public / private or mission owned), individual nurse characteristics, doctors’ attitudes and practices, resources and experience of nursing managers, level of income and characteristics of patients. Most patients (including women) prefer to consult with doctors and in their absence, male nurses rather than female nurses. Some nurses, patients and doctors felt that a preoccupation with diagnosing and prescribing left nurses with little time for compassion and caring. In addition, the key stakeholders felt that some nurses were overstepping their professional boundaries, or had inadequate knowledge and were acting in a manner detrimental to patient care. Extended roles for nurses have the potential to enhance accessibility to care, to enhance the status and job satisfaction of nursing staff and maximise the use of scarce resources. Despite the benefits, there is growing concern that nurses do not have the advanced level of training and behaviour necessary to take on this expanded role and that some are neglecting the traditional caring side of their profession in pursuit of a more medical oriented disease-focused approach.

Advance care planning for adults is a process of consideration, discussion and decisions about care at the end of life. There is evidence that advance care planning improves outcomes such as the achievement of preferred place of death and the quality of dying. However, the uptake of advance care planning is variable. There are calls for more research to understand what influences people to carry it out to plan services and improve the quality of life of patients and their families. This dissertation reports on a qualitative, video interview study of 15 adult hospice patients. The study was interpretative influenced by the narrative approach with data driven thematic analysis and a video aide memoir. Coding was carried out using the Computer Assisted Qualitative Data Software programme Transana. The rigour and credibility of the study was viewed through the lens of trustworthiness which included the development of a Continuous Conversation Framework. The aim of the study was to investigate what would influence hospice patients to discuss their advance care planning to develop future education programmes based upon the perspectives of people at the end of their life: 1. What influences hospice patients in their advance care planning? 2. What communication skills do hospice patients find helpful when clinicians discuss advance care planning? Three findings are reported. These suggest that the influences on advance care planning activity and conversations is the less reported relationship of the personal context of a person's life (as well as services, diagnosis and prognosis considerations). First, the findings highlight the relevance of how people with an incurable illness live with and talk about their dying within the individual context of their daily lives. Secondly, differences are illustrated between how people prepare (for themselves) and plan (for others) in their dying. Thirdly, clinician communication behaviours such as empathy (through mutual connection and visible behaviours), tailored conversations (through accessible and selective honesty) and the design and use of space empower people to carry out conversations which support them as they live with, prepare and plan for dying. The three findings contribute to the perspective which supports the complexity of advance care planning that should focus on the context of person's life as well as the paperwork, prognosis or diagnosis. A contribution to person-centred care is suggested through a model of relational advance care planning.

This study explored the views of patients, carers and staff within one UK hospice on talking about preferred place of death (PPD). The UK Government's End of Life Care Strategy (EOLC, 2008) states that patients' PPD should be identified, documented and reviewed; yet the hospice in this study did not systematically record such information. It was, therefore, important to ask questions about patient, carer and staff views on PPD as this had not yet been explored. Hence the aims of this exploratory study were to: • Explore key considerations about PPD from the perspectives of hospice patients, carers and staff • Generate theory about the participants’ experience of PPD The methodology of constructivist grounded theory enabled a substantive theory to be generated which offered an interpretative explanation of the participants’ concerns regarding PPD. Data collection methods of focus groups amongst hospice staff, and semi-structured interviews with hospice patients and carers, captured the views of a cross-section of people within the hospice context. The grounded theory demonstrated that recording the patient’s PPD is a means of ‘Enabling the Patient Voice to be Heard’. The ways in which the grounded theory impacts the end of life care landscape were explored including questions around contemporary societal discourses on death; current end of life planning; communication issues at the end of life; health service provision and the roles of healthcare professionals, patients and carers. A reflexive account of the research process and the limitations of the study are also presented. The unique contribution of the study is stated and recommendations for further work are suggested.

No description available.