Social prescribing aims to offer an alternative to pharmaceutical or psychological treatments for mild to moderate mental health problems that present in primary care. Social prescribing seeks to link people with community-based sources of support, which are provided outwith the traditional National Health Service (NHS). As such, it calls for collaborative working between three groups: service users, prescribers (health professionals), and providers of community-based activities. However, little is known about these stakeholders' perceptions of social prescribing as an acceptable and appropriate alternative care pathway. ~; ..• Drawing on the theory of social capital, this study aimed, firstly, to develop an understanding of the nature and potential of social prescribing as a means of health improvement. Secondly, it sought to identify factors that were likely to help or hinder' successful implementation. This qualitative, exploratory study adopted a case study methodology underpinned by a critical realist perspective. Three cases were selected purposively. Each was a community-based organisation offering activities which were being 'prescribed' by NHS health professionals. At each site, semi-structured interviews were carried out with a purposive sample of health professionals, service users and providers of the service (n=49). Findings indicate that service users were enthusiastic about the activities provided by the three community-based organisations. Processes of self-efficacy and social support appeared to have been facilitated by participatory person-centred relationships with service providers. These mechanisms were encouraged to operate by providers' creation of enabling contexts. Although challenges to the successful implementation of social prescribing were identified at individual, inter-personal, institutional and infra-structural levels, the findings suggest that social prescribing offers a promising alternative care pathway for people with mild to moderate mental health problems. It provides a holistic framework which, potentially, shifts the focus of care from an individual's deficiencies to their strengths, and from seeing people as passive recipients of services to active participants.

Background: Nurses, midwives, health visitors, pharmacists, chiropodists and others have all begun to assume the role of prescriber of medicines. However, little work has been done comparing how effective these prescribers are in relation to the medical or traditional prescribers; and even less looking at the overall safety of prescribing in relation to errors and near misses. This study examines the safety element to prescribing and encompasses training to prescribe, prescribing in practice, support required, errors and near misses and the experience of both traditional and non-traditional practitioners. Methods: Embedded single case study analysis was used which included three subunits; analysis of one year of reported errors and near misses, semistructured interviews with each group of prescribers and a review of archival records of prescribing. Prescriptions were analysed using a validated error tool and interviews were analysed using Colazzi's procedural steps (1978); all data were then reviewed using the Brunswikian lens model (Scholz & Tietje 2002). Results: All prescribers wanted better initial prescribing education and continual updates once qualified. Non-traditional prescribers made fewer errors than traditional prescribers, though they do have a higher near miss rate than traditional prescribers. 3 Prescribers use a range of staff for support, though non-traditional prescribers are more likely to use their peer group. Traditional prescribers have a more relaxed attitude to mistakes. Prescribing staff do not trust the incident reporting system primarily since there is no useful feedback given which would improve prescribing practices. Conclusions: The trust needs to work with educational institutions to improve prescribing training for all staff. They also need to ensure that there is some method available for all prescribers to be regularly updated or tested on their ability to prescribe. Errors or near miss incidents involving prescribing must be shared with all prescribers so that everyone can learn from them. This information is transferable to other, similar institutions.

Medicines management involves the safe and cost-effective use of medicines across the health economy in order to produce informed and desired outcomes of patient care. Anecdotal evidence suggested that various aspects of medicines management in the British Anny, both in peacetime and on operational deployments, were not as robust as in mainstream NHS care. This study aimed to explore British Army doctors' views on medicines management (prescribing and dispensing) on matters such as ethical a professional concerns with the role of dispensing doctor and cost-effective prescribing.

The Medicines Use Review and Prescription Intervention (MUR) service was commissioned as part of the 2005 community pharmacy contract for England and Wales. The aim of the MUR service is to improve patients’ knowledge and use of medicines and to reduce avoidable medicines waste. MURs form part of a Government strategy that aims to improve patients’ adherence to medicines in order to optimise health gain and reduce cost associated with unused medicines. MURs are also seen as a ‘concordance review’ and pharmacy’s professional bodies acknowledge the service as a means to further the professional role of community pharmacists. However, it remains uncertain from studies investigating the outcomes of MURs, the extent to which the service is benefitting patients. One significant drawback to previous studies is the lack of in-depth investigation of the MUR consultation and the patients’ perspective of the service. This thesis provides valuable insights into what occurs during an MUR consultation and investigates the patient’s perspective of the service and that of the pharmacy staff. This work also explores whether the MUR policy aims are being realised in practice and translated into more effective use of medicines. Ten weeks of fieldwork observations were undertaken in two English community pharmacies. One-week placements were made over a 12-month period between November 2008 and October 2009. Observations were made of all pharmacy activities, including fifty-four MUR consultations. Thirty-four patients subsequently agreed to be interviewed about their experience of the MUR. Eight patients were observed to decline the offer of an MUR, of which three patients were interviewed about the reasons why they declined. After the pharmacy observations were completed, five pharmacists and twelve support staff interviews were held to discuss professional perspectives of MURs. The findings from this study suggest that the MUR service is a modern and developing service but one that remains unestablished. Patient awareness of MURs was poor and nearly all MURs were initiated by the pharmacist; no patients were referred from the GP. Pharmacy staff did not actively seek to recruit patients who may benefit most from an MUR and the majority were invited in ad hoc manner. Patients were given little time to consider whether to take part in an MUR and were insufficiently informed of their purpose or personal value. MURs were framed as a monitoring activity and most patients reported that the MUR did little to improve their knowledge of their medicines and rarely affected their use. They perceived their GP to have the main authority over their medicines. Patients considered that significant medicine-related problems would be best resolved by talking to the GP rather than with the pharmacist during an MUR. In effect, a supplier induced demand for MURs was observed. Nevertheless, all patients reported feeling comfortable speaking to the pharmacist during an MUR and most described the consultation in positive terms. Most patients viewed the pharmacist as a knowledgeable expert and some felt reassured about their medicines following an MUR. Observations of the MUR consultation revealed pharmacists were subordinate to the ‘technology’ of the MUR form and adhered to its ‘tick-box’ format. Pharmacists used predominantly closed questions which enabled the MUR form to be completed efficiently, but this forestalled wider discussion of the patient’s health and medicines. The MUR service was at odds with the intention to create a patient-centred service. When complex or indeterminate issues were raised, these were often circumvented or the patient referred to the GP. Pharmacists reported in their interviews that they welcomed MURs and the resultant potential to raise their profile with patients. However, they were unclear about what they wanted to advise during an MUR and how patients might gain maximum benefit from the review. They also reported concerns over patient recruitment, organisational pressures to pursue a target number of MURs and difficulties integrating MURs within their existing activities. MURs were pragmatically accommodated alongside existing duties without additional resource. Support staff reported feeling discomfort when they were left to explain to patients and customers why the pharmacist was absent during an MUR and described using various strategies and personal judgements to deal with waiting patients. This study has important implications for patients, professionals and policy makers. Patients should be aware that the MUR service is funded by the NHS and is available for them to use. More support from GPs is needed to identify patients who may most benefit from an MUR. This study highlights the need for consultation and communication skills training for pharmacists, so they are able to effectively elicit patient beliefs, concerns and preferences about medicines during the MUR. Organisations also need to reconsider the way they motivate pharmacists to undertake MURs to avoid unintended consequences for patient care. Policy makers should reconsider strategies that are based on rationalised policies as a means to improving patient adherence to medicines. Effective services need to be responsive to the patient’s individual circumstance and preference. Further research is needed into MURs in a wider and more diverse range of pharmacy settings in order to explore these issues further.

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Actuellement, plus de 70% des biomédicaments commercialisés sont des glycoprotéines recombinantes. Les coûts élevés de production de ces biomédicaments ont poussé les scientifiques à développer des organismes de production alternatifs. Récemment, les microalgues ont été proposées en tant que potentiel système de production compte-tenu de leur rapidité de croissance et de leurs faibles coûts de production. Cependant, avant de produire des biomédicaments industriels chez les microalgues, il est impératif de s’assurer que les modifications post-traductionnelles, comme la N-glycosylation, soit conservées et compatibles avec une utilisation thérapeutique. Dans ce contexte, l’étude de la Nglycosylation de deux microalgues modèles, Chlamydomonas reinhardtii (microalgue verte) et Phaeodactylum tricornutum (diatomée) a été réalisée. Dans un premier temps, l’ingénierie de la N-glycosylation de C. reinhardtii a été initiée en exprimant une Nacétylglucosaminyltransférase I (GnT I) hétérologue. Les résultats obtenus ont permis de réévaluer les voies de N-glycosylation de C. reinhardtii et de montrer que cette microalgue synthétise une structure glycannique linéaire qui n’est pas substrat de la GnT I. Dans un second temps, un protocole d’extraction et de caractérisation des précurseurs glycanniques de C. reinhardtii et P. tricornutum a été développé et appliqué pour déterminer la structure des précurseurs glycanniques dans ces espèces. Enfin, la caractérisation de deuxxylosyltransférases potentielles (XTA et XTB) de C. reinhardtii a été menée en utilisant des mutants d’insertion et des analyses des N-glycannes par spectrométrie de masse. Cette étude a confirmé les rôles spécifiques de XTA et XTB dans la voie de N-glycosylation de C. reinhardtii. / Currently, more than 70% of the commercialized biopharmaceuticals are glycoproteins. The high production costs lead scientists to develop alternative organisms suitable for such production. Recently, microalgae emerged as a potential interesting production system thanks to their quick growth rate and low production costs. However, prior to start industrial glycoproteins production in microalgae, protein post-translational modifications like Nglycosylation, must be carefully controlled. This PhD thesis focused on the analysis of the Nglycosylation pathway of two different microalgae, Chlamydomonas reinhardtii (greenmicroalgae) and Phaeodactylum tricornutum (diatom). In order to start N-glycan engineering, heterologous N-acetylglucosaminyltransferase I (GnT I) sequences were expressed in C.reinhardtii. This study demonstrated that C. reinhardtii synthetize a linear N-glycan unsuitable for GnT I activity and allows the reinvestigation of the C. reinhardtii N-glycosylation pathway. A second chapter of this work focus on the optimization of a protocol suitable for analyzing the structure of the Dolichol N-linked precursors of C. reinhardtii and P. tricornutum. Lastly, two potential xylosyltransferases (XTA and XTB) from C. reinhardtii were characterized using insertional mutants and N-glycomic analyses by mass spectrometry approaches. This work allows us to propose specific involvement of XTA and XTB in the xylosylation processing of C.reinhardtii N-glycans.