Doctor of Philosophy / ABSTRACT Integrative medicine (IM) is a dynamic and increasingly prevalent model of primary health care that combines complementary and alternative medicine with mainstream medicine. This research is about the practice of IM and its value to primary health care in Australia. It locates IM within Australian health care by revealing its processes and outcomes in terms of: practice styles, interactions between practitioners and clients and among practitioners, range of diagnostic and treatment options, and health benefits. In this research I examine the nature of integrative medicine (IM) in co-located primary health care practices and consider the influence that integrating mainstream medicine and CAM can have on the perceived quality of primary health care in Australia. My goal was to contribute the knowledge of the phenomenon of IM through a deeper understanding and interpretation of IM gained by investigating the perceptions of core stakeholders, in this case clients and practitioners of IM. This research was situated in the interpretive paradigm and used two research methodologies: hermeneutics (to interpret the value of IM as reported in the literature) and hermeneutic phenomenology (to understand meanings and significance that clients and practitioners attach to their experiences of IM). Data collection involved the collation of existing literature texts and by cumulative case studies (using semi-structured interviews and observation), focus groups, and key informant interviews. Using a blend of methodologies provided a rich and powerful means of understanding the processes and outcomes of IM through the interpretations of its core stakeholders’ lived experiences. In particular I sought perceptions of clients and practitioners of IM about their health and health care including assessment and treatment options, health outcomes, congruence with beliefs and values, collaborative practices and power sharing. Data analysis was conducted concurrently with and subsequent to data collection so that questioning, observation and textual interpretation were progressively guided by the data. A set of meta-themes emerged from the fusion of findings from all phases of the research. These meta-themes represented answers to key research questions. They are: • Power/authority • Mutual respect • Professionalism • Ontological perspectives • Duty of care. This thesis identifies IM practice styles according to different levels of client agency and degrees of power sharing that exist among CAM and mainstream medical practitioners. A theorised model based on the research findings which depicts quality of health care as a variable consequence of diverse practice styles of IM is produced in two parts: Part 1 acknowledges that IM is a variable phenomenon in practice with different levels of collaboration, power-sharing and quality of health care; Part 2 presents an optimum mode of IM practice. Authentically client-centred health care is at the core of all of these practice styles. This thesis has significant implications for the way IM is practised and for primary health care delivery more broadly. IM that is mutually respectful and genuinely collaborative is flexible, inclusive, and socially relevant and has a substantial and far-reaching contribution to make to the quality of primary health care.

Doctor of Philosophy / ABSTRACT Integrative medicine (IM) is a dynamic and increasingly prevalent model of primary health care that combines complementary and alternative medicine with mainstream medicine. This research is about the practice of IM and its value to primary health care in Australia. It locates IM within Australian health care by revealing its processes and outcomes in terms of: practice styles, interactions between practitioners and clients and among practitioners, range of diagnostic and treatment options, and health benefits. In this research I examine the nature of integrative medicine (IM) in co-located primary health care practices and consider the influence that integrating mainstream medicine and CAM can have on the perceived quality of primary health care in Australia. My goal was to contribute the knowledge of the phenomenon of IM through a deeper understanding and interpretation of IM gained by investigating the perceptions of core stakeholders, in this case clients and practitioners of IM. This research was situated in the interpretive paradigm and used two research methodologies: hermeneutics (to interpret the value of IM as reported in the literature) and hermeneutic phenomenology (to understand meanings and significance that clients and practitioners attach to their experiences of IM). Data collection involved the collation of existing literature texts and by cumulative case studies (using semi-structured interviews and observation), focus groups, and key informant interviews. Using a blend of methodologies provided a rich and powerful means of understanding the processes and outcomes of IM through the interpretations of its core stakeholders’ lived experiences. In particular I sought perceptions of clients and practitioners of IM about their health and health care including assessment and treatment options, health outcomes, congruence with beliefs and values, collaborative practices and power sharing. Data analysis was conducted concurrently with and subsequent to data collection so that questioning, observation and textual interpretation were progressively guided by the data. A set of meta-themes emerged from the fusion of findings from all phases of the research. These meta-themes represented answers to key research questions. They are: • Power/authority • Mutual respect • Professionalism • Ontological perspectives • Duty of care. This thesis identifies IM practice styles according to different levels of client agency and degrees of power sharing that exist among CAM and mainstream medical practitioners. A theorised model based on the research findings which depicts quality of health care as a variable consequence of diverse practice styles of IM is produced in two parts: Part 1 acknowledges that IM is a variable phenomenon in practice with different levels of collaboration, power-sharing and quality of health care; Part 2 presents an optimum mode of IM practice. Authentically client-centred health care is at the core of all of these practice styles. This thesis has significant implications for the way IM is practised and for primary health care delivery more broadly. IM that is mutually respectful and genuinely collaborative is flexible, inclusive, and socially relevant and has a substantial and far-reaching contribution to make to the quality of primary health care.

AIMS Managed care is a market model of health care distribution, aspects of which are being incorporated into the Australian health care environment. Justifications for adopting managed care lie in purported claims to higher levels of efficiency and greater ‘consumer’ choice. The purpose of this research, then, is to determine the ethical implications of adapting this particular administrative model to Australia’s health care system. In general, it is intended to provide ethical guidance for health care administrators and policy-makers, health care practitioners, patients and the wider community. SCOPE Managed care emerges as a product of the contemporary, neo-liberal market with which it is inextricably linked. In order to understand the nature of this concept, then, this research necessarily includes a limited account of the nature of the market in which managed care is situated and disseminated. While a more detailed examination of the neo-liberal market is worthy of a thesis in itself, this project attends, less ambitiously, to two general concerns. Firstly, against a background of various histories of health care distribution, it assesses the market’s propensity for upholding the moral requirements of health care distributive decision-making. This aspect of the analysis is informed by a framework for health care morality the construction of which accompanies an inquiry into the moral nature of health care, including a deliberation about rights-claims to health care and the proper means of its distribution. Secondly, by way of offering a precautionary tale, it examines the organisational structures and regulations by which its expansionary ambitions are promoted and realised. CONCLUSIONS As a market solution to the problem of administering health care resources, the pursuit of cost-control, if not actual profit, becomes the primary objective of health care activity under managed care. Hence, the moral purposes of health care provision, as pursued within the therapeutic relationship and expressed through the social provision of health care, are displaced by the economic purposes of the ‘free’ market. Accordingly, the integrity of both health care practitioners and communities is corrupted. At the same time, it is demonstrated that the claims of managed care proponents to higher levels of efficiency are largely unfounded; indeed, under managed care, health care costs have continued to rise. At the same time, levels of access to health care have deteriorated. These adverse outcomes of managed care are borne, most particularly, by poorer members of communities. Further, contrary to the claims of its proponents, choice as to the availability and kinds of health care services is diminished. Moreover, the competitive market in which managed care is situated has given rise to a plethora of bankruptcies, mergers and alliances in the United States where the market is now characterised by oligopoly and monopoly providers. In this way, a viable market in health care is largely disproved. Nonetheless, when protected within a non-market context and subject to the requirements of justice, a limited number of managed care techniques can assist Australia’s efforts to conserve the resources of health care. However, any more robust adoption of this concept would be ethically indefensible.