This thesis is concerned with the transfer of prison healthcare to National Health Service (NHS) responsibility, and investigates whether equitable provision has been achieved for prison-based patients. The chronic ill health of prisoners in England has been recognised for centuries. For example, Howard debates the issue in 1784. When released from prison, English prisoners’ abilities to carry ill health and infection into the community is more recently acknowledged as an additional significant concern (Ramsbotham, 1996). Three themes are evident when analysing the policy and legislative background demanding fair and equitable provision for all. These are: Philanthropy and Concern for Prison Healthcare, Prison Specific Policy and Recommendations, and the Wider NHS Policy, National Service Frameworks and Strategies. Three distinct phases of the Public Health Agenda are considered in this thesis: 1784 - 1890, 1945 - 1996, and 1997 - 2010. Investigation of the Public Health Agenda is divided into sub-categories: Health Promotion, Health Education, Disease Prevention, Healthy Settings, and Prisoner Health providing a valuable structure within which the wider literature can be evaluated empirically via this thesis’ fieldwork. Interpretivist in its methodology, this qualitative study adopts Case Study as an appropriate methodology. Research methods include focus groups, interviews, and participant correspondence. Presentation of research phenomena through graphic representation was designed to overcome reported literacy and language issues present within the research population. Combined, these methods offer an opportunity to build a “polyhedron of intelligibility” (Foucault, 1981, p. 6) demanded of this methodological approach. Between 2005 and 2010, this study explored prisoners’ experiences of healthcare post-transfer to NHS responsibility via five distinct phases of fieldwork: the identification of key patient themes of interest within a self-selecting sample, the validation of Phase One material and the generation of 5 | P a g e additional themes, focus group discussions, followed by interviews with participants and wider stakeholders, and finally a discussion group. Data are analysed and structured according to prison category and gender, age, and ethnicity. Resultant analytical themes linked to a central coding category, the overarching topic of Patient Equivalence. Furthermore, there are three analytical Key Themes: Beliefs, Attitudes and Behaviour; Service Commissioning, Delivery and Constraints; and Patients’ Health and Patient Outcomes. Here, the identification of Imprisoned Carers provides a unique and novel finding of this work. From these three analytical categories, a Core Theory emerged. Research data indicates that, despite considerable policy focus and activity, the lack of integrated service commissioning means that equitable provision for this prisoner population has not been consistently experienced by imprisoned patients. In its absence, prisoners have themselves adopted the role of carer for the sick and frail amongst their prison communities. These individuals report that they undertake these caring roles unsupported by the NHS and/or the Prison Service, whilst at considerable risk to both themselves and the person for whom they care. To achieve equitable provision for English prisoners, this thesis suggests the development of a prison multi-agency health and social care integrated service commissioning plan which recognises the needs of imprisoned carers as highlighted in this study.

Health and social care systems, primarily designed for people with single diseases rather than those with multimorbidity (two or more long-term conditions [LTCs]), are becoming more complex. With increases in the older population, a rise of multimorbidity and greater fragmentation in the care landscape, little is known about how multimorbidity affects the patient’s task to find appropriate care in the right place and at the right time (i.e. care navigation). Difficulties in care navigation have proven to cause delays in access and use of inappropriate services. For older individuals with a number of LTCs, there is an urgent need to support them in appropriately navigating the care system to maximise their health and wellbeing. Using a mixed method design, this study aims to map the personal care network (PCN) of older people (aged 55 years and over) with multimorbidity. It explores the use of Information and Communication Technologies (ICT) to support this patient group in finding their way through the care system. The research involves three stages, addressing the overall question: “Navigating the care system: what is feasible and acceptable with regard to the use of ICT to support older people with multimorbidity?” A scoping review brings together the limited literature on care navigation in older people with multimorbidity and identifies gaps in knowledge. The results demonstrate that navigating the care system is perceived to be a daunting task for many patients. Patients have to learn through experience, rather than being able to rely on systems and actors within the care environment. The gaps in knowledge and practice, identified in the scoping review, are the drivers of the second stage of the study. Stage two investigates from a patients’ perspective, the structure and composition of the PCN surrounding older people with multimorbidity. People and services (actors) involved in the care for this patient group are explored through data from self-administered questionnaires (n=62) and semi-structured interviews (n=7). PCNs are visualised through Social Network Analysis (SNA), detailing those actors involved in the network and their relationship. The application of framework analysis enables a definition of roles and responsibilities within the PCN. Stage three of the study outlines the process of creating data-driven personas for the design of digital PCN navigation support for the study population. This study stands at the intersection of care and ICT. With the expansion of research informing design of ICT for care, this study delivers a number of original contributions to the field. First, the study develops and applies a new conceptual framework: Patient-Centred-Design. Patient-Centred-Design is grounded in and connects three distinguished theories (patient-centred care, patient empowerment and user-centred design). Secondly, the use of innovative methods dictated by this conceptual framework provides valuable additions to the field of SNA by comparing pre and post interview maps of PCNs. Thirdly, this study contributes to health and social care by filling current gaps in care navigation in older people with multimorbidity. Finally, theoretical and practical additions are presented to the field of Human-Computer Interaction through the provision of design requirements.

This work represents a significant contribution to the body of knowledge in the area of renal transplantation as it brings together the research related to policy analysis, empirical research, and cultural and religious issues related to organ donation and transplantation among South Asians in the UK. The candidate's work in this area is the first in the UK to systematically document and map a national picture of kidney transplant waiting lists and to identify and examine the complex reasons underlying how and why patient ethnicity impacts upon the likelihood of receiving a kidney transplant. The candidate has also developed a new evidence-base exploring the adequacies of the existing procurement arrangements and the implications of introducing any alternative policies within the context of a multi-ethnic and multifaith UK. Finally, the candidate's work has focused on developing an evidence-base of the public perceptions, attitudes, and religious viewpoints towards organ donation and transplantation among a cross-section ofthe South Asian population. The candidate's published works have been the foundation blocks for stimulating and informing the debate on the provision of renal transplant services for minority ethnic groups through the generation of an empirical evidence-base in a subject area which has traditionally relied upon anecdotal evidence. The evidence-base illuminates a very complex issue which has multi-faceted solutions that need to be addressed in different settings.

The Kingdom of Saudi Arabia (KSA) faces an increasing chronic disease burden. Despite the increase in numbers of primary health care centres (PHCCs) current evidence from the KSA, which is limited overall, suggests that access and utilisation of PHCCs, which are key to providing early intervention services, remain unequal with its rural populations having the poorest access and utilisation of PHCCs and health outcomes. There is a dearth (lack) of information from the KSA on the barriers and facilitators affecting access and utilisation of primary health care services (PHCS) and therefore this study aimed to examine the factors influencing the access and utilisation of primary health care centre (PHCC) in urban and rural areas of Riyadh province of the KSA. The behavioural model of health services use (Andersen’s model) provided the contextual and individual characteristics and predisposing, enabling and need factors which assist with an understanding of the barriers and facilitators to access and utilisation of PHCCs in Riyadh province. A mixed methods approach was used to answer the research questions and meet the objectives of the study. The converged qualitative and quantitative findings show that there are a number of predisposing (socio-demographic characteristics; language and communication and cultural competency) enabling barriers such as; distance from PHCCs to the rural residence, lack of services, new services, staff shortages, lack of training, PHC infrastructure, and poor equipment. Facilitators: service provider behaviour/communication, free PHCS, service provision and improvements, primary health care (PHC) infrastructure, manpower, opening hours, waiting time, and segregated spaces and need (increasing prevalence of chronic diseases, PHC developments in the KSA) factors influencing access and utilisation of PHCS. This study highlights important new knowledge on the barriers and facilitators to access and utilisation of PHCS in Riyadh province in the KSA. The findings have some important policy and planning implications for the MOH in the KSA. Specifically, the findings suggest: the need for clear documentation/guidance on minimum standards against which the PHCS can be measured; an audit of service availability at the PHCCs, regular patient satisfaction evaluations of PHCS, that the MOH take a parallel approach and continue to resource and improve buildings and equipment in existing PHCCs, the recruiting of more GPs, nurses, pharmacists, nutritionists and physiotherapists to meet patient demand and more Saudi health care staff, more targeted health education and interventions for the prevention of chronic diseases in the KSA and the need for an appointment system for attending the PHCCs. There is a need for further research into the barriers and enablers to accessing and utilising health care in Riyadh and the KSA overall. This research would be made easier with a clearer definition of rural and urban in the KSA context which would allow a greater comparability between urban and rural PHCS for future research, audit and evaluation as well as comparison with PHCS in other parts of the world. The Andersen model provided a useful conceptual model to frame this research and provided a structure for contrasting and comparing the findings with other studies that have used the Andersen model to understand the barriers and enablers to accessing and utilising health care services.