In the UK there has been growing concern about the relationship between levels of alcohol consumption and offending behaviour. The Alcohol Treatment Requirement (ATR) was introduced to the UK in 2007 and was piloted in a District in the north of England in July 2007. The ATR is a coercive form of treatment delivered jointly by the probation service and the National Health Service (NHS) and was funded by the NHS. The ATR centres on supporting offenders to cease their offending behaviour and reduce or end their alcohol misuse. Two female alcohol treatment workers have been appointed to specifically deliver the ATR. Therefore this study aimed to investigate the delivery of the ATR, and more specifically, aimed to explore what impact the ATR might have in relation to positive behaviour change and rehabilitation for offenders with alcohol problems. In order to meet the expectations of producing ¿outcome¿ data for the NHS funders, and indepth theoretical data worthy of an academic PhD, this research took a pragmatic methodological approach which enabled different social realities of the ATR to be explored. To this end, a mixed methods design was employed involving quantitative and qualitative data collection methods. The data for this research was generated in three phases with Phase One aiming to explore quantitatively the characteristics, impacts and outcomes of those sentenced to the ATR. This phase revealed that the ATR is being delivered to predominantly young, male, alcohol dependent, violent, persistent offenders. This analysis further revealed that the ATR was effective in bringing about positive treatment outcomes and in reducing reoffending. In order to explore further how this positive change was occurring, Phase Two consisted of qualitative participant observations of the treatment interaction involving the female alcohol treatment workers and the male offenders. By drawing on positioning theory, the analysis considered the complexity of the gendered interactions that occurred during these encounters. It was found that the two female alcohol treatment workers resisted positions of ¿feminine carer¿ offered up by these young men in order to occupy positions of control. Indeed this analysis provided great insight into the constant flow of negotiations and manoeuvring of positions that occurred between the alcohol treatment worker and the offender, argued to be vitally important in working towards positive behaviour change. During Phase Three ten offenders were interviewed in order to explore through a dialogical lens (Bakhtin, 1982) how they constructed and experienced treatment on the ATR. In exploring the offenders¿ stories dialogically, the analysis highlighted how the ATR was enabling, in that it offered a ¿space¿ for these offenders to engage and internalise a dialogue that draws on the authoritative voice of therapy. Therefore it was revealed that through dialogue with the ¿other¿, offenders were able to re-author a more ¿moral¿ and ¿worthy¿ self. Moreover, the ATR has been found to be successful in enabling the offenders¿ hegemonic masculine identities to be both challenged and protected as a result of the multilayered interactions that occurred during these treatment encounters. This research therefore concludes that coercive treatment, rather than being a concern, should be embraced as a way of enabling change for offenders with alcohol problems. Furthermore, this research has highlighted the value of the relational aspect of treatment in bringing about positive behaviour changes. Finally this research has shown that community sentences offer a more constructive way of engaging with offenders than those who receive a custodial sentence.

Background: The impact children with complex healthcare needs have on the healthcare system is significant and requires a multidisciplinary response. Congenital anomaly (CA) is a group of conditions requiring complex and variable input from primary and secondary healthcare. This thesis explores the literature on health system preparedness for children with complex healthcare needs and quantitatively describes healthcare use for a population of children with CA, an exemplar for children with complex healthcare needs. Methods: Routine health data from primary care was explored to identify children with CA and linked to secondary care data, outpatient records, and questionnaire data from a multi-ethnic prospective birth cohort over a five-year period. Rates of CA were calculated and healthcare use for children with and without CA was analysed. Results: Out of a birth cohort of 13,857 children, 860 had a CA. Using primary care data for children aged 0 to 5 years, the number of children with CA was found to be 620.6 per 10,000 live births, above the national rate of 226.5 per 10,000 live births. Healthcare use was higher for children with CA than those without CA. Demand for use of hospital services for children with CA was higher (Incident rate ratio (IRR) 4.38, 95% confidence interval (CI) 3.90 to 4.92) than demand for primary care services (IRR, 1.27, 95% CI 1.20 to 1.35). Conclusion: These results suggest that using primary care data as a source of CA case ascertainment reveals more children with CA than previously thought. These results have significant implications for commissioning healthcare services for children with complex healthcare needs.

No / The National Health Service (NHS) in England must improve productivity by 6% per annum if projected savings of £21 billion are to be attained by 2014, while simultaneously improving or at least maintaining the quality of care (Department of Health (DH), 2009; 2010a). Given that staff costs represent 60% of the current NHS budget, it is likely that both the number and composition of the 1.7 million strong workforce will need to be changed to meet these targets. In the Department of Health's draft Structural Reform Plan (2010b), the emphasis is on shifting resources to promote better healthcare outcomes, to which end a review of working practices and role relationship must take place, with increased delivery of services by community nurses.

No / There are 353 NHS hospitals in the United Kingdom, and within these hospitals there is wide variation in the electronic prescribing systems applied. Indeed, only one hospital uses a single system in all of its clinical areas. Medication error is the biggest issue in the health care profession in respect to patient safety—

Yes / Even prior to the conclusion of the European Union (EU) referendum (Brexit), the NHS was showing tremendous signs of strain. Immediately after the outcome was announced, promises of major re-investment of funds saved from payments to the EU were retracted. Since then, hospital closures, cuts and changes to health and social care have been revealed, with regular news broadcasts highlighting the crisis facing the NHS. The uncertainties about post-Brexit relationships, economy, politics and security are likely to further significantly impact the NHS and its sustainability. Higher Education Institutions (HEIs) and the NHS are inextricably linked through research and education of health and social care professionals – changes therefore having implications for both.

No / Worldwide healthcare systems are facing immense changes in the demand of care with vast cost explosions caused by aging populations and the increase in chronic and mental diseases. The move towards patient-centered healthcare seems to be an ideal approach to meet future challenges but still clashes with reality. Patient Advice and Liaison Service (PALS) in the UK is one of the unique examples of patient empowerment to influence changes in healthcare systems like the National Health Service (NHS). The purpose of this paper is to look at user-driven organizational change management in PALS in retrospect to learn from its ‘best’ and ‘worst’ practices. In conclusion, patient-centered healthcare becomes more realistic if healthcare users and workers are empowered at the same time. The vision of patient, public, and staff involvement in the move towards patient-centered health needs to be backed up by adequate and secure resources as well as consistent organizational leadership and change management. Organizational change processes in general should be seen as biological continuous cycles with unpredictable evolutionary turning points rather than linear progressions. This helps to stay optimistic and embrace change as challenging, exciting, and difficult all the way through the change process.

This thesis examines a middle manager’s response to strategic directives on integrated care in a National Health Service (NHS) organisation and the development of an awareness of prejudice that acknowledges its relationship to the process of understanding. The research focuses on an integration of two community NHS trusts and an NHS hospital trust into one integrated care organisation (ICO). A change programme was initiated and promulgated on an assumption that integrating the three organisations would facilitate integrated care. However, despite the use of organisational change approaches (such as communication plans and systematic approaches to staff engagement), implementing the strategy directives in practice remained problematic. What emerged during the integration process was resistance to change and a clear division in the different ways of working in the community NHS trusts versus the community and hospital trusts – differences that became apparent from the prejudices of individuals and staff groups. The proposition is that prejudice is an important aspect of relationships whose significance in processes of change is often overlooked. I argue that prejudice is a phenomenon that emerges in the processes of particularisation, which I describe as an ongoing exploration and negotiation in our day-to-day activities of relating to one another. Our pejorative understanding of the term ‘prejudice’ has overshadowed more subtle connotations, which I propose are unhelpful in understanding change in organisations. However, I suggest a different way of thinking about prejudice – namely as a process that should be acknowledged as a characteristic of human beings relating to one another, which has the potential to generate and enhance understanding. The research is a narrative-based inquiry and describes critical incidents during the integration process of the three organisations and focusing on interactions between key staff members within the organisation. In paying attention to our ongoing relationships, there has been a growing awareness of disconnection from traditional management practices, which advocate systematic approaches and staff engagement techniques that are designed to encourage cooperation and reduce resistance to proposed change. This thesis challenges assumptions surrounding prejudice and how middle managers traditionally manage organisational change in practice in their attempts to apply deterministic approaches (which assume a linear causality) to control and influence human behaviour. I have taken into consideration a hermeneutic perspective on prejudice, drawing on the work of Hans Georg Gadamer, and have argued from the viewpoint of the theory of complex responsive processes. This offers an alternative way of thinking about management as social processes that are emergent in our daily interactions with one another, that are not based on linear causality, or on locating leadership and management with individuals. It provides a way of taking seriously the relationships between individuals by paying attention to what emerges from the interplay of our expectations and intentions. This leads to a different way of thinking about the relationship between prejudice and strategic directives, which I argue are not fixed instructions but unpredictable articulations of our gestures and responses that emanate from social interaction and continually iterate our thinking over time. This paradoxically influences how we make generalisations and particularise them in reflecting on and revising our expectation of meaning I suggest that it is not possible to predetermine a strategic outcome; and that traditional management practice, which locates change with individuals – and reduces aspects of organisational life, such as resistance, into a problem to be fixed – obscures our capacity to understand the processes of organisational change in the context of a much wider social phenomenon. I therefore conclude that my original and significant contribution to the theory of complex responsive processes and to practice is encouraging a different way of thinking about prejudice – as a process that can be productive and generate understanding, when considered as encompassing our expectations of meaning, linked to our own self-interests. This then opens up possibilities for transforming ourselves in relation to others – and, through this process, to transform the organisations in which we work.

Previous research has reported that inequalities exist in uptake of NHS sight tests in relation to socio-economic status, and that community optometric services have potential to improve system efficiency. The current research found inequalities in sight test outcome related to socio-economic status and the type of practice that a patient visits (multiple, or independent). Patients attending multiples were more likely to receive a ‘new or changed prescription’ relative to ‘no prescription’ compared to patients that attended independent opticians (36-71% more likely). Those living in the least deprived areas were also less likely to receive a new prescription (1-12%) and those aged <16 years were less likely to be referred (9%). The study examining the need for a Minor Eye Condition Service in Leeds and Bradford found it would produce theoretical cost savings, whilst maintaining high patient satisfaction. Subsequently, a MECS was commissioned in Bradford. The study attempting to collect data from MECS across all areas of England found that data is not routinely collected, or shared. The limited data available typically showed that 73-83% of patients were retained in optometric practice with 12-18% receiving a hospital referral. A prospective evaluation of a COVID urgent eye care service found that teleconsultations frequently did not resolve patients’ eye problems (27%). These telephone consultations failed to detect some serious conditions such as scleritis, wet macular degeneration, retinal detachment. The results from the thesis support the view that the current method of delivering eye care in England is contrary to the public health interest.

No / Using data for every elective procedure in 2007 in the English National Health Service, we found evidence of socioeconomic inequality in the probability of having a procedure cancelled after admission while controlling for a range of patient and provider characteristics. Whether this disparity is inequitable is inconclusive.; Using data for every elective procedure in 2007 in the English National Health Service, we found evidence of socioeconomic inequality in the probability of having a procedure cancelled after admission while controlling for a range of patient and provider characteristics. Whether this disparity is inequitable is inconclusive. Copyright A[c] 2012 John Wiley & Sons, Ltd.; � Using data for every elective procedure in 2007 in the English National Health Service, we found evidence of socioeconomic inequality in the probability of having a procedure cancelled after admission while controlling for a range of patient and provider characteristics. Whether this disparity is inequitable is inconclusive.