No / There is a marked increase in the number of General Practitioner (GP) organisations across Europe providing out of hours (OOH) emergency primary care services whereby GPs and/or Nurse Practitioners (NPs), provide telephone consultations to patients (Giesen et al., 2007a, McKinstry et al., 2009, Derkx et al., 2009). This has been an important development to manage the rising demand for health care with increasingly scarce resources (Blank et al., 2012, Purc-Stephenson and Thrasher, 2010) and also reduces unnecessary attendance at accident and emergency departments or home visits by GPs (Bunn et al., 2005, Roberts et al., 2008)... In this study we describe the characteristics of telephone consultation calls made by pregnant women to an OOH service run by a GP co-operative and also to compare and contrast the differences between the way the calls were handled by GPs and Nurse Practitioners (NPs). The NPs were qualified and registered nurses experienced in primary care or emergency care settings and none were practicing.

Decisions about where and when to seek advice about illness are known to be complex and are often bound up with issues of risk, responsibility and legitimacy. They can be particularly difficult in situations where the meaning and severity of symptoms is unclear. In deciding whether or not to seek help, people must negotiate the tension between using health services in ways that are considered appropriate, while not taking risks with their health or that of the person they are caring for. This thesis explores how individuals account for a specific decision to call NHS 24 about symptoms in themselves or someone they were caring for and how that decision fits within their use of health services more generally. Building on what is already known about help-seeking behaviour, it seeks to understand how people interpret symptoms as needing or not needing attention and what is understood by appropriate help-seeking in the context of out-of-hours care. There have been significant changes to the way that out-of-hours health care is provided in Scotland. An increase in routes into care means that people must negotiate a complex health system when seeking help. At the same time, pressure on resources has created an imperative to ensure that health care is used in the most efficient way possible. NHS 24 is primarily an out-of hours triage service providing assessment and, where necessary, referral to other services. At its inception, NHS 24 was presented as being designed to simplify access to health care by acting as a ‘gateway’ to the NHS in Scotland. However, increasing demand has led to attempts to limit use of NHS 24, in the out-of-hours period, to situations where symptoms are considered to be too urgent to wait for a GP appointment. NHS 24 can now be understood as one of a number of different points of access to health care that people must choose between; this requires individuals to engage in a process of categorising their symptoms according to urgency as a way of ensuring that their call is considered appropriate. The thesis draws on data from 30 in-depth semi-structured interviews with people who had called NHS 24 in the out-of-hours period. The symptoms the participants had called about were generally, though not universally, what might be classed as minor symptoms. Most of the interviewees were given self-care advice rather than referral for a face-to-face consultation. The interviews focussed on a specific contact with NHS 24 but aimed to situate the call in the context of the interviewee’s understanding of NHS 24, as well as their illness behaviour and use of health services more generally. The analysis suggests that people’s understandings of NHS 24 are not straightforward and that this can cause some confusion and even anxiety for callers. Interviewees’ accounts emphasise uncertainty about the severity of symptoms, a sense of worry that symptoms may be indicative of a serious problem, and the inadequacy of their own knowledge in the face of potential risks. In talking about their reasons for calling NHS 24, they describe seeking, and obtaining, reassurance that they were ‘doing the right thing’. Although they generally construct themselves as healthy individuals, confident in their ability to self-care, and as responsible users of health services, people spoke frequently about their reliance on expert clinical knowledge in decision-making. The analysis suggests that when explored in the context of individual circumstances and the broader social context, calling NHS 24 about minor symptoms can be constructed as a rational and responsible act. While this thesis is primarily an exploration of the accounts of individuals who have called NHS 24, the accounts are situated within the broader social and structural context in which those individuals make their decisions about symptoms and help-seeking. A social constructionist perspective sees illness behaviour as shaped by the social structures and values of a society and by the health system operating in that society. Equally, the health system is shaped by individual actors, who define it by how they choose to use it and what they expect it to deliver. This thesis argues that understandings of risk and individual responsibility, as well as a policy emphasis on self-surveillance and self-care, shape the decisions made by individuals as well as the discourses available to them to account for those decisions. Drawing on theories of medicalisation and lay re-skilling, the thesis also aims to develop an understanding of the space that NHS 24 occupies in Kleinman’s (1980) model of the health system, and whether the service might best be conceptualised as ‘legitimation’ or ‘colonisation’ of the popular sector (Stevenson et al. 2003).

Yes / To compare and contrast job descriptions for nursing roles in out-of-hours (OOH) services to obtain a general understanding of what is required for a nurse working in this job. OOH services provide nursing services to patients either through telephone or face to face contact in care centres. Many of these services are newly created giving job opportunities to nurses working in this area. It is vital that nurses know what their role entails but also that patients and other professionals know how OOH nurses function in terms of competence and clinical role. Design: Content analysis of OOH job descriptions. Method: Content analysis of a convenience sample of 16 job descriptions of OOH nurses from 5 OOH care providers across England was undertaken. The findings were narratively synthesised, supported by tabulation. Results: Key role descriptors were examined in terms of: job titles, managerial skills, clinical skills, professional qualifications and previous experience. Content analysis of each OOH job description revealed a lack of consensus in clinical competence and skills required related to job title although there were many similarities in skills across all the roles. Conclusion: This study highlights key differences and some similarities between roles and job titles in OOH nursing but requires a larger study to inform workforce planning. Relevance to clinical practice: OOH nursing is a developing area of practice which requires clarity to ensure patient safety and quality care. What does this paper contribute to the wider global clinical community? • There is a need for a consensus of opinion for nursing roles in OOH care linked to education, professional regulation and competence, based on expectations linked to particular job titles. • Educational and professional standards are required for different roles, which has implications for the training of OOH practitioners. • Health providers trying to meet the expectations of service users for 24 hour health care globally may invest in OOH nursing to meet demand

En-dehors des horaires d’ouverture des cabinets de médecine générale, la permanence des soins ambulatoires (PDSA) est assurée par des médecins effecteurs mobiles (MPDSA), missionnés par le SAMU – Centre 15 et effectuant des visites au domicile des patients. L’ordre de réalisation de ces visites est basé sur un modèle intuitif, défini selon le degré d’urgence établi lors de l’appel au SAMU – Centre 15 et la connaissance du secteur par le MPDSA. Cette méthode intuitive est le plus souvent dictée par la problématique du plus court chemin entre les visites. Le maintien de délais compatibles avec le besoin médical dépend ainsi du flux de visites et du temps d’acheminement des MPDSA. Or, ce temps d’acheminement dépend notamment des effectifs de MPDSA de garde et des conditions de trafic. Les modèles existants d’optimisation des trajets sont inapplicables à la PDSA, en raison de la réactualisation continue de la liste des visites à effectuer, ainsi que de la pondération du délai cible par le degré d’urgence.Nous proposons donc de créer un modèle spécifique d’optimisation des trajets des MPDSA missionnés par le SAMU–Centre 15. Nous développons une méta-heuristique évolutionnaire de type algorithme génétique, dont nous comparons d’abord les performances calculatoires à celles d’une méthode exacte d’optimisation linéaire en nombres entiers (méthode d’optimisation combinatoire non évolutionnaire), sur données théoriques, intégrant les données cliniques (3 degrés de priorité de visite), opérationnelles (taille de la flotte des MPDSA) et les objectifs temporels (3 délais d’effection cible). Les objectifs de ce travail sont de montrer que l’algorithme génétique, comparativement à la méthode linéaire en nombres entiers, conduit à une réduction des délais d’effection des visites MPDSA, donc à un plus grand respect des délais d’effection cibles ainsi qu’à une augmentation du nombre de patients vus par unité de temps (plage horaire de PDSA). Les résultats obtenus suggèrent que l’algorithme génétique est à la fois plus performant que la méthode linéaire en nombres entiers sur tous les critères établis, et que ses performances s’améliorent avec la complexité du problème à résoudre (nombre de patients à visiter, taille de la flotte des MPDSA).L’utilisation de la méthode d’optimisation développée dans ce travail pourrait permettre aux SAMU-Centres 15 d’améliorer le service rendu à la population, en termes d’accès au juste soin et de sécurité du patient. / During out-of-hours times, mobile general practitioners (GPs), appointed by the SAMU - Centre 15 (French public emergency call center), can provide out-of-hours home visits (OOH-HV).The order in which these visits are carried out is based on an intuitive model, i.e. the shortest path problem, and determined according to the degree of urgency established at the time of the call to the SAMU - Centre 15 and the knowledge of the sector by the mobile GP. Maintaining timelines consistent with the medical need thus depends on the flow of visits and the GP’s response times. However, this transit time depends in particular on the number of available GPs and traffic conditions. Existing models for routing optimization are inapplicable to OOH-HV, due to the continuous updating of the list of visits to be carried out, as well as the weighting of the target time by the degree of urgency.We therefore propose to create a specific model for the optimization of the mobile GPs’ sent by the SAMU-Centre 15. We develop an evolutionary meta-heuristic of the genetic algorithm type, whose computational performances we first compare with those of an exact method of integer linear optimization (non evolutionary combinatorial optimization method), on theoretical data, integrating the clinical data (3 degrees of priority of visit), operational constraints data (mobile GPs’ fleet size) and response times objectives (3 target effection times). The objectives of this work are to show that the genetic algorithm, compared to the integer linear method, leads to a reduction in mobile GPs visit completion times, to a greater respect of the deadlines of target outcomes, as well as an increase in the number of patients seen per time unit (GPs time slot).Our results suggest that the genetic algorithm is more efficient than the integer linear method on all established criteria, and that its performances improve with the complexity of the problem to be solved (number of patients to visit, size of mobile GPs’ fleet).The use of the optimization method developed in this work could enable the SAMU-Centres 15 to improve the service provided to the population, in terms of efficiency, safety and quality of access to care.

Allt fler patienter som drabbats av en obotlig sjukdom väljer att leva livet ut i sitt eget hem. Döende patienter är ofta i behov av god symtomlindring. När patienten väljer att dö i det egna hemmet ställer detta också krav på närstående som finns i patientens närhet. Dessa närstående är viktigt att sjuksköterskan också uppmärksammar. För att ge både patient och närstående en trygg och säker vård i livet slut, är det av vikt att det finns personal med kunskap i palliativ vård dygnets alla timmar.   Syftet var att beskriva hur nattarbetande sjuksköterskor upplevde det medicinska stödet i omvårdnadsarbetet till patienter i behov av palliativ vård i hemmet.   Metoden var en kvalitativ semistrukturerad intervjustudie. En innehållsanalys genomfördes av det insamlade materialet. Sammanlagt genomfördes 11 intervjuer i två olika vårdorganisationer, specialiserat palliativt team dygnet runt och kommunal hemsjukvård i samverkan med specialiserat palliativt team.   I resultatet framträdde fyra domäner i relation till sjuksköterskornas upplevelser av det medicinska stödet. De fyra domänen var läkarstöd, journal/planering, slutenvården och rapportering. Inom dessa domän framkom både positiva och negativa upplevelser. Inom läkarstödet beskrevs behov av möjlighet till kontakt med läkare med inriktning till palliativ vård. De eftersökte stöd i form av hembesök när detta behövdes. Hur tillgången till journal/planering var, såg väldigt olika ut beroende på vilken vårdorganisation som sjuksköterskan tillhörde. Det framkom negativa faktorer så som total avsaknad av tillgång till journal men också positiva upplevelser så som god tillgång och möjlighet att följa patientens planerade omvårdnadsvårdplanering. I fyra av enheterna fanns ingen tillgång till direktinläggning nattetid för de patienter som behövde. Slutenvården fyllde en så mycket större roll än bara sina slutenplatser. Sjuksköterskorna i hemmet uppskattade att kunna bolla idéer och rådfråga kollegor inom slutenvården, vilket minskade känslan av ensamhet. Rapporteringen till och från övriga kollegor var ett område som samtliga sjuksköterskor upplevde kunde förbättras. Övergripande kände sjuksköterskorna sig säkra i sin roll och upplevde sitt jobb givande men önskade överlag ett bättre medicinsk stöd i sitt arbete i patienternas hem.   Slutsatsen är att sjuksköterskorna upplever en ökad trygghet när läkare med inriktning mot specialiserad palliativ vård fanns kontaktbar dygnet runt. Även tillgången till journaler var en avgörande faktor för att känna att förutsättningarna fanns för att kunna lösa situationer som kunde uppstå i patientens hem. Det finns ett övergripande behov av ökad kommunikation mellan vårdlag. Föreliggande studie visar på ett behov av att granska verksamheters sätt att inkludera sina nattarbetande sjuksköterskor i behandling- och omvårdnadsplaner. Denna information som dessa sjuksköterskor besitter kan vara till stor vikt för att öka livskvalitet för patienten och deras närstående. / An increasing number of patients suffering from incurable illness/disease choose to live the last days of their lives in their own homes. Terminally ill patients are often in need of good symptom management. When the patient chooses to spend the last days of his life in his or her own home it affects the closest family and imposes demands on them. Therefore it is important for the registered nurse (RN) to also support the closest family in order to create a safe and secure end-of-life care. It is important to have health professionals with expertise and knowledge in palliative care when giving support around the clock.   The aim was to describe how RN´s who work night shifts experienced the medical support while providing nursing care for patients in need of palliative care at the patient's home.   The method used was a qualitative semi-structured interview. A content analysis of the collected material was conducted. The total of eleven interviews were conducted in two different healthcare organizations, namely, in a hospital-based specialized palliative team working around the clock and a municipal home-care team that collaborates with the specialized palliative team.   In the results, four domains appeared in relation to the nurses’ experiences of the medical assistance. These four domains are the support of physicians, medical records, inpatient care, and reporting. Within these four domains both positive and negative experiences were described by the nurses. The support of physicians was described as a possibility to contact a physician with knowledge of palliative medicine. Even the possibility of making a house call was expected. Access to patient's  medical record varied depending on the healthcare organization where the RN`s were working. There were negative experiences such as a total lack of access to medical records but also positive ones such as good access to medical records and the opportunity to follow patients care plan. Four of the units did not have the possibility of inpatient care when needed at nighttime. For the RN`s who were providing homecare, the access to inpatient care did not only mean to have access to a bed when needed, it also gave them the possibility to consult and discuss problems with their colleagues working at the inpatient care, so they did not feel left one on one with their problems. Reporting between colleagues was an area that all RN´s working night shifts described as being in need for improvement. Overall the RN´s felt secure in their role and found their work rewarding but desired a better medical support in their work in homecare.   The conclusion of the study is that RN´s feel more secure when a physician specialised in palliative care is available around the clock. Furthermore, access to medical records was a crucial factor for RN`s to be able to resolve situations that could occur at the patient’s home. There was a significant need for an increase in communication between different care teams. The present study also shows a need to review how RN`s who work night shifts are included in the process of treatment and the creation of care plans for the patient. The information that RN`s working night shifts possess can be of great importance to increase the quality of life of patients and their families.

Acknowledgement: "My sincere thanks to my supervisors Julie, Alison and Christina" - Identified Julie and Alison from the Department staff webpages - sm 26/02/2019 / There is little research investigating factors that facilitate or inhibit timely access to palliative care medicines from community pharmacies. Though palliative care is recognised within the UK government’s strategy and community pharmacists are considered to have a role it is uncertain to what extent this aim is incorporated into local practice. This thesis uses mixed methods to investigate the time taken to access palliative care medication from five community pharmacies in one area of England. The effect of prescription errors, stock availability and other factors is examined. Furthermore, semi-structured interviews with five community pharmacists and eleven other healthcare professionals explore medication access and the community pharmacist’s role in palliative care using the Framework method. Stock availability led to delays with one in five customers going to more than one pharmacy to get urgently required palliative care medications. Legal prescription errors were more common on computer generated prescriptions but did not lead to delays. Three subthemes were identified in accessing palliative care medicines: environment and resources; communication and collaboration; skills and knowledge. The community pharmacist’s role in palliative care was limited due to reluctance from other healthcare professionals to share information, poor access to patient records and lack of integration into the primary healthcare team. This study highlights implications for professionals, commissioners and providers to improve services for those trying to access palliative medication. Community pharmacies remain a largely untapped resource for supporting patients, relatives and carers towards the end of life in both cancer and other advanced life-limiting diseases.

There is little research investigating factors that facilitate or inhibit timely access to palliative care medicines from community pharmacies. Though palliative care is recognised within the UK government’s strategy and community pharmacists are considered to have a role it is uncertain to what extent this aim is incorporated into local practice. This thesis uses mixed methods to investigate the time taken to access palliative care medication from five community pharmacies in one area of England. The effect of prescription errors, stock availability and other factors is examined. Furthermore, semi-structured interviews with five community pharmacists and eleven other healthcare professionals explore medication access and the community pharmacist’s role in palliative care using the Framework method. Stock availability led to delays with one in five customers going to more than one pharmacy to get urgently required palliative care medications. Legal prescription errors were more common on computer generated prescriptions but did not lead to delays. Three subthemes were identified in accessing palliative care medicines: environment and resources; communication and collaboration; skills and knowledge. The community pharmacist’s role in palliative care was limited due to reluctance from other healthcare professionals to share information, poor access to patient records and lack of integration into the primary healthcare team. This study highlights implications for professionals, commissioners and providers to improve services for those trying to access palliative medication. Community pharmacies remain a largely untapped resource for supporting patients, relatives and carers towards the end of life in both cancer and other advanced life-limiting diseases.

Yes / The lack of separation between urgent and non-urgent medical goods encourages sub-optimal vehicle fleet operations owing to the time critical nature of urgent items. An unattended electronic locker bank, to which individual urgent items can be delivered thereby separating urgent and non-urgent supply, was proposed for the Great Ormond Street Hospital in London, UK. This concept was quantified using ‘basic’ and ‘intuitive’ hill climbing optimisation models; and qualitatively using staff interviews and expert reviews. Results indicated that a locker bank with a fixed height (1.7 m) and depth (0.8 m) required a length of 4 m (basic model) and 3.63 m (intuitive model), to accommodate 100% of urgent consignments for a typical week. Staff interviews indicated the wider benefits such as staff personal deliveries.

Hospital admissions for patients close to the end of life are considered ‘inappropriate’ in contemporary English health policy. Hospitals are supposedly unable to offer a ‘good’ death for patients, and dying there is thought to contradict patient choice, since patients are assumed to want to die at home. However, almost half of all deaths in England in 2015 occurred in hospital, and of these, nearly a third died within three days of admission. This thesis seeks to explore why these admissions are considered to be a problem and how they occur. Through a systematic review of UK literature I found that it cannot be stated that most patients want to die at home, because of the extent of missing data (preferences not asked, expressed, reported or absent). This finding challenges the justification that admissions are inappropriate because they contravene patient choice. Similarly inconclusive evidence about the undesirability, cost, and lack of need for patients to be in hospital were also found in a review of policy. Together with analysis of historical trends in hospital and hospice provision, it is apparent that attitudes towards end-of-life admissions reflect existing tensions about the role of hospital as an acute provider, and as a place of death. An analysis of interviews conducted with healthcare staff and next-of-kin involved in the admission of patients (case-patients) who died shortly after being admitted to Meadowbridge, a large English hospital explored these tensions further. I found that whilst hospital was not recognised as a place where ‘good’ deaths typically occurred, it was acknowledged as an emergency place of care. In this context, patients without obvious need for hospital care were nevertheless admitted to the hospital and the environment was subsequently recognised to offer distinct benefits. The need for emergency care reflected the difficulties of providing end-of-life care in the community. For dying to occur appropriately, home had to be adapted and care organised by healthcare staff. Both tasks were complicated by the unpredictability of dying, and family carers helped to absorb much of the uncertainty and support patients to die at home. Ambulance staff became involved when patients had care needs that exceeded care quickly and easily available in the community. When called to the case-patients, ambulance staff instituted familiar practices in transferring them to hospital. Hospital was recognised as a default place of care because ambulance staff struggled to facilitate alternative care and lacked sufficient professional authority to keep patients at home. The admissions of the case-patients represent the best attempts of staff to navigate the tangled practices of end-of-life care. These practices are the result of the actions of the staff, which in turn both constrained and enabled their action in providing care to patients. The term ‘inappropriate’ to describe admissions does not encompass these attempts, and moreover, devalued the significant care provided by healthcare staff in the community and hospital.