This research uses mixed methods to critically analyse health regulation systems in England, in a macro and micro sense. The qualitative side of the research involves interviews with key staff members from four NHS Trusts and two Clinical Commissioning Groups. These semi-structured interviews offer unique specific insights from the key actors, from varying perspectives in the process. The quantitative element of the research focuses on trends and correlations of the data sets used by particular arm’s length bodies operating in the policy area. Specific arm’s length bodies operating in the health policy arena, which are assessed in the research, include the Care Quality Commission, Monitor and Dr Foster Intelligence. The findings and conclusions centre on the deficiencies that are present in the current regulatory regime, what is occurring in this area, and why this is occurring. Following the Grounded Theory Approach, the research develops inductive theory, from the data, culminating in a “Feedback Loop Theory of Regulation”. Key words: NHS, regulation, mixed methods, arm’s length bodies, feedback loop theory, grounded theory, Care Quality Commission, Monitor, and Dr Foster Intelligence.

The NHS has to meet the Climate Change Act targets of an 80% reduction to their carbon emissions by 2050. Investigation into the components of the carbon footprint of mental health care is needed to understand how services can meet these targets. This thesis first seeks to understand what is known about the carbon footprint of mental health care through two systematic reviews and two national surveys. Second, existing methodologies for estimating carbon footprints are examined to assess whether an approach is available that is ‘fit for purpose’ in mental health care. The approach needs to be applied feasibly within a clinical context and the results need to be sufficiently robust to reliably inform decisions about service design. The aim of this research is to provide an approach that service providers can use to estimate the carbon footprint of services and then use the information obtained to inform service design. This thesis defines the boundaries of assessment to ensure a consistent approach. It suggests an approach to data collection that includes financial and activity data. It presents a review of the available methods for converting this data to carbon equivalents and finds a potential five-fold range associated with carbon footprint estimates of medication. The approach developed within this study is termed the combined approach. The combined approach is then evaluated using a scenario analysis, a four-year retrospective cohort analysis and a prospective care modelling analysis to assess whether it is fit for purpose according to specified criteria. It is concluded that the combined approach is fit for the purpose of assessing how the carbon footprint of a service changes over time. However, due to the use of financial data and the problems with estimating the carbon footprint of medication, this approach has significant weaknesses, which limits its wider use.

The aim of this study is to evaluate the implementation of the Payment by Results (PbR) policy in mental health in England through the identification of the driving factors that have caused the delayed implementation of the system. Payment by Results, the English version of Diagnosis Related Groups, is a prospective payment system under which the nationally-fixed prices are set against the clinically-classified groups in which patients share similar health care needs. First introduced in acute services in 2003/04, PbR was expected to control healthcare costs, increase providers’ efficiency and improve the quality of service delivery in the market-based healthcare system. An expansion of PbR to mental health was initially planned to come into effect by 2013, but at the time of writing (October 2015) it had yet to become the definitive framework of funding for the NHS secondary mental health services. In light of the debate on the feasibility of implementing this policy in mental health, this study has adopted a mixed-methods approach to conduct a three-stage analysis of the PbR policy. Firstly, through the theoretical analysis of the initiation of the PbR policy, this study has revealed that the policy was poorly initiated due to the mismatches between the market theory and public services in the current context. Secondly, through the investigation of the design of PbR, this study has argued that the policy was poorly formulated due to the conceptual and the constructional drawbacks of the Mental Health Clustering Tool (MHCT) classification system as well as the inappropriateness of applying the “standardisation-to the-average” principle to the cost calculation. In the fieldwork stage, this study has carried out 12 semi-structured interviews and online surveys to explore the implementation phase of the policy-making process. The divergent, and even conflicting perspectives obtained among the three interest groups have pointed to the fact that the policy was poorly executed, and it suffered from “bad luck” (Hogwood and Gunn, 1984) as a result from the political context of austerity. Through the comparison of the implementation of PbR in mental health with that in acute services this study has highlighted the importance of the external context to the success of any policy. It has also argued that one size does not fit all systems since the PbR payment system may be able to serve the purposes in acute services, but it does not fit mental health services. In this respect, this study reminds policymakers to consider the potential trade-offs between the political objectives and the inevitable consequences. As a policy evaluation, based on the experiences drawn from the failure of implementing PbR in mental health, this study has suggested that policy should be consistent, and policy should be tested prior to full implementation.

This thesis aimed to develop an understanding of the concept of emergency preparedness through the lived experiences of paramedics, utilising an interpretative phenomenological analysis (IPA) methodology. Emergency preparedness is a developing speciality, with a limited evidence base. Current research is mainly atheoretical, with the majority of literature comprising of anecdotal reports, government guidance, clinical protocols, audit and clinical policy. The published literature offers little more than opinion and a retrospective view of experience, with few studies examining and understanding the individual lived experience within this area. To address the identified gaps in the literature and in line with the idiographic focus of IPA, thirteen paramedics were recruited and face-to-face interviews explored their individual experiences of emergency preparedness. Through data analysis, the following superordinate themes were identified for further discussion:- self determination, control and experience-based practice. Participants appeared to value their role and the unpredictable environment that they worked in. Personal resilience, an area that they suggested is not covered effectively within individual preparation, was viewed as important. The participants articulated that risk, threat, uncertainty, safety, trust and control were important concepts within individual preparedness. These paramedics valued practice-based knowledge and education as credible and transferrable to their clinical work. Additionally, storytelling appeared as a preferred method of conveying knowledge in an area with minimal real-life experience. Dimensions of individual preparedness are presented, with the paramedic central to the experience within a conceptual model (the DiEP model), creating a new form of emergency preparedness that reflects the individual paramedic’s experience.

This thesis explores the transition from hospital to community living for mental health patients and carers. This period presents a number of challenges and risks for patients and the support from family members throughout this period is invaluable. Through further exploration of the discharge process and period, this thesis considers how both patients and carers can be better supported to manage the challenges and increase the likelihood of a successful transition. The first paper is a systematic literature review investigating the predictors of suicide up to a year after discharge from mental health inpatient services. After database and manual searches were complete, thirteen studies met inclusion criteria and were reviewed and critically evaluated. Despite inconsistent findings across studies, the review identified some predictors of post-discharge suicide which have been replicated within and across cultures. Clinical implications in relation to thorough discharge planning and maintaining continuity of care are discussed. The second paper reports on a qualitative exploration of family members’ experiences of the discharge process from inpatient mental health services. Six family members were recruited and interviewed using a semi-structured method. The data was analysed using Interpretative Phenomenological Analysis. The three phenomenological themes emerging from participants’ accounts indicated that the discharge process was characterised by isolation, fear and exhaustion. The themes are discussed, explored and considered in relation to how services can increase carers’ involvement and strengthen their position in the discharge process. The final paper reflects on insights into the world of carers gained through the research process, with a focus on loss and grief in caring. Comparing the processes of therapy and research, the paper considers how research offered greater freedom to ‘hear’ experiences and the potential advantages of transferring these reflections to the therapy room.

Following the recommendation of the WHO and UNAIDS the Ethiopian Government revised its guidelines on Prevention of Mother-to-Child Transmission to adopt a routine provider-initiated ‘opt-out’ HIV testing approach to all maternal health care services. The testing approach requires all pregnant women to be provided with HIV test unless they expressly decline it. This thesis examines the human rights and ethical implications of the implementation of this HIV testing approach within the maternal health care settings in Ethiopia to screen pregnant women. It argues that this HIV testing approach may be able to meet the pressing public health imperatives presented by the incidence of HIV in Ethiopia. However, a full understanding of the context in which this testing takes place reveals that, the implementation of this testing approach can result in the denial of pregnant women’s rights to informed consent, to have access to adequate counselling and to ensure confidentiality of their HIV test results. This thesis argues that the implementation of routine provider-initiated ‘opt-out’ HIV testing approach in the maternal health care settings is affected by the weak health system, the feminization of poverty, and the persistence of HIV related stigma and violence as well as gender inequality. The fieldwork undertaken in the Tigray region provided insights into the subjective experiences of women in relation to their ability to make autonomous decisions regarding the HIV test offered during their pregnancies. It involved in-depth semi-structured interviews with pregnant women and key stakeholders as well as non-participatory observation. In addition, the normative and conceptual aspects of human rights and ethical principles inform the thrust of discussions and arguments in this thesis. This thesis concludes that although the HIV testing approach adopted by the Ethiopian Government to screen pregnant women for HIV infections does not violate human rights requirements, its implementation in the context Ethiopian socio- economic, cultural and legal context raises serious concerns. The study therefore recommends that attention must be paid to balancing the scaling up HIV testing of pregnant women in Ethiopia to prevent vertical transmission of HIV and respecting the individual’s rights to make their own medical decisions including refusing the HIV test.

Taiwan adopted its National Health Insurance (NHI) scheme in 1995. Presently, the scheme covers virtually all of the island’s citizens. However, it is under the threat of a serious imbalance between expenditure and revenue. As spending has become unsustainable, everyone has realised the need for financial reform. However, the reform process itself is beset by political confrontations. There is a need to deepen the understanding of the relationships and dependencies among the policy actors. With a view to helping address this problem, this study empirically examines the multiple types of ties prevailing between the policy actors and the resulting power distribution while the DPP government was working earnestly towards reforming the NHI’s financial system in the period 2000-2008. Apart from official documents, data are drawn from a network survey coupled with semi-structural interviews of 62 policy actors including government officials and related unofficial policy participants. Measures such as the in-degree centrality index and core/periphery model, betweenness centrality, structural hole index (effective size), density index, E-I index and CONOOR procedure (Blockmodeling and multidimensional scaling - MDS) are used to identify the major participants and network structures in the NHI domain and assess their relative influence-powers on the basis of information transmission patterns, resource exchanges, action-set coalition relationships and reputational attributions. It is shown that, although the public sector and the medical associations were at the helm of the NHI reform, financial reform remained unfulfilled mainly because of poor communications among societal actors. We then performed a social network analysis and systematically mapped the prevailing political conflicts among diverse policy stakeholders. We confirm that SNA is an effective research tool for political feasibility evaluation; it can facilitate smoother policy adoption by enhancing better interactions within networks.

I investigated the longitudinal relationship between alcohol use, cannabis use and cigarette smoking and serious violence using data from a prospective longitudinal, nationally representative cohort of 17,519 individuals interviewed on 4 occasions. Participants were between 12 and 17 years of age at wave I and were between 23 and 32 year of age at wave IV. There was a linear relationship between the number of drinks consumed but not frequency of drinking alcohol and violence. The number of individuals needed to abstain from drinking alcohol to prevent one from becoming violent was estimated. Smokers were also twice as likely to report subsequent violence within the next year, however there was no relationship between cannabis use and incident violence within the next year. Analysis of the entire cohort (whether or not they reported violence at baseline) incorporated individual change in substance use over time to investigate the longitudinal relationship between substance use and violence. Moderate drinkers were approximately 1.4 times more likely to be violent than non-drinkers. Cigarette smoking and cannabis use was also associated with similar increases, but heavier drinkers were more than twice as likely to report serious violence. When the trajectories of violence were investigated, predictive marginal effects showed that drinking 1-4 drinks on each occasion was associated with an increased risk of violence during adolescence, but as the individuals got older the risk of violence tended to converge with that of non-drinkers by age 20. Heavier drinking however, was associated with a greater risk of violence well into adulthood, although the trajectories tended to converge by age 30. The relationship between personality traits, alcohol and violence was then investigated using structural equation modelling. Alcohol was found to mediate the association between violence and specific personality characteristics, especially anger/hostility and extroversion.

Compassion has become a topic of interest amongst researchers and policy makers. Research has started to explore compassion from the perspectives of staff and patients. Research on compassion with carers is an under researched area. The present thesis aims to address this gap in the literature. Chapter One: This paper presents a systematic review of compassionate care from the perspective of patient and professionals. Seventeen studies met the inclusion criteria and were critically reviewed and evaluated. Within the literature reviewed compassionate care is described as a skilled interpersonal and relational process. The review found that compassionate care needs to be more clearly defined in practice, education and training. Clinical implication of the findings and directions for future research are discussed. Chapter Two: The second paper is a qualitative exploration of carers’ lived experiences of compassion while caring for adults with severe and enduring mental health difficulties. Eight carers were recruited to the study and interviewed using semi-structured interviews. The data was analysed using Interpretative Phenomenological Analysis. Findings revealed two superordinate themes: ‘Burdensome responsibility’ and ‘Something that holds you’. Findings are discussed in the context of clinical implication and areas for future research are considered. Chapter Three: The final paper provides a reflective account on the research process including insights into carers’ experiences of care and compassion. It offers reflections around six attributes of compassion: care for wellbeing, sensitivity, sympathy, empathy, distress tolerance and non-judgemental. This paper allows a chance to reflect on some of the outlying experiences that arose from the research that were not prevalent enough to become central themes.

Background: In 2008, the health departments of the United Kingdom implemented a routine and catch-up HPV immunization programme in schools to reduce the incidence of cervical cancer. European studies conducted from 2007 to 2012 showed inconsistent results on HPV vaccine uptake in relation to ethnicity and girls’ age. Aim: To examine the relationship between area deprivation and the take-up of informative materials related to HPV vaccination in secondary schools in England. Another aim was to investigate the association between uptake of HPV vaccine and area deprivation, ethnicity and religion and to explore the views and experiences of girls, teachers and health providers on the HPV vaccine to understand how mechanisms of programme delivery, strategies and practices contributed to HPV vaccine uptake in a city in the West Midlands. Methods: Secondary data about uptake of professionally developed teaching materials by 4,750 schools in England was employed to explain the relationship between the takeup of the materials and the level of social deprivation of the area within which the school was located using logistic regression. Other secondary data about uptake of the third dose of HPV vaccine by year 8 girls in a city in the West Midlands was used to explain the variability of uptake across 20 schools between 2008 and 2012. Analytic statistics included simple and multivariate linear regressions. Qualitative data was collected through 47 semi-structured individual interviews with nine nurses, four school staff and 34 year 8 girls as well as through non-participant observations in 12 secondary schools between February and September 2013. Thematic analysis identified major themes related to the school context of implementation of the HPV vaccine programme as well as facilitators and barriers to uptake of HPV vaccine in the city of the study. Results: Of all secondary schools in England invited to receive the HPV educational materials, 1,395 schools (30.17%) responded. These schools were in the largest quintile of school size as well as maintained schools. After controlling for other covariates, it was found that schools in the least deprived quintile had 1.31 the odds of requesting materials compared with the schools in the most deprived areas (95% CI=1.05-2.53). Deprivation of school address postcode remained statistically significantly associated with uptake of HPV vaccine after controlling for ethnicity, school type and academic year. Similarly, the academic year 2009/10 remained statistically significantly associated with uptake of HPV vaccine adjusting for geographic and school factors. Deprivation of school catchment area was no longer statistically significantly associated with uptake of HPV vaccine when the other variables were held constant and the same was true for the association between ethnicity and uptake. Thematic analysis showed that school based HPV vaccination programme was accepted by most of the schools in the city of study and was delivered by a mobile clinic aiming to vaccinate all eligible girls. Chasing up the consent forms and communication with the parents were the most challenging activities in the HPV vaccination administration. However, they were essential for a high HPV vaccine uptake. The manner in which the school staff and nurses sought parents’ and girls’ consent before and on the day of vaccination was often very persuasive and not entirely ethically justified. The HPV vaccine was poorly promoted in the school environment because of tight curriculum for compulsory subjects and the lack of adequate staff. A number of other influences affected girls’ choices about receiving the vaccine. The family played the most important role for daughters’ emotional support as also did the provision of information to help girls understand and make their own decision about the vaccine. The interactions with friends and nurses were beneficial for girls’ confidence and feelings on the day of vaccination. Girls’ fear of injection caused by their poor knowledge, rumors spread by peers and parental negative attitudes about HPV vaccine were major obstacles to uptake before and on the day of vaccination. The main parental reasons for vaccine refusal were lack of understanding of the information about HPV vaccine, which they received from the school, their inadequate information, obtained from sources other than health professionals, their misconceptions about the safety of the vaccine and their religious beliefs related to their daughters’ sexual activity in the future. Conclusion: The impact of the HPV vaccination education campaign suggests differential level of exposure due to unevenly distributed requests for the materials across England. At local level, the HPV programme was not equally well implemented across the schools in the city. This was mainly due to school factors, including the location as well as the organization of delivery. The findings highlight the need for further investigation of factors associated with uptake of HPV vaccine to guide health policy and public health interventions for effective implementation of the HPV vaccination programme in all schools.