Chapter 1 of the thesis is divided into 5 sections. Section A begins by defining a Discrete Choice Experiment (DCE), and outlines the key stages involved in conducting a DCE. Sections B and C outline theories underpinning DCE analysis. Section B outlines the characteristics theory of demand, whilst section C, explains random utility theory (RUT), compensating variation (CV), marginal willingness to pay (MWTP), and willingness to pay (WTP) analysis. Section D of the thesis provides a review of the DCE literature. Section E outlines the research questions addressed in the thesis including calculating WTP and hypothetical bias; the description of the cost attribute; preference heterogeneity; and altruism. Chapter 2 shows how DCEs can be used to calculate WTP, using a DCE relating to Deep Vein Thrombosis (DVT). Chapter 3 uses data from a DCE applied to Menstrual disorder and Gynaecology patients. It evaluates an experimental method I developed to establish whether respondents might fail to factor in the monetary attribute into their DCE decision making, leading to hypothetical bias. Chapter 4 applies essentially the same DCE design but only analyses data from Gynaecology patients. Chapters 4-8 all use data obtained from a DCE relating to preferences for different allocation criteria for allocating kidneys for transplantation. Chapters 5 and 6 look at preference heterogeneity which is observable using interaction dummy variables (the issue of unobserved preference heterogeneity is considered in chapter 7). Chapter 5 establishes how marginal rates of substitution (MRS) differ between different respondent groups including renal patients, healthcare professionals, live donors / relatives of deceased donors, carers, and ethnic minority versus non-ethnic minority patients. Chapter 6 establishes how MRS differs between non-white ethnic minority patients versus other patients; South Asian patients versus other patients; and according to respondent gender. Chapter 7 of the thesis compares results from models which do not cater for unobserved preference heterogeneity, with results from models which do. Initially 2 basic models which do not cater for preference heterogeneity at all (because they do not include dummy variables) are applied including random effects logit and conditional logit. Then models catering for unobserved preference heterogeneity including Mixed Logit and a Latent Class Model (LCM) are used. Finally there is an analysis involving the application of conditional logit with interaction dummy variables. Chapter 8 of the thesis explores how preferences might differ according to how altruistic respondents are. It establishes how respondent preferences differ according to respondent self-disclosed perspective when answering DCEs. In other words whether they claimed to answer the DCE in terms of what would be best for me; what would be best for me and others; or what is best for others. Finally chapter 9 involves a discussion of the findings emerging from the thesis, and draws conclusions about the merits of material contained in it.

Background: Diabetes is a growing public health problem affecting people worldwide both in the developed and developing countries, and poses a major socio-economic, psychological and Behavioral challenge. Consequently, diabetes takes a staggering toll on the people in Nigeria and the economic burden is very high. It is a well known fact that numerous factors influence diabetes self-care: such as patient’s physical, psychological, social, cognitive and health care system factors. In this study, the researcher set out to elicit an understanding of the association between socio-demographic, socio-cognitive, and psychological health and to specifically provide explanations for how these three factors are related and differ across ethnicity, gender and type of diabetes. Conversely, studies investigating the psychological health in people with diabetes have observed disparities in terms of gender, ethnicity and the type of diabetes. More so, the impact of socio-cognitive health indicators on psychological status in the Nigerian context remains invisible and unknown. Additional investigations were carried out to assess the pattern of the psychological health of diabetic patients using socio-demographic and socio-cognitive factors, to identify if differences occur in the psychological and socio-cognitive factors by gender, ethnicity and type of diabetes. Finally, an exploration of the contextual and explanatory factors perceived to have underlain the gender ethnicity and type of diabetes differences observed in the psychological status and socio- cognitive health was carried out. Methods: A sequential explanatory mixed methods design comprising a quantitative phase followed by a qualitative phase was employed. In the quantitative phase general survey, data from the N= 486 participants were analysed to test for significant differences of ethnic groups, gender, type of diabetes and the relationship they all have on psychological status and socio-cognitive health. The qualitative phase on the other hand, was based on a follow up of the significant results by using semi-structured focus group interviews with 18 recruited respondents across gender, ethnic groups and type of diabetes. Findings: A 2x4x2 MANOVA hypotheses: 2 and 3 from the quantitative study showed a significant interaction between gender, ethnicity and type of diabetes; ethnicity and type of diabetes; gender and type of diabetes; gender and ethnicity. From the partial eta squared 2 , type of diabetes explains more of the variance remaining (after excluding the variance attributable to other variables) (21.4% vs 20.1%); than gender (21.1% vs 13.3%); which, in turn, explains more of the variance than ethnicity (5.6% vs 6.5%) on the combined DVs Psychological and Socio-cognitive health respectively. The qualitative results revealed extreme and overwhelmingchallenges diabetes imposed on the sufferers. It provided specific insight and on patients contextual experiences such as non-adherence; concerns about the present and the future’ health care systems and the way medical practitioners interact with patients which negatively impact on psychological status. These factors broadened the quantitative result in terms of the consistence in the patients’ descriptions of living with and self-managing their diabetes. Conclusions: The outcome of the t study has extended knowledge on the complex and dynamic nature of individuals’ responses to the challenges of diabetes in day-to-day self-care management and how best diabetic patients should be supported in order to promote adherence, positive treatment processes, provide assistance to the physical discomfort associated with diabetes, and support pro-diabetes coping behaviors (diet), through psychotherapy so as to enhance optimal psycho-behavioral health.

This thesis develops probabilistic models for the spread of infectious diseases in which individuals experience a period of transient immunity after recovering from infection. Quasi-stationary distributions (QSDs) and limiting conditional distributions (LCDs) are used to describe the temporary equilibrium that is reached between an initial exponential growth phase and the epidemic dying out. This thesis includes results characterising QSDs corresponding to existing birth-death processes and epidemic models and to new processes such as the Evolving Strain SIRS model which we define to describe the progression of a disease undergoing antigenic drift, such as seasonal influenza. Existence and uniqueness results are proven for specific LCDs. Results regarding marginals of special cases of these processes are proven, including the preservation of x-invariance for Q as discussed in Pollett [1988]. Many of the models considered in this thesis are multidimensional, which makes explicit calculation of QSDs extremely challenging. To combat this, specialised techniques for simulating QSDs are developed to illustrate and explore these distributions. These novel methods, involving variants on SMC samplers, are shown to facilitate the simulation of QSDs for discrete-valued stochastic processes, particularly reducible processes. A formal proof of convergence of the SMC sampler is provided for some simple examples. The simulation methods are then used to characterise the properties of QSDs and LCDs related to endemic epidemic models with evolving strains under an equivalence relation. These QSDs are used to define a reproduction number similar to Ro when the process starts from quasi-stationarity. The epidemic models with evolving strains are shown to have the standard SIR and SIRS epidemic models arising as limiting processes as evolution at each infection becomes certain.

This interdisciplinary cultural studies research uses critical discourse analysis to review the four political declarations on HIV & AIDS adopted by the United Nations in 2001, 2006, 2011 and 2016. Religion is implicated in the tensions and conflicts around issues of HIV and sexual and reproductive health and rights in the negotiations that hinders consensus, resulting in compromises and omissions in the texts. The research identifies four dominant discourses in the declarations and an additional two in the wider HIV response of relevance to these tensions; a public health, biomedical discourse; a human rights, gender equality and community engagement discourse; political discourses of leadership and national sovereignty; and a traditional religio-cultural discourse. In the wider HIV response a broader religious discourse and secularist discourse are evident but missing from the text of the declarations. This critical discourse analysis of the declarations investigates how the discourses interact in the text; how the traditional religio-cultural discourse influences the text; what is missing from the final text; and reasons for the gaps. Close textual analysis of the declarations identifies tension between the public health, human rights/gender equality discourses and the traditional religio-cultural and national sovereignty discourses. The traditional religio-cultural discourse operates to limit public health and rights-based approaches to HIV prevention and frames women and girls as passive victims, without agency to exercise their rights. When compared against UNAIDS strategies as a standard, the declarations are missing commitments to address the risks of key populations to HIV. Missing also is reference to any contributions the faith community brings to the epidemic. The broad religious discourse includes supportive approaches to public health, human rights and gender equality, with the potential to bridge gaps in the negotiations. The traditional religious discourse is implicated in gaps in the text on key populations and rights. The dominance of secularism at the UN is implicated in exclusion of the broad religious discourse. While obstacles around rights-based approaches to HIV prevention and key populations persist, common ground and synergies between the discourses exist. Recommendations include: to ask new questions at the UN about the role secularism plays that may increase space for conservative voices to operate; seeking new ways of working to bridge some of the gaps; and including different perspectives that have the potential to bridge the gaps and open up new ways to achieve consensus.

Psoriasis is a chronic skin disease that affects up to 2% of the UK population. The clinical presentation ranges from mild disease to extensive, severe disease that causes considerable discomfort and distress. Severe disease usually requires photochemotherapy or systemic treatment. Information about the effectiveness, safety and costs of the different treatments is required to enable dermatologists to formulate evidence-based treatment guidelines. Systematic reviews of the four main treatment modalities for moderate-severe psoriasis (cyclosporin, methotrexate, systemic retinoids and photochemotherapy) were performed. Randomised controlled trials were located systematically by electronic searching, hand searching and personal communications. Data on trial characteristics and outcomes were extracted and tabulated. Where possible data were pooled to give summary effect sizes as odds ratios, rate differences or numbers needed to treat (NNTs). Firm RCf evidence of efficacy was found for cyclosporin, oral ret.inoids, particularly in combination with PUV A, phototherapy, photochemotherapy and for combinations of topical calcipotriol or steroids with phototherapy. The corresponding NNTs were low, indicating high levels of efficacy. RCI' evidence of efficacy is lacking for methotrexate. Two observational studies of patients attending the Psoriasis Specialty Clinic were performed. The first was a crosssectional study that used data in existing disease assessment docwnentation to identify the characteristics of a group of 256 patients. The second was a longitudinal study that followed the treatment pathways of 166 patients in the first group. These studies confirmed that this group of patients and their treatments were comparable with those described in the literature. An economic analysis was performed, using a previously published decisionanalytic model, to compare four treatment strategies for severe psoriasis from the health service perspective. The results (cost-effectiveness ratios) showed that methotrexate was the most cost-effective primary treatment followed by cyc1osporin, acitretin and PUV A. The rank order was not sensitive to changes in response rates. Modifications to the decision analytic model are proposed including a wider array of pathways and an allowance for adverse effects of treatment. Future analyses should include narrowband UVB alone as a primary treatment.

Fitness to Practise (FtP) is an emerging area of interest within the health and social care field due to the increasing high profile cases relating to professionalism and conduct of practitioners. Research has ‘yet to catch up’ with the emerging interest and the current body of evidence predominately consists of literature reviews and descriptive or discursive papers which examine the process and functionality of FtP panels. Currently no research has attempted to examine the decisions made or indeed how these decisions were arrived at within the following health and social care professions, Nursing, Paramedic Practice and Social work. Professional regulation for each of these professional groups is established through regulatory bodies. The regulation and determination of FtP of students on leading to registration is the role of the Higher Education Institution (HEI) and is less uniform in its approach. This may lead to disparity and the potential risk of inconsistency, unfair and unjust decisions for students. Aim: In order to gain a greater understanding FtP and professional conduct, this research study aimed to examine the decision-making process involved in ‘FtP’ panels for undergraduate health and social care students, comparing the decision-making process of students, lay person and practitioners (both experienced and inexperienced). This study explored the factors that influence the decision-making processes including experience and skills. Methods: Three simulated ‘FtP’ case studies were created and filmed to examine the decision-making process that takes place in panels for undergraduate nursing/paramedic/social work students. These were informed by real life cases and expertise of professionals within each of the professional groups. Actors were recruited for each of the case studies and the simulations were filmed. Debriefing of the simulation was conducted with the actors and the data collected was analysed using thematic analysis. The case studies were then examined and deconstructed by four focus groups for each case (twelve in total) with degrees of experience, lay people and students. This deconstruction also included an evaluation of the simulation and its potential use in the field of FtP. The data collected was analysed using thematic analysis and key emergent themes were identified. Findings: The findings highlighted two key areas. Firstly, the importance of those involved in panels, 'the people involved in FtP panel' and secondly the ‘decisions that were made during the panels’. These findings suggest that there are a number of identified roles within FtP. The influence of these roles is measured not by the role but the execution of the role and personalities are more influential than identified roles. There is a further suggestion that experience of FtP panels can influence decision-making processes and can make for lengthy yet robust decision-making and that when systematic approaches to decision-making are employed that there is clearer understanding of decisions it leads to more effective decision-making processes. Conclusion: Understanding student FtP decision-making and the influential factors involved in that process will inform HEIs in the overall management of FtP and consequently promote consistency and fairness in decision-making. This will be achieved by recognising the influential factors on the processes of FtP and considering these when FtP are conducted. It should prompt attention to the approaches adopted by individuals during FtP and the need for a more uniformed approach to FtP not dissimilar to that of the regulatory bodies approach. Implications: Recognising that personalities as well as identified roles are influential in the decision-making is important to consider when HEIs reflect panel composition. It is also essential to consider the experience and the skill when selecting panel members for FtP.

Chapter one is a literature review of the experiences of carers from Black and ethnic minority communities caring for someone with dementia in the United Kingdom. Critical analysis of eight articles revealed that carers viewed symptoms of dementia as a normal process of ageing. Furthermore, the carers perceived their role as an extension of an existing responsibility to provide care and support for their family member. The literature review highlighted the majority of carers being female and stigma of a family member having a mental health issue still influenced carers’ willingness to engage in formal health services. Chapter two is an exploration of the experiences that staff within alcohol services have had whilst providing support to relatives of alcohol dependent individuals from the Sikh community. Ten staff members were recruited to take part in semi-structured interviews. Thematic analysis was conducted on the derived data, eliciting a number of themes illustrating the nature of familial support provided for someone who is alcohol dependent, the pro-social attitude towards alcohol held by Sikh family members, a lack of understanding regarding addiction and the confidential nature of alcohol services. This article provided evidence of inter-generational differences between Sikh family member’s knowledge of addiction and the expectation of alcohol services. Lastly, the present study identified variations in how alcohol services target and tailor their services in specific ways to meet the needs of Sikh family members of someone with alcohol dependence. Chapter three is a reflective article on the process of conducting the empirical research. The article addressed reasons why the lead researcher conducted research in this area and considers the effects of participant experiences of working with Sikh family members of someone with alcohol dependence. This chapter also discusses the lead researcher’s relationship with participants and how the research process impacted on the lead researcher’s personal life.

Background Physical activity in children with intellectual disabilities is a neglected area of study, which is most apparent in relation to physical activity measurement research. Although objective measures, specifically accelerometers, are widely used in research involving children with intellectual disabilities, existing research is based on measurement methods and data interpretation techniques generalised from typically developing children. However, due to physiological and biomechanical differences between these populations, questions have been raised in the existing literature on the validity of generalising data interpretation techniques from typically developing children to children with intellectual disabilities. Therefore, there is a need to conduct population-specific measurement research for children with intellectual disabilities and develop valid methods to interpret accelerometer data, which will increase our understanding of physical activity in this population. Methods Study 1: A systematic review was initially conducted to increase the knowledge base on how accelerometers were used within existing physical activity research involving children with intellectual disabilities and to identify important areas for future research. A systematic search strategy was used to identify relevant articles which used accelerometry-based monitors to quantify activity levels in ambulatory children with intellectual disabilities. Based on best practice guidelines, a novel form was developed to extract data based on 17 research components of accelerometer use. Accelerometer use in relation to best practice guidelines was calculated using percentage scores on a study-by-study and component-by-component basis. Study 2: To investigate the effect of data interpretation methods on the estimation of physical activity intensity in children with intellectual disabilities, a secondary data analysis was conducted. Nine existing sets of child-specific ActiGraph intensity cut points were applied to accelerometer data collected from 10 children with intellectual disabilities during an activity session. Four one-way repeated measures ANOVAs were used to examine differences in estimated time spent in sedentary, moderate, vigorous, and moderate to vigorous intensity activity. Post-hoc pairwise comparisons with Bonferroni adjustments were additionally used to identify where significant differences occurred. Study 3: The feasibility on a laboratory-based calibration protocol developed for typically developing children was investigated in children with intellectual disabilities. Specifically, the feasibility of activities, measurements, and recruitment was investigated. Five children with intellectual disabilities and five typically developing children participated in 14 treadmill-based and free-living activities. In addition, resting energy expenditure was measured and a treadmill-based graded exercise test was used to assess cardiorespiratory fitness. Breath-by-breath respiratory gas exchange and accelerometry were continually measured during all activities. Feasibility was assessed using observations, activity completion rates, and respiratory data. Study 4: Thirty-six children with intellectual disabilities participated in a semi-structured school-based physical activity session to calibrate accelerometry for the estimation of physical activity intensity. Participants wore a hip-mounted ActiGraph wGT3X+ accelerometer, with direct observation (SOFIT) used as the criterion measure. Receiver operating characteristic curve analyses were conducted to determine the optimal accelerometer cut points for sedentary, moderate, and vigorous intensity physical activity. Study 5: To cross-validate the calibrated cut points and compare classification accuracy with existing cut points developed in typically developing children, a sub-sample of 14 children with intellectual disabilities who participated in the school-based sessions, as described in Study 4, were included in this study. To examine the validity, classification agreement was investigated between the criterion measure of SOFIT and each set of cut points using sensitivity, specificity, total agreement, and Cohen’s kappa scores. Results Study 1: Ten full text articles were included in this review. The percentage of review criteria met ranged from 12%−47%. Various methods of accelerometer use were reported, with most use decisions not based on population-specific research. A lack of measurement research, specifically the calibration/validation of accelerometers for children with intellectual disabilities, is limiting the ability of researchers to make appropriate and valid accelerometer use decisions. Study 2: The choice of cut points had significant and clinically meaningful effects on the estimation of physical activity intensity and sedentary behaviour. For the 71-minute session, estimations for time spent in each intensity between cut points ranged from: sedentary = 9.50 (± 4.97) to 31.90 (± 6.77) minutes; moderate = 8.10 (± 4.07) to 40.40 (± 5.74) minutes; vigorous = 0.00 (± .00) to 17.40 (± 6.54) minutes; and moderate to vigorous = 8.80 (± 4.64) to 46.50 (± 6.02) minutes. Study 3: All typically developing participants and one participant with intellectual disabilities completed the protocol. No participant met the maximal criteria for the graded exercise test or attained a steady state during the resting measurements. Limitations were identified with the usability of respiratory gas exchange equipment and the validity of measurements. The school-based recruitment strategy was not effective, with a participation rate of 6%. Therefore, a laboratory-based calibration protocol was not feasible for children with intellectual disabilities. Study 4: The optimal vertical axis cut points (cpm) were ≤ 507 (sedentary), 1008−2300 (moderate), and ≥ 2301 (vigorous). Sensitivity scores ranged from 81−88%, specificity 81−85%, and AUC .87−.94. The optimal vector magnitude cut points (cpm) were ≤ 1863 (sedentary), ≥ 2610 (moderate) and ≥ 4215 (vigorous). Sensitivity scores ranged from 80−86%, specificity 77−82%, and AUC .86−.92. Therefore, the vertical axis cut points provide a higher level of accuracy in comparison to the vector magnitude cut points. Study 5: Substantial to excellent classification agreement was found for the calibrated cut points. The calibrated sedentary cut point (ĸ =.66) provided comparable classification agreement with existing cut points (ĸ =.55−.67). However, the existing moderate and vigorous cut points demonstrated low sensitivity (0.33−33.33% and 1.33−53.00%, respectively) and disproportionately high specificity (75.44−.98.12% and 94.61−100.00%, respectively), indicating that cut points developed in typically developing children are too high to accurately classify physical activity intensity in children with intellectual disabilities. Conclusions The studies reported in this thesis are the first to calibrate and validate accelerometry for the estimation of physical activity intensity in children with intellectual disabilities. In comparison with typically developing children, children with intellectual disabilities require lower cut points for the classification of moderate and vigorous intensity activity. Therefore, generalising existing cut points to children with intellectual disabilities will underestimate physical activity and introduce systematic measurement error, which could be a contributing factor to the low levels of physical activity reported for children with intellectual disabilities in previous research.

This research is concerned with patient dignity in nursing. It proposes the introduction of the concept of Perceptual Adjustment Level (PAL) in order to resolve the problem of the definition of patient dignity and its maintenance within nursing care. The aims of the study are to identify how patients and nurses perceive patient dignity, to investigate the extent to which patient dignity is maintained and to identify nursing care activities in maintaining patient dignity. The implications of the findings of this study for nursing education and the development of policy on clinical practice are also examined. The literature review revealed a paucity of research on patient dignity. There was no clear definition of dignity that could be understood by both nurses and patients during their day to day interaction. Little was known of the maintenance of patient dignity and its influencing factors. A qualitative methodology utilising a phenomenological approach was used. A total of 102 patients and 94 nurses from medical and surgical wards in three hospitals within the United Kingdom were interviewed using semi-structured interview techniques. Although neither patients nor nurses specifically defined patient dignity, they came up with similar categories in terms of how they perceived patient dignity: privacy, respect, communication, the need for information, involvement in care, independence, patients' choice, form of address, decency and confidentiality. Control was only mentioned by patients. Although there was congruence between how the patients and nurses described patient dignity, it emerged that nurses tended to operate on different levels from how patients perceived the maintenance of their dignity. While nurses utilised primarily their own perception of dignity to maintain patient dignity, it was discovered that hospitalised patients went through a process of adjustment of their notion of dignity and came to a level they could accept. As a result a new concept termed Perceptual Adjustment Level (PAL) is proposed. Patients felt dignified if events matched with this level. This research has, therefore, proposed a tentative definition of patient dignity as the fulfilment of patients' expectations or needs in terms of values within each patient's perceptual adjustment level taking into account the hospital environment. The need for assessing patients to discover their perceptual adjustment level has been highlighted. A number of patients were satisfied with how their dignity was maintained but a significant number were not. Ways of improving the maintenance of patient dignity have also been proposed. In order to maintain patient dignity, nurses should consider six questions: "what?" signifies the needs of dignity which should be met. "Why?" highlights the importance of full explanations of the purpose of tasks carried out on patients, and whether it matters to the patient. "Who?" relates to who is going to perform the task on her or him? "Where?" considers whether privacy will be ensured when the tasks will be done and "how?" sensitively the tasks will be done? It is also important to make the patient aware "when?" tasks will be carried out. The main factors that influenced the maintenance of patient dignity are revealed and implications for nursing practice, management, education and research are discussed.

This thesis presents an instrumental case study of a National Health Service (NHS) mental healthcare trust in relation to race related equality policy in the delivery of secondary mental healthcare in England. The study takes a constructionist ontological position, and an interpretivist epistemology. Semi-structured interviews were conducted with the 20 participants working at three different levels of the organisation. These include strategic leaders: Chief Executive Officer, Operational Director, Director of Nursing Quality and Patient Experiences, Director of Learning and Development, Head of Human Resources, Equality and Diversity Lead; service level middle managers: General Manager, Modern Matron, Team leader, Manager of the Recovery College; and frontline practitioners: clinical directors, psychiatrist, occupational therapist, staff nurses, community psychiatrist nurse, Recovery College instructor, all working in an adult mental healthcare setting of the organisation. Narrative interviews were also conducted with eight members of the Pakistani community living in the local service area to gain their perspectives on mental illnesses and mental health services. The study was conducted because national race equality policy expects NHS mental healthcare organisations to change their culture and deliver equitable, culturally appropriate and satisfactory mental health services to all members of society, including those who identify themselves as ‘BME’ groups. However, there is evidence in the policy and research literature of inequalities in mental healthcare experienced by service users who identify themselves as being from ‘BME’ groups in England. This study, therefore, explores how a NHS mental healthcare Trust is trying to bring about cultural changes in order to meet the expectations of policy as well as meeting the needs of service users of ethnic background. For example, on the organisational side, the study explored vision and strategy as well as interventions for bringing about organisational change and the views of the participants on this change. The views from the members of the Pakistani ethnic group highlight how mental illnesses are perceived and responded to within this ethnic group. Data obtained from the staff group were analysed using a thematic framework approach. Resultant themes include: interpretation of racial equality policy in the organisation; organisational vision and strategy for change; and the challenges, barriers and facilitators to achieving the stated vision on racial equality in the service provision, especially for people of Pakistani ethnic group. The analysis benefited from the organisational development literature in analysing the data. Data obtained from the members of the Pakistani community were analysed using a thematic narrative approach. This data reflected ways in which mental health/illness is perceived and responded to within this group including: the social identity claims that people of Pakistani ethnicity make when perceiving and responding to mental illnesses; the extent to which they associate themselves with western and/or eastern models of mental illnesses; and their identification as an ethnic group with diverse and multiple social identities. Social identity literature is used to analyse and interpret this data. The relationship between the organisational data and the ethnic group data is discussed, and a way forward is suggested for bringing about the expected cultural change to the organisation in order to meet the mental health needs of ‘BME’ groups in England. The instrumental organisational case study, along with perspectives of the service users, have served to underline the challenges for the organisation on a day-to-day basis as they attempt to meet the expectations of policy, as well as the views and expectations of people of Pakistani ethnicity.