The focus of this thesis is to provide hospitals and local authorities in an urban setting with a set of recommendations for sustainable methods of supply for healthcare institutions, to minimise the negative externalities of freight associated with urban hospitals. The structure and nature of the healthcare supply chain engenders unsustainable freight patterns as a result of the poor communication and unpredictability of inventory demand from hospitals to suppliers, resulting in high freight volumes (403 freight movements recorded over a 5-day period during a November 2011 survey), and the mixing of urgent and non-urgent goods within the same supply chain. In addition to this ancillary hospital services such as hospital laboratory couriers are found to be a large traffic generator with 476 individual services booked over a 3 month period (January – March 2014). In fulfilment of these issues three solutions are proposed to improve the economic and environmental sustainability of freight: mobile consolidation, to address the high numbers of deliveries received by hospitals; unattended locker bank delivery, to separate urgent goods from the supply chain; and, consolidation of laboratory courier services. Assessment of the mobile consolidation centre for GOSH only operating over 1 site to 4 sites, using 93 records from the 2011 freight survey indicated savings for the week between: 10,591 VKm (1 site operation) and 12,173 VKm (4 site operation); 181.53 – 225.05 journey time hours for 2 site and 4 site operations, respectively; and, 2 – 2.33 tonnes of CO2 equivalents between 1 site and 4 site operations. Implementation of a London-wide scenario indicated reductions of 64,204 VKm, 579 Journey Time Hours and 89 tonnes of CO2e. Assessment of the proposed electronic locker bank was assessed using a hill climbing model operating with a database of consignment movements; and qualitatively using staff interviews. Results indicated that a locker bank measuring 3.69m length, 1.7m height and 0.8m depth, comprising 19 partitions would be required to accommodate all urgent consignments for any given day. Staff perceptions of the concept were positive suggesting the locker would potentially improve the speed and quality of healthcare delivered to patients. Current hospital and courier service providers’ practices centre on collecting items as and when they arrive for outward journeys at the hospital. Using a database of 323 courier journeys at Great Ormond Street Hospital, 8 different consolidation scenarios, varying the length of time an item is delayed (ranging between 30 minutes to 10 hours). Findings indicated that consolidated approaches yielded reductions in vehicle numbers, between 120 and 255, compared to the current model of operation, but that the current model of operation is actually more environmentally efficient, generating 0.42 to 0.84 fewer metric tonnes of CO2 than consolidated approaches. Assessments of other hospitals such as University Hospital Southampton indicated that the three proposed solutions may be considered relevant to other hospitals. However, in the citywide context, the benefits for each solution when implemented at a single hospital site were minimal suggesting a greater number of hospital sites would be required to deliver larger gains.

In Sri Lanka, urban hospitals offer specialized healthcare services, while rural hospitals have limited services and normally offer only basic hospital facilities. Therefore people in rural areas have to travel relatively long distances to urban hospitals which offer specialized healthcare. This is expensive, while the poor transportation systems in rural areas make travel to urban hospitals time-consuming often involve an overnight stay. The aim of this research is to improve access to healthcare by adopting telemedicine in rural areas where the patient and the clinician in the rural hospital can contact the consultant in the urban hospital using audio, video and data communication methods for specialized healthcare services. The methods used were questionnaires and interviews in the exploratory study, which had small number of participants (83) covering three regions, followed by the main survey which had large number of participants (225) and ten regions. A model for adoption of a telemedicine system in Sri Lanka was developed from the analysis of the literature and the exploratory study. The exploratory study was conducted in three districts of Sri Lanka involving clinicians, hospital staff and the general public from both rural and urban areas, and Health Ministry officials, medical directors and consultants. The major study was conducted in ten districts and on two islands of Sri Lanka to identify the factors in the model which influenced the adoption of telemedicine. The findings of the main survey clearly indicate how important the telemedicine solution is to the rural population. The results also show that hospital staff and the general public were very much in favour of adopting telemedicine. The results also indicate that both clinicians and hospital staff believe that staff involvement, and introducing new policies and standards, will influence the adoption of telemedicine. Clinicians believe that Internet connectivity and the equipment used will not have an effect on introducing telemedicine. This model will be beneficial when implementing a telemedicine system into rural areas of Sri Lanka, which will provide patients with access to specialized healthcare services.

Beginning from the 1990s when the ‘New Public Management’ was introduced in the public sector, many countries around the world embraced this new way of working, especially in the developed countries. This adoption kept public sector services in economies like the United Kingdom (UK) under a tremendous pressure to become more efficient in the delivery of effective services. This phenomenon was named - ‘Value for Money’ initiative within the UK public sector. In order to achieve these goals, the public sector has been inundated with several reform regimes, thereby adopting management techniques and tools, which are arguably similar to that being used in the private sector. The National Health Service (NHS) was not left out of this wave. The NHS introduced the market system in the 1990s, in which the providers and purchasers of health services were segregated, giving them the opportunity to negotiate price of services with each other. The wave of reforms have since not stopped; by 2004, Foundation Trust (FT) status was introduced in the NHS, where the government chose to devolve accountability for health service to the local communities. The purpose of the devolution is to allow NHS hospitals to become locally accountable to their communities. The conferment of a new status on the NHS organisations is expected to set them loose from the government’s apron, granting them financial freedom, where they can keep surpluses generated for reinvestment in services, make investment decisions without deferring to the government and have a better control of the organisation. This research has six major objectives. First, it seeks to understand the entirety of Foundation Trust Status in the NHS, second, to outline the role of accounting as the controlling tool in the organisational setting, third, is to identify the string of local accountability within and outside the FT organisation, fourth, is to establish the effect of the structural change witnessed within organisation types, fifth, is to locate the FT change within the general form of the New Public Management (NPM), thereby evidencing the study as an empirical learning and finally evaluating the effectiveness of the FT reform within the organisations being studied. The study adopted an interpretive perspective, gathering data through interviews, documentary analysis and researcher’s observation. The study later adopted the thematic synthesis strategy in analysing the data. It is a multi-case study research, which involved three (3) NHS Trusts in the UK. The first organisation is a non-FT hospital, undergoing the process of becoming a Foundation Trust, the second and third operates as fully licensed Foundation Trust hospitals. This paper reflected on institutional theory as a tool, to understand the FT status in the NHS. In particular, we identified the forces that exerted pressure on the NHS organisations, the place of accounting as a tool in the process, how these organisations responded to innovation uptake. Data analysis unveiled organisation’s struggle for compliance through legitimacy for power and resource, which became the central phenomenon of this study. The NHS organisations were found to be resolute in their choice to implement the FT reform, in spite of the inherent complexity of the process on top of their day to day operational challenges. The struggle for compliance resulted in a mixed result, initiating an active pursuit of efficiency especially in the early adopter and then a negative influence on the late adopter organisation as actors engaged in a number of creative activities as they seek legitimacy. The result from this thematic study proposed that organisations adopt and implement accounting changes for the purpose of achieving legitimacy and promoting efficiency, as well as advancing self-interests. The effect of each choice was found relative to organisational motive for the adoption of the change, either for efficiency or legitimacy. This paper contributes to the theoretical understanding and relevance of institutional theory, particularly the New Institutional Sociology (NIS) in the NHS. Thus, providing a framework for legitimacy, this further illuminates possible explanations for the interrelationships between organisation’s adoption and the implementation of an accounting change in organisations, with the attendance of loose coupling. In addition, it contributes to the practical understanding of the FT change amongst practitioners in the NHS, an understanding, which helps grasp the importance of the change within the context of today’s society, as driven by the current and developing economic terrain.

Stroke is a major cause of disability world-wide, representing a significant health and social burden (Feigin et al., 2009). Self-management has potential importance for reducing the personal and health service impact of illness, but is yet to be fully understood or measured in stroke (Boger et al., 2013, Jones & Riazi, 2011).This research sought to develop a new patient-reported outcome measure (PROM) of self-management following stroke. A mixed methods paradigm with three distinct phases was adopted. Focus group methodology (n=28) first explored self-management from the perspectives of people following stroke and informed the content of a preliminary PROM. Three key themes identified from the data affect stroke self-management; Individual capacity; Support for self-management and Self-management environment. Following the focus group enquiry, the preliminary PROM item pool consisted of 57 items relating to Individual Capacity. Cognitive Interviewing methodology (n=11) was next employed to refine the item pool and explore acceptability of the items. Finally, the revised PROM was subject to psychometric evaluation using responses from a nationally derived sample (n=87). Mokken scale analysis and correlations with additional outcome measures of theoretical importance were used to identify scale structure and investigate reliability and validity. The subsequent PROM, the Stroke Self-Management Questionnaire (SSMQ) forms a unidimensional Mokken scale which measures the construct of self-management competency. The SSMQ possesses excellent internal consistency reliability (Mokken r 0.89), test retest reliability (ICC 0.928) and represents a valid tool for the evaluation of stroke self-management interventions.

Recovery from Traumatic Brain Injury (TBI) is a lengthy and complex journey. The ability to Return to Work (RTW) is often severely compromised and not easily predicted by medical sequelae. Recent qualitative research has highlighted the importance of the environment and the support available. Despite this, little is known about how people present in their workplaces, manage their own impressions and how they use support to re-establish their workplace identity. This qualitative study using a multiple case study approach explores two RTW journeys. Each case includes the person with TBI and others identified as being helpful in the process. Data were collected over two years at six time points using semi-structured and unstructured interviews, genograms and social networks diagrams. Analysis has been informed by the work of Goffman (1959). The findings are presented in keeping with Goffman’s dramaturgical metaphors. Individuals offer many performances that are shaped by their interactions with others, each performance requiring the actor to project an accepted front so that the audience may view their performance as authentic. The thesis highlights how workplace fronts become disconnected in four key areas (appearance, manner, emotion and work skills) following a TBI and how a sense of connectedness is re-established over time. The findings highlight the importance of stage areas and how these distinct areas impact on the type of performance given and how it is supported by workplace and non-workplace actors to shape and save the performances that a person with a TBI is required to give in the workplace. I conclude that RTW is not a simple linear process but involves complex interactions between the individual with TBI and the workplace environment, employers, health care professionals, family and friends. I propose that the dramaturgical metaphor offers a way of understanding the complexities associated with RTW and re-framing the possibilities for RTW programmes.

The rapid growth in genetics knowledge with a subsequent impact on the health of the population has and will continue to increase the demand for NHS clinical genetics services. It has been proposed that general practitioners (GPs) could manage patients at low genetic risk. However, GPs do not have either the knowledge level or the confidence unless support is provided. A primary care genetic counsellor-led clinical genetics service could potentially support GPs in appropriate referral and as emerging NHS policy is planning to shift some specialist services from secondary to primary care settings, would seem a suitable setting for patients, who are not ill, but seek genetic information. This cluster-randomised trial was designed to evaluate the impact of two genetic counsellor-led primary care interventions: education to improve GP referral rates, and clinics to improve the patient pathway. GPs in 73 general practices (clusters) were randomised to receive a case scenario based seminar (intervention) or not (control), and their referred patients to receive a primary (intervention) or secondary (control) care clinic appointment. Outcome measures included GP referral and clinic attendance rates (primary), appropriate cancer and case scenario referral rates, GP referral attitude, clinic waiting times, patient satisfaction, patient and NHS clinic costs and referral case management (secondary). GP overall referral rate was not significantly higher and there was no indication of difference in clinic attendance rates, between groups. GPs from educated practices made significantly more referrals of patients at moderate and high genetic risk, of developing cancer (P=0·035, RRR 2×36, 95% confidence interval 1·07 to 5·24). To attend a primary care clinic appointment cost patients £3·28 less (P=0·000; £3·60 v. 6·62, 95% confidence interval -£4·76 to -£1·79) and 19 minutes less travel time (P=0·000, 95% confidence interval -30·70 to -7·90) than those who attended a clinic appointment in secondary care. More non-cancer than cancer appointments achieved the NHS 13-week clinic waiting time target (P=0·000, 81% v. 19%). 62% of all GP referrals, and 80% of all cancer referrals were entirely managed by genetic counsellors within the 18-week NHS referral to treatment pathway target. This trial has demonstrated that genetic counsellors can 1) provide GP education and improve access to clinical genetics services for individuals at increased cancer genetic risk and, 2) manage both the majority of all patients referred by their GP and those referred with a cancer diagnosis, irrespective of referrer, in a clinic closer to their home than the secondary care clinic and with less patient cost.

Background: Schizophrenia has long been considered to be remarkably heterogeneous, and there have been a number of attempts to identify sub-groups of this disorder which are more homogeneous. Nevertheless, most of these have not been used in either research or clinical practice to any great extent, because diagnoses by way of these strategies would be unstable over time and impractical. In such circumstances, the vulnerabilitystress model has led to the development of a new concept of sub-grouping schizophrenia into 4 sub-types – drug related, traumatic, anxiety, and stress sensitivity. This conceptualisation is quite promising, not only because it may provide stable and practical diagnoses, but also because the terminology used therein is useful when it comes to destigmatising those who are currently diagnosed with schizophrenia. Methodology: In order to adapt this concept for practical use, this project set out to develop a semi-structured interview for making diagnoses according to it. Thereafter, psychometric properties of the interview were examined. This assessment tool was then used to confirm the longitudinal stability of the diagnosis. In order to establish the construct validity of this classification system, it was examined if the anxiety and stress sensitivity sub-groups in this system were different in terms of their external validators. Three psychopathological variables – evaluative belief, fear of negative evaluation from others, and depression – were assessed in a cross-sectional study during this process of validation. Three other clinical variables – two for the duration of hospitalization and one for the risk of self harming – were also used in a retrospective cohort study for the evaluation of the predictive value of the differentiation. Results and conclusion: Both the English and Japanese versions of the semi-structured clinical interview for psychosis sub-groups (SCIPS) were developed to sub-group patients into 4 categories, and their reliability and concurrent validity were established. The 6 month stability of SCIPS diagnoses of the drug related, anxiety and stress sensitivity sub-types was also indicated through a longitudinal study. A preliminary analysis provided little evidence of construct validity. The risk of self harming was, however, suggested as being associated with a distinction between the anxiety and stress sensitivity categories when the SCIPS was applied to a broader range of psychosis, including schizophrenia and schizoaffective disorder.

This thesis is an ethnographic exploration of group walking practices in the Hampshire countryside, investigating the embodied, affective and social practice of the shared walk and its relation to the individual pursuit of wellness. Responding to the growing literature in qualitative health geography using ‘therapeutic landscape’ as a conceptual framework, group walking practices are approached in this thesis from a perspective of more-than-representational theories of social practice that aims to address group dynamics and the role of social relations for the establishment of therapeutic spaces. While also drawing attention to the embodied and affective nature of experience, this thesis opens a discussion between health geography and cultural geographies on the issues of the body, mobility and collective experience. Further, the thesis aims to place the study findings within the wider cultural phenomena of ‘walking for health’ through an exploration of practices of assemblage. Deleuzian assemblage theory, both as a pragmatic analytical tool and an ontological position, offers a new approach to thinking health and place relationally, arguing for a distribution of agencies and providing a framework for tracing their emergent effects across complex networks. The thesis finds its empirical focus in ethnographic fieldwork with five walking groups as well as individual mobile interviews. The findings discussed in the thesis firstly pertain to the significance of social relations for well-being, exploring the kinds of socialities that are produced while walking together, and arguing that the shared walk has the potential to establish a place-specific social aesthetic that can be experienced as restorative. Secondly, the rural walkscape as a therapeutic landscape is analysed as a specific outcome of place-based rhythms, implicated in the performativity and mobility of the body in the creation of a restorative place/practice. It is found that the shared walk is characterised by specific rhythmic qualities and that walking as a health practice is subject to a range of norms, regulations and performative styles. The findings and conceptual development in this thesis contribute to an interrogation of the complex processes through which therapeutic landscapes are established, practiced and experienced. The thesis also contributes to more-than representational geographies of embodiment, affect and landscape, which are intimately tied up in the production and performance of both wellness and place.

Recent government reports indicate that there is a high incidence of enduring mental health problems in the African and African Caribbean communities living in the UK. Although research has explored the experience of service users from both of these communities, little is known about how family carers experience caring for a relative with an enduring mental health problem from the same communities. The aim of this investigation was to explore the lived caring experience of seven carers from the African and African Caribbean communities who cared for family members with an enduring mental health problem. A hermeneutical phenomenological approach, as described by Van Manen was used, which encompassed descriptions of carers’ experience of caring and subsequent interpretation of their lived experience. Analysis of the findings revealed the caring experience to encompass: (i) being there and staying there; (ii) losing oneself and re-discovering self; (iii) keeping an on-going dialogue with others, (iv) a conscious awareness of cultural stereotypes and (v) sustaining hope during the caring experience. The study concluded that carers from both communities maintain a strong familial obligation in their caring experience. Carers also make use of local community care groups to assert their carer role with mental health and social care services. Recommendations for future research are discussed in relation to improvements in mental health and social care provision.

Antibody production in the lungs is an essential defence mechanism against respiratory pathogens. However, little is known about the local activation of B cells in the lung. The production of BAFF and APRIL by airway epithelial cells could contribute to local recruitment, activation, class switch recombination and antibody production by B cells in the lung. In vitro, BEAS-2B cells were used to characterize BAFF and APRIL production simulated either by RSV infection or addition of cytokines. RSV and IFN-β significantly induced expression of BAFF mRNA and protein but not APRIL. BAFF mRNA reached significantly high levels at 12h and declined at 48h after either RSV infection or IFN-β stimulation. Western blot analysis of resting epithelial cells showed that membrane BAFF was expressed by resting cells. On RSV infection or IFN-β stimulation, expression of membrane BAFF increased at 12 and 24hours and disappeared at 48h, which suggests soluble BAFF was cleaved from the membrane and released into the culture supernatant by 48h, where it was measured by ELISA. When BEAS-2B cells were infected with RSV after pre-incubation with anti-IFN β, expression of BAFF was blocked, which indicates that airway epithelial cells can produce BAFF in an interferon dependent manner. BEAS-2B cells did not express CXCL12, CXL13, CCL19 or CCL21, which indicates there are other potential sources that express these chemokines during RSV infection rather than the airway epithelium. A murine model of RSV infection was used to examine expression of BAFF, APRIL and of the chemokines CXCL12, CXCL13, CCL19 and CCL21. Cytokine mRNA and RSV N gene expression were measured by Taqman PCR in lung tissue from control mice at day 0 and mice challenged with RSV (A2 strain) or control UV-treated RSV at days 1, 2, 4, 7, 8, 10, 14 and 21 days after RSV infection by ELISA. RSV N RNA was significantly detected at day 1, 2 and 4 after RSV infection compared to UV RSV control. BAFF mRNA expression was increased significantly after RSV infection on day 1 ,7 and 8 in comparison to UV treated RSV control at the same time points. Equally, BAFF protein was also elevated significantly after RSV infection at days 1, 2, 4, 7 and 8 in comparison to UV- RSV control at the same time points. CXCL13 mRNA expression was increased significantly after RSV infection on day 1 and 7 in comparison to UV-RSV control at the same time points. Moreover, CXCL13 protein was increased significantly after RSV infection at day 1, 2 and 7 in comparison to UV RSV control at the same time points. CXCL12, CCL19 and CCL21 mRNA and protein levels were not increased significantly after RSV infection, which may indicate they are not active during RSV infection. Examination of mouse lung sections showed strong positive staining of B cells (CD20) following RSV infection at day 1, 2, 4, 7 and 8 and FACS analysis B cells numbers were increased significantly at day 6 and 8 following RSV infection relative to UV-RSV control. RSV infection results in up-regulated BAFF and CXCL13 expression, consistent with a role for CXCL13 in recruiting B cells and BAFF in promoting airway B cell survival or differentiation. Collectively, these results suggest that the airway epithelial could help recruit and support B cell growth and development and Ab production in the lung.