Previous histories have tended to look beyond the asylum for innovations in early twentieth-century mental healthcare. In contrast, this thesis appraises the mental hospital as the nexus for a new approach to convalescent care and makes the case for a more integrated conception of institutional and community care in the interwar period. Despite a concentration of convalescent facilities in certain areas, this study argues that the period between 1919 and 1939 witnessed the emergence of a more standardised and coordinated model of care that traversed institutional boundaries. Consequently, it challenges a prevailing view that sees asylum care as separate from developments in borderline care in this period. It is demonstrated that public mental hospitals after 1919 widely added new convalescent villas within their grounds, whilst voluntary organisations diversified and extended their community-based cottage homes. This thesis explores the reasons for this expansion and seeks to explain the functions it served those who planned, managed and utilised mental convalescent homes. It is argued that those with professional interests in the mental hospital focused on the „modern‟ convalescent villa partly as a strategic response to the low status of mental hospitals in the 1920s, as well as to alleviate overcrowding, and oversee recovery in managed and healthful environments. The spatial and rhetorical connection between the admission hospital and the convalescent villa allowed these interests to claim they formed part of a broader movement of mental hygiene and early treatment. In contrast, patient representations of cottage homes offer an alternative perspective of convalescence as a holiday and break from social demands. Particular attention is paid to the case of the London County Council. The analysis focuses on descriptions of convalescent homes found in organisational records. These are compared with plans and photographs to make sense of the uses such homes served.

The development outcome of ICT and information systems in developing countries is often influenced by international development policies and the action of international actors such as donor agencies. In particular, ICT adoptions and implementations in developing countries may be influenced by the contradictions arising mainly from the tension between international managerialist development policies and the main rationalities of actors in the local implementation context. Based on the case study of health information systems in Kenya, the objective of this thesis is to increase the understanding of how these contradictions may affect the development and change potential of health information systems and ICTs in developing countries in relation to international development policies. Drawing on a dialectical perspective on institutional work, the thesis argues that the change and development trajectories arising from the implementation and usage of health information systems depend on how actors involved in the restructuring of health information systems – i.e. donor partners, national decision makers and local health information systems managers and users – respond to the ongoing dialectic between global and local pressures of institutional change and stability. The main findings of the research presented in this thesis point to the importance of analysing political donor relations and the institutional entrepreneurship of local actors in order to understand the change and development outcomes of health information systems and ICT in developing countries.

1.1 Background There is a large body of empirical evidence to suggest that social conditions are one of the major determinants of population health. These are defined as the ‘Social determinants of Health (SDH)’. SDH refers to the specific pathways by which social forces affect health. Developing a better understanding of the social determinants of health is critical in order to ameliorate the social determinants associated with poor health and to reduce the health disparities within the population. 1.2 Aim To examine the relationship between social determinants and infant mortality in Malaysia 1.3 Methods This study comprises an ecological (area-based) population health survey involving all 135 administrative districts of Malaysia. A literature review was undertaken in order to develop a model that hypothesises the main social determinants of infant mortality in Malaysia. In order to test the model, secondary data comprises of social determinants and infant mortality rate data from a range of sources were collected and analysed. Statistical analysis of the data using general linear model including correlations, factor analysis and multiple regression were undertaken in order to examine the collective influence of a range of social determinants on variations observed in infant mortality. Determinants of infant mortality in Malaysia tested in this study include GDP per capita, poverty rate, mean income of bottom 40% income earner, Gini coefficient, ratio of top 20% income: to bottom 40% income, doctors density ratio, hospital bed per population ratio, car ownership per population, computer ownership per population, urbanization rate, percentage living in single housing and flats, women education and social development index. 1.4 Results Although simple regression revealed significant relation between IMR with fifteen predictors, further analysis using multiple regressions failed to demonstrate any significant linear relationship except cars per population ratio which may reflect accessibility to food and services. This phenomenon may be due to problem of multicolinearity among variables. Factor analysis was done to identify similar items and new variables were created based on the identified factors. With the new group of variables, social development index explained 18%, income distribution explained 10.6% and health service provision explained 3.8 % of the variability observed in IMR. However, with multiple regressions, only social development index remained significant at p<0.05 level. Collectively, the variables were able to explain only 23% of the variability in IMR using multiple linear regressions analysis. 1.5 Conclusion This study managed to inform us regarding the important social determinants that can be altered with policy change in order to improve child survival in a developing country undergoing its health and economic transitions.

Informal carers of people with mental health problems receive little attention from both researchers and services. They constitute a neglected but extremely important population, whose care often prevents patients’ need for hospital admission and helps to sustain their life in the community. However, the price that carers pay for supporting their loved ones can be high in terms of their own levels of stress and burden. In the absence of support and often without outside help, they may struggle to comprehend mental illness and to navigate their way through the maze of various services. Their needs, particularly for emotional support, are rarely considered. The present thesis aims to address this gap in the literature, and hopefully to draw direct clinical implications for mental health services.

The pursuit of healthcare quality is a global trend as countries attempt to maximise the usage of resources amidst concerns about increasing costs and patient safety. The incentives for high quality care were traditionally provided by the tort system of medical negligence; however, modifications to this system saw it replaced in the UK in 1990 with a fault-based enterprise liability system (NHS Indemnity) - NHS trusts were now indemnified for clinical negligence claims in return for the payment of insurance premiums to the NHSLA which assumed responsibility for claims management. The incentives for quality care in this system evolved to a system of risk management standards in the 2002-2009 period – such standards offered reputational and financial benefits to trusts who achieved higher risk management levels (the attainment of such higher levels is proposed to be dependent on the trust governance structure and financial health), and the impact of this system on the clinical negligence outcomes of NHS trusts is the particular focus of this study. A lack of suitable data restricted previous studies of the effectiveness of risk management standards; however, the availability of such data permitted an empirical analysis of a unique panel database. This analysis initially found that the adoption of a new governance structure (i.e. foundation trust) is significantly associated with higher risk management levels, while efficient risk management processes are found to be significantly associated with lower numbers of clinical negligence claims. Finally, foundation trusts were found to be associated with higher closed claim values i.e. such trusts are willing to offer higher amounts to settle claims early. Overall, this study supports the proposition that more efficient risk management processes will lead to improved clinical negligence outcomes for NHS trusts, and recommendations are offered to assist trusts to become more efficient at risk management.

New techniques are proven in this thesis which allow the visual examination of the tear film on the cornea and on different types of contact lenses. The techniques are as follows: 1. A high magnification technique of photography using the biomicroscope and crossed polarised light, allows the measurement of tear film layer thicknesses and on the surface of rigid contact lenses and 'in vivo receding contact angle'. 2. A low magnification technique of photography allows the recording and the analysis of the superficial layers of the tear film over a wide area of the eye and contact lens surface. 3. A clinical instrument has been designed for the routine clinical observation of the tear film. It permits the visual measurement of the tear film break-up time (BUT) without the use of fluorescein. 4. A unique technique of in-vivo photography of the mucous coverage of the corneal epithelial surface and contact lens surfaces is presented. Such techniques improve the understanding of surface wettability problems. As a result of this work the appearance of the normal lipid layer of the pre-ocular tear film has been classified into seven grades within a thickness range of 0.02μm to 0.58μm. As we well as the normal, two examples of abnormal lipid layers are described. The manner by which Meibomian gland secretion occurs and performs its role in the tear film is illustrated and analysed. Forced gland secretion by pressure induced localised lipid thickness increase. Eyelid closure was seen to compress the lipid film and instillation of saline broke up the lipid film. It can be seen that the pre-soft lens tear film usually possesses a thin superficial lipid layer and an aqueous phase of limited dimensions. On the other hand the pre-PMMA rigid contact lens tear film rarely possesses a visible superficial lipid layer and its aqueous layer measured 1.5μm on average. The addition of the 'wetting' solution acts on the thickness of the aqueous phase which increases to 2.5μm and supports a minimal lipid layer. The use of contact lens materials of better wettability permits the formation of films of increased thickness (up to 5.5μm) with a visible superficial lipid layer which was seen to stabilise the film and retard its drying. The main differences in mucous coverage are described as follows. At the level of the basal layer of the tear film the mucous coverage takes a continuous undulated form on the corneal epithelium but a discontinuous sporadic distribution on soft lenses decreasing to sporadic occurrence on rigid lenses. Finally, because of the acquisition of the quantitative results, new infra-structures of the pre-lens tear film for soft and rigid lenses are proposed.

This thesis presents a qualitative study of service users’ and providers’ experiences of one UK inner city medium secure forensic mental health service. The study focused on the processes through which service users and providers attempted to manage their risk status. Aims The study had three main aims: 1. To develop a greater understanding of the complex formal and informal risk assessment and management processes operating in medium secure forensic mental health services. 2. To investigate the processes through which providers and users of medium secure services attempt to manage risk by balancing safety with the promotion of service user autonomy. 3. To generate recommendations derived from the study findings for the development of forensic mental health services. Methodology and methods A qualitative grounded theory methodology was used to explore forensic mental health care from the perspectives of service users and providers. Data were collected through lightly structured interviews and participant observation. Participant observation occurred over a period of eighteen month. Activities that took place within the service were observed and spontaneous informal conversations between the researcher and participants recorded. A theoretical sampling approach was adopted. Design, data collection and analysis were done in cycles so that the direction of inquiry could be grounded in participants’ concerns. Eventually, data collection and analysis were organised around the core category of the regulation of communication. Findings The regulation of communication was analysed in relation to three other important categories: the management of own risk status; the dynamics of self-forming groups; and external role expectations. It is hypothesized that the regulation of communication provided a means of attempting to meet competing role expectations and thus manage risk status. Conclusions The study provides an insight into how service users and providers situated within a complex and conflicted system may attempt to manage their risk status through regulating their communication. This strategy enables service users and providers to attempt to achieve the highly problematic mission of the forensic mental health service; to provide mental health care and public protection. However, organisational learning and risk management may be hampered by the regulation of communication as information regarding clinical and organisational risks may be silenced within official organisational systems. Furthermore underlying problems may remain unresolved for users and providers who feel unable to express dissent.

The increasing comorbid burden of tuberculosis (TB) and diabetes mellitus (OM) worldwide requires the management of all stakeholders including pharmacists. This raises the question whether current single disease management system fulfils patients' health needs and whether pharmacists could effectively play a role in enhancing the joint management of these two commonly associated diseases. Pharmacists have begun to provide pharmaceutical care through pharmacist-led medication therapy adherence clinics and clinical pharmacy services for several diseases and conditions (e.g. OM, asthma) in some public hospitals in Malaysia but are yet to be involved in the management of TB. The management of TB has been largely delivered through directly observed treatment (OOT) as high level of adherence to treatment is vital. However, little is known on how TB patients with OM are being managed and how these patients cope with their medication. The aim of this study was to develop a pharmaceutical care service for patients with TB and OM. The first three phases (preclinical, phase 1 and phase 2) of the UK Medical Research Council framework for the development of complex interventions to improve health was applied to develop a pharmaceutical care service for patients with both TB and DM in a tertiary hospital in Malaysia. First, literature relating to TB and OM was reviewed (preclinical). Second, the pharmaceutical care needs of TB and DM patients were explored using semi-structured interviews with twenty patients, three physicians, three nurses, and a focus-group with four pharmacists (phase 1). Third, action research was conducted to assess the feasibility of providing a pharmaceutical care service for patients with TB and OM (phase 2). This study received ethical approval from the Medical Research and Ethics Committee (MREC), Ministry of Health, Malaysia. Patients and health care professionals reported several medication-related issues in the phase 1 study. Patients were most inclined to discuss their concerns about their medication. Patients also tended to display different attitudes towards medication-taking, depending on their beliefs, the severity of illnesses, perceived efficacy of the treatment, and the severity of medication-related problems. The findings also revealed that many of these concerns had not been discussed with their physicians. This was also caused by the patients' and physicians' tendencies to prioritise the management of TB, and unintentionally neglecting other comorbidities especially when patients were primarily managed at the chest clinic. Other difficulties identified in comorbid management included delayed initiation of both TB and OM treatment, chest physicians' lack of confidence in managing 'difficult' OM in TB patients and the burden of attending multiple clinics for patients. Health care professionals believed that pharmacist-led medication therapy adherence clinics (MTACs) encouraged the provision of patient-centred care, enhanced pharmacist-patient communication, created opportunities for inter-professional interactions and could be used as a model to provide pharmaceutical care services. Health care professionals urged pharmacists to play a role in the management of TB and OM by providing patient education and counselling. The phase 2 study revealed that the prevalence of OM in TB patients was 15%. Action research allowed the researcher, together with a hospital pharmacist, to identify pharmaceutical care needs in TB and OM patients, and fulfilled some of them. Pharmaceutical care issues identified included lack of medication adherence, poor management of OM, the need to manage adverse drug reactions, and the lack of frequent monitoring of certain monitoring parameters for TB, OM and other comorbidities at the chest clinic. Many patients had uncontrolled OM, however, many were more likely to be adherent to TB medication than medication of OM and/or other conditions. As a follow-up action, pharmacists advised these patients to place equal importance to TB and non-TB related management. Additionally, pharmacists also made treatment recommendations and referred patients to their chest physicians for further management of medication-related problems. Nevertheless, there were barriers that impinged the provision of pharmaceutical care service. The barriers include the lack of space with privacy to provide education and counselling to patients; the unavailability of medication records and other clinical information for comorbidities at the chest clinic; and the lack of time to develop inter-professional relationship. Despite the need to address the barriers, the provision of pharmaceutical care service to TB and OM patients was feasible as pharmacists were able to integrate TB and OM management by identifying, communicating, and resolving some medication-related problems. In summary, this study provided the groundwork by conducting phase 1 and phase 2 study prior to developing a full-fledged pharmaceutical care service for TB and DM patients. Future work can be done to improve the service through critical analysis of the challenges faced in the developmental phase with the effectiveness of the service care plan assessed through a randomised controlled trial (RCT).

The central theme of this thesis is the place of a report provided by the trainer on the performance of the trainee as part of a process of regulating entry to independent general medical practice in the United Kingdom (summative assessment). The thesis aims both to analyse the place of a such a report within a process of summative assessment and to consider whether it is possible to develop a report form for this purpose that enables aspects of the general practitioner trainee's skills, knowledge, attitudes and practice to be assessed by the trainer in a feasible, valid and reliable way. It is argued that the certification process for entry to independent general practice in the United Kingdom needs review and that tests of performance, such as a trainer's report, have a particular role in such a process; that such tests should be criterion-referenced; and that a number of properties are of particular importance in the development and testing of a trainer's report in the context of the assessment of doctors completing general practitioner training in the United Kingdom. A set of research objectives are delineated for a sequential series of five research studies. Using a variety of methods (semi-structured group interviews, postal questionnaire surveys, consensus conference, and pitot testing), these studies demonstrate: that there is a specific place for a trainer's report; that valid contents can be selected and minimum standards set; that the report form that has been developed is reliable and feasible and allows discrimination; and that, should it be widely adopted, there is a strong need for further testing, a continuing quality assurance system and further developmental work. It is concluded that summative assessment does have a role in providing an initial step in assuring the public of the quality of doctors entering independent general practice and that the report form developed here is suitable for wide application within such a process. It is also reasoned that a number of lessons about the application of such a process, and the inclusion of such a report, in other settings can be learnt. In particular it is suggested that a report provided by a trainer may have a particular role in assessment when the requirement is the assessment of performance of complex attributes within the context of training designed to enable the trainee to carry out a particular purpose but that it should rarely be used as the sole instrument.

This dissertation examines the 'implementation gap' and reports evidence on progress in implementing closure of health services at micro-implementation level. Specifically, the research develops an historically bound, processual and contextual account of the development and fate of permanent closures of General Practitioner Maternity Units (GPMU) in four neighbouring Oxford DHAs. The major objectives of this study are to illustrate and analyse the process by which the 'implementation gap' is closed and to identify. some of the potentially important factors which help to explain the pace and rate of change differential across health districts. The key questions, guiding the research include: What affects the pace of implementation? Why do districts fail or succeed in implementing change? What affects the 'implementability' of the GPMU closure proposals? To make further progress towards an understanding of implementation, this research adopts a new, eclectic, and integrative approach: the Contextualist Approach. One major theme underlying most of the results and ideas presented here, is that the outcome of implementation can be explained by the interplay between the content, the context and the process of implementation itself. The research is essentially qualitative. The data collection process comprises three main activities: documentary search, in-depth interviews, and ethnographic material. The strategy of data presentation and analysis was to develop a descriptive framework for organising the data (Yin, 1989). A set of three interacting groups of factors is found to affect implementability and rate and pace of change at micro-implementation level - the nature of the locale, leadership, and the quality of the proposal itself. Although other authors have studied health service policy, this research is unique in offering an extensive treatment of the changing policy context under investigation. It is also the first to investigate partial, as opposed to total, closure of hospitals within the context of the NHS, with particular emphasis on the GPMU.