This thesis includes theoretical contributions to organisational studies and medical sociology, drawn from a three levelled ethnographic case study of commissioning by General Medical Practitioners in the setting of the English National Health service. In order to locate these levels as interrelated structures, the concept of “field” (Bourdieu, 2005, Fligstein, 2001, Fligstein and McAdam, 2012, Lewin, 1997 [1951]) is used. Jens Beckert (2010) has developed a framework in which cognitive frames, networks, and rules are in a relationship of irreducible interdependency. The definitions of analytic categories in the extant framework are under-developed. In this thesis, the framework is empirically applied to add definition to the analytic category “cognitive frame”. Beckert’s Framework and Weick’s (Weick, 1995, Weick, 2000, Weick et al., 2005) Sensemaking Perspective are intersected to develop a reciprocal relationship between the two theories. By conceptualising cognitive frame as a sensemaking process, insight is gained in three different but overlapping facets: wider contexts, temporality, and distributed sensemaking. At the level of an industry a cognitive frame can be described as a sensemaking type, which will have constituent sensemaking styles associated with that industries internal networks. When rules require organisations from separate industries or sectors to form partnerships then actors with different sensemaking types will be required to interact within one network. Organisational development techniques can be used to support and align sensemaking in both of these circumstances. Sensegivers may have an important role in pacing, including suspending, sensemaking. The thesis also contains insights for medical sociology in respect of how and why GPs commission as they do. These relate to the impact of belonging to the NHS family; differing permutations of changes to the profession (hybridisation, restratification, and the delimitation of autonomy) in GP networks; GP compliance with rules; and the characteristics of an inner-city GP workforce.

People living with advanced disease face challenges to their being-in-the world; these are attributable to both the nature and progression of their illness and the level and variability of their care needs. Recent policy initiatives and literature promote community care for patients with advanced disease, and there are a plethora of different health services that may be involved in care provision for people in the last year of their lives. The current research takes a phenomenological approach, informed primarily by the work of van Manen, to explore the lived experiences of patients and their spousal-carers in relation to the multiple services that are involved in their care. In-depth, semi-structured interviews with twelve patients with advanced disease, and eight spousal-carers were conducted. These interviews employed the Pictor technique to support people in reflecting on, and communicating, their experiences of care situations. Pictor is an innovative technique that is used with lay-participants for the first time in this research. The technique encourages people to reflect on relationships and personal experiences, and then to communicate these through the creation and discussion of a visual chart. The digitally recorded data were transcribed verbatim and analysed using interpretive phenomenological methods, supported by Template Analysis, which allowed the hierarchical coding of themes. The research findings indicate that advanced disease affects people in many different ways; participants’ perceived meaning of illness is instrumental in how they view and engage with health care services. The lived experience of this phenomenon is discussed as an ‘unhomelike-being-in-the-world’, and ‘striving for poise’. The varied experiences of participants are illuminated and further explored with a focus on key relationships with health care providers. Here, it is argued that consideration of ‘authentic relationships’ is a valuable resource in supporting people affected by advanced disease.

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Aim: Within the field of obesity, evidence shows that weight regain following weight loss is extremely common, demonstrating that weight loss treatments are not effective. Considering that attachment history influences a person’s capacity for emotional regulation and that some people use food to self-soothe, increasing our understanding of the relationship between attachment style and obesity might inform better treatments. This study is comprised of two parts: the first part investigates whether attachment style predicts outcome in a 12-session group treatment for obesity and the second part explores the experience of that treatment. Design: The study utilises a mixed methods design with participants from a group treatment for obesity which comprises: the Attachment Style Questionniare (ASQ), completed by 52 group members, along with their body mass index (BMI) measures at the start and end of the treatment, analysed using a backwards multiple regression to test whether the 5 dimensions of the ASQ can predict participants’ change in BMI; and semi-structured interviews with 7 people from the same treatment analysed according to Interpretative Phenomenological Analysis (IPA) guidelines. Method: Data was collected from 52 people attending group treatment for obesity with an NHS service in South East England, which included the ASQ and BMI measures at Week 1 and Week 12 of treatment. The change in BMI was entered as the dependent variable for the regression in SPSS and the five attachment dimensions were entered as predictors. 7 people who had taken part in Part I of this research participated in interviews about their group experience. Transcripts were subjected to IPA. Results: Quantitative findings produced a model in which the ASQ dimension Confidence (in relationships) significantly predicted change in BMI in a negative direction (i.e. the participants who scored higher on Confidence lost less weight than those with lower scores). Confidence explained 8% of the variance (R2=0.08, F(1,50)=4.32, p<0.05). Qualitative findings produced four super-ordinate themes which included: the sadness at the course ending; the support and comfort felt from others in the group experience; the positive aspects of the group treatment; and the negative aspects of the group treatment. Other group members appeared to have a substantial impact on participants, whether positive or negative. Some accounts reflected the importance of others in feeling accepted and supported. Other accounts conveyed less of an emphasis on feeling part of the group and more on feeling separate. Conclusions: The quantitative results are inconclusive and possible reasons for this are discussed. The qualitative findings suggest that it is likely that group intervention for obesity could be improved by attention to attachment and by tailoring treatments more specifically to individuals.

This thesis develops statistical methodology for disease mapping, an increasingly important field of spatial epidemiology. Disease mapping has applications in public health by allowing for identification of areas which are at high risk of particular health problems. Such approaches are generally based on areal data, which involves partitioning the study region into a set of non-overlapping areal units and recording counts of disease cases within each areal unit. The majority of approaches assume a spatially smooth risk surface, but this may not be realistic, and there has been recent interest in developing methodology which allows for discontinuities in this structure. This can be done by identifying clusters of areal units with similar disease risks, and allowing for discontinuities between these clusters. The work presented in this thesis develops models to identify such clusters and also estimate disease risk. Three Bayesian hierarchical models are proposed; the first two are based on spatial data at a single time point, while the third extends into the spatio-temporal domain by modelling across multiple time points. Each model is applied to respiratory hospital admission data from the Greater Glasgow and Clyde Health Board area in order to identify clusters which have high disease risk.

This thesis explores the various roles that visual representations played in the theoretical understanding of, and practical approaches to, venereal disease in London’s medical marketplace from around 1780 to 1860. Venereal disease was understood in a variety of ways, and conceptualised within a number of different medical disciplines, such as pathology and dermatology. The analytic lens of visual representation allows the historian to explore the complexities of these understandings. This thesis therefore contributes to the literature on the historicising of disease. The period under discussion was one of enormous change in medical theory, practice and disciplinary organisation. Disease was being conceptualised as something physical within the body, meaning images of the disease took on new meanings. Furthermore, these representations played an important role in medical education of the period, as well as in the legitimisation of new disciplines. Within these new theoretical paradigms and institutional spaces, various new meanings were created for the visual representations, and their creators and users had to employ various strategies to limit their meaning and control their interpretations. This thesis utilises a variety of visual and material representations – atlas illustrations, wax moulages, paintings, casts, models and pathological preparations – to see how meaning was negotiated for these visual representations. Venereal disease is a particularly complex case, as it was considered difficult to depict, therefore debates and disagreements over how it was to be visualised reveal much about how the disease was conceptualised. Through five chapters, the thesis explores how these representations functioned within different spaces in London’s medical marketplace, such as public museums, private schools, hospitals and university medical departments.

The health experiences, and the lived experiences in general, of homeless young women have largely been overlooked. In seeking to redress this situation, the research findings presented in this thesis support those from other homelessness studies; the sample's health was poor. However, drawing upon a wider range of research traditions than is normally the case, conceiving health in terms of physical, mental and social well-being, and employing qualitative methods to facilitate verstehen of the epiphanies and processes involved in the outcome of 'homelessness', the meanings these lived experiences had engendered, and the lifeworld of 'homeless' young women, this study problematises the rather biomedical orientation of most homelessness and ill-health studies. The fundamental argument presented is that homelessness and poor health outcomes are products of the same iniquitous structures that affect a much greater population, yet the medicalisation of homelessness has served to obscure this and reinforce difference. Accordingly, the concepts of social exclusion, youth transitions and identity in late modernity provide a normative 'way of seeing' the experience of homelessness and its relationship with health. By simply conceiving the subjects of research as cognisant and purposive agents whose lived experiences are rooted in the structures and processes of exclusion inherent in late modernity, yet mediated by the affective body, the importance of acknowledging relativity, as a social concept in homelessness research is demonstrated. This is accomplished by exploring the sample's lived experiences as the contexts within which their health meanings and actions are informed and effected. It is shown that 'homelessness', portrayed by the sample as a stage of transition between the structured limitations of the past and their aspirations for the future, does not only produce negative health outcomes.

The broad aim of this thesis on ‘Health Economic aspects in the management of Chronic Obstructive Pulmonary Disease’ (COPD) was to study the natural history of the disease in order to inform the conceptualisation and development of a new economic model. Existing economic evaluations for COPD were critiqued and information on the natural history of the disease gathered though literature searches and analyses of two large datasets, a COPD randomised controlled trial called TORCH and a general population observational dataset called the Renfrew/Paisley (MIDSPAN) study. Particular attention was paid to identifying the COPD population using different diagnostic criteria. The elicitation of utility estimates under a number of circumstances was considered. A regression based prediction model was conceptualised and developed. Significant contributions of this thesis include, but are not limited to: a NICE COPD cohort were identified who were found to be at higher risk of all-cause and COPD mortality than a GOLD defined cohort; a mapping equation was successfully developed that predicts the EQ-5D from the SGRQ; and an entirely new concept for modelling COPD was developed that uses a series of regression equations to predict cost and effect based on lung function, symptoms and exacerbations and weighted by survival probability in order to generate a model with one arm representing current treatment and a second arm representing a comparator treatment. The thesis successfully combined information gathered throughout the period of research on the natural history of COPD with treatment effects in a novel way in order to conceptualise and develop a new economic model for COPD.

Introduction: The consequences of sustaining a head injury (HI) are varied. Recent research has begun to explore the experience of HI on identity which can, in turn, affect wellbeing. The move into a care home is also associated with changes to identity and wellbeing. Arguably changes to social identity (a form of identity based on membership to social groups) are particularly salient in this setting. Despite this, there have been no studies examining social identity in individuals with severe HI who reside in care homes. Aims: This exploratory study examines the perceptions of adults with severe HI residing in care homes, their relatives and care staff using a social identity framework. Methods: Eight participants from three group perspectives took part in this study (three adults with severe head injuries, two relatives and three staff carers) comprising two participant triads and one participant dyad. Semi-structured, open-ended interviews were completed and recorded with each participant on an individual basis. Transcripts were analysed using Interpretative Phenomenological Analysis. Results: Three superordinate themes were found: doing as normality, HI as separate from the individual and being a child and an adult. Discussion: Social identity processes of pre-injury identity loss and the acquisition of new social identities relating to the HI and being a resident in a care home are discussed. HI and the care home environment lead to perceptions of the PPs as part of a homogenous group which result in stigmatising interactions. The role of socially meaningful behaviour in mediating perceptions of the PPs is raised as well as the need to acknowledge issues relating to insight and current ability. It is unclear based on the results of this study whether needs relating to identity are met within care homes. Conclusion: The importance of taking an individual approach to explore meaningful social activity for the PPs and the recognition of the importance of this in relatives and carers is highlighted. Further research into interventions for this population and care staff is recommended.