This thesis explores a number of interrelated factors that influence the development of telehealth. Telehealth refers to health-related services that can be provided in electronic form over various telecommunications networks, including applications beyond clinical settings and reaching out to communities and homes. As such this study encompass different disciplines and draws not only on the medical tradition but also on information systems, social theory and ideas of information society. The study is based on the fundamental claim that technology does not follow a pre-determinate path but is shaped by people, who in turn are constrained by historical conditions and current structures. The research takes into consideration a number of such defining structures, including the organisation of healthcare in Britain, the health policy process, strategies for the employment of information and communications technologies (ICTs), conflicting ethical traditions and their manifestations in evaluation processes, and visions of an information society. The theoretical position and research approach is informed by critical theory. Thus the work focuses on the different, often conflicting, interests of varied stakeholders. It also unveils factors constraining social aims to which telehealth could aspire, e.g. reducing social exclusion and supporting empowerment of patients and citizens. Insights into these concepts and their practical manifestations are explored through a set of linked case studies, which investigate a variety of telehealth projects and initiatives in the London Borough of Lewisham. The thesis' contribution is twofold - practical and theoretical. The practical contribution is aimed at those who work in and study telehealth, offering a new approach and focus that is not substantially found in other telehealth studies. In this the thesis makes a contribution to the ongoing debates about telehealth's potential implications for the healthcare process. The theoretical contribution is found in the thesis' re-affirmation of the applicability of critical theory to the development of ICT-based social and organisational innovations, re-conceptualised in the light of post-modern and information society theories.

In 1995, the Taiwanese government introduced the Case Payment Scheme (CPS) to initiate a prospective payment method for diagnosis-related groups under the National Health Insurance (NHI) programme. The aim of the CPS was to rectify the supplier induced demand caused by the fee-for-service plan and to improve the efficiency of health services. However, this scheme created a dual reimbursement system for the NHI, under which, some services were reimbursed on the basis of claims for fees, while others were bundled together and paid a fixed rate per discharge. This study examines changes in hospital behaviour in this context based on the assumption that hospitals have incentives to maximise the profits from both payment plans. The aim is to quantify the effects of reimbursement changes on different dimensions of the delivery of health care. This research also evaluates the global budget programme which has changed the budget allocation mechanism within the hospital sector since 2002. Empirical investigations were carried out for all the hospitals contracted into the NHI over the period 1998-2004. To model hospital behaviour, this study employs different econometric methods, including instrumental variables, panel data model, semiparametric estimation, seemingly unrelated regressions and limited dependent variable models. The results suggest that hospitals react to the shift toward the dual payment system by selecting patients, altering treatment patterns, changing the case mix and adjusting treatment intensity. Policymakers do not appear to have anticipated these phenomena. These findings indicate that there could be fundamental problems in the parallel use of retrospective and prospective payments, due to the improper reimbursement incentives embodied within the system. As mixed payment systems have been adopted around the world, this research has implications for existing and future reimbursement reforms.

Saudi Arabia is struggling to provide quality healthcare services in light of the growing population, rapid spread of chronic diseases, and limited resources available. In addition to these obstacles, the Saudi society is a highly conservative one, and certain traditions may sometimes limit how healthcare services can be offered. This work examines the impact of a Telecare solution on the healthcare system at the National Guard Health Affairs (NGHA). It focuses on diabetes, and the challenges faced by both the healthcare officials at NGHA, and the patients. These challenges also include social factors that may pose at obstacle in delivering healthcare services. The ‘Telecare for Managing Diabetes – TeMaD’ system is designed and developed using the Soft Systems Methodology. It was then integrated into the hospital information systems at King Abdulaziz Medical City in the Central Region, and consisted of 52 participating patients, and four involved Diabetic Educators. HbA1c levels of all patients were recorded prior to commencement of the study. Patients were required to use TeMaD for a 3-month period, then, had their HbA1c levels recorded again after completion of the study. Overall observation of the results showed a reduction in the HbA1c levels of 83% of the patients. Participating patients expressed their acceptance of the system, indicating that TeMaD allowed them to overcome some obstacles such as lack of transportation. It also assisted the majority of participants to better manage their diabetes and ease communication with their diabetic educators. Most patients requested that the system be offered permanently at the clinic. Diabetic educators were in favour of integrating TeMaD into the current healthcare system at NGHA, and they were enthusiastic about its numerous benefits. Telecare solutions can be used to enhance the quality of healthcare services, meet current demands, and address obstacles faced by the healthcare system in Saudi Arabia, including social factors that are unique. They can be adopted by neighbouring Gulf States which share common obstacles in healthcare.

No description available.

Waiting times for elective surgery constitute a key performance indicator for the NHS. The principal policy response has been to introduce maximum waiting time targets against which performance is measured and rewarded. The aim of this thesis is to shed light on the mechanism of patients’ admittance for elective surgery in UK by examining the whole distribution of their waiting times from an empirical and theoretical perspective. In Chapter 2, we empirically investigate the effect of government targets on the distribution of patients’ waiting times by applying duration analysis techniques to waiting time data from 2001/02 and 2002/03 for three specialties: general surgery, trauma & orthopaedics and ophthalmology. In Chapter 3, we examine further the variation in the way hospitals and surgeons manage their waiting lists by exposing detailed patterns regarding the shape of the survival and hazard curves of patients’ waits. We use an expanded dataset (1997/98 to 2005/06) both in a cross-sectional and across time framework controlling for factors such as size, type and performance rating for hospitals and activity level for doctors. We also address the issue of the evolution of waiting time distributions over time. Chapter 4 provides a theoretical supply model on how a hospital manages its stock of patients given its objective function and the constraints it is faced with. We derive the optimal waiting time distribution and identify important factors that could explain the differences between the observed empirical patterns.

Background: Epidemiological studies have shown that social and emotional support can protect against premature mortality and prevent illness. The longterm consequences of poor parent-child relationships on adult mental health have been a major focus of research. Much less attention has been directed towards the effects on physical health outcomes. Objective: Based on the life course model, this thesis assessed the extent to which child-parent relationships influence physical health in later life. Methods: The dissertation was based on a systematic review of longitudinal studies linking parent-child relationships and physical health in adulthood, and on secondary data-analyses of the Christchurch Health and Development Study. The role played by different confounders and mediators was discussed. The analyses were based on multivariate regression methods. Results: Most of the systematic review studies showed a positive association between poor parenting and health in later life. Supportive of the association were studies on general health relying on self-reports. Non-supportive were studies looking at mortality and rare diseases and relying on official records. Some of the studies presented their findings in relation to gender, girls being more likely to somatise in adolescence or in adulthood. An association was found for the Christchurch Health and Development Study between the quality of parent-child relationship and hospital admission or the number of doctor visits. These effects were more pronounced in females. Overall, adjusting for different confounders and mediators added some information, but did not replace the effect of the exposure variables on the outcomes. Conclusion: More research is required in understanding how the early behavioural, environmental and social factors work together in the development of long term health outcomes. Given the growing evidence of the long term effects of poor parent-child relationships, greater efforts are clearly needed in developing effective strategies for prevention and intervention.

Whilst the need for leadership in healthcare is well-recognised, there is still a lack of understanding about how leadership contributes to improving healthcare services. The body of knowledge concerning improvement has grown significantly in recent years, but evidence about links between leadership and health services improvement remains poor, especially within the UK National Health Service. It remains unclear how and why leadership is important to service improvement. This thesis describes aspects of a broader study commissioned by The Health Foundation. Firstly, the work aimed to explore the extent to which different types of service improvement require different types of leadership behaviour. Secondly, it aimed to investigate the nature of any links between leadership behaviour and improving services. The work draws on theoretical models and concepts of leadership and improvement in the literature, as well as empirical research in these areas. A typology of healthcare improvement was developed in order to classify different types of improvement work. Data about leadership behaviours were derived from semistructured interviews and using Q-Sort methodology. The study provides insights into which aspects of leadership are used for different types of improvement work. It makes an original and NHS-specific contribution to the literature, providing empirical evidence of how NHS leadership is associated with service improvement. Results highlight the importance of the relational aspects of leadership behaviour in improving NHS services, reinforcing trends in the literature which promote shared and distributed leadership approaches. A model of improvement leadership is proposed, based on the concept of ‘interdependence’. This model could provide the basis for an alternative emphasis in developing leadership in healthcare organisations, away from teaching skills to individuals, towards a collective, team-based approach to leading services with a shared purpose.

In 1986, the first case of HIV/AIDS was reported. A decade later, it had killed over 25 million people. Many, especially those in the developing world, were dying slowly and agonisingly from a disease that had no cure. Entire communities were losing so many people in the prime of their lives changing the fabric of those societies irrevocably. When antiretroviral medicines were discovered, there was a sense of optimism. Although these medicines were not a cure for AIDS, sufferers for the first time had hope of an almost normal life, a life without debilitating pain, a life where getting AIDS did not necessarily mean a death sentence. Unfortunately, the new ARVs were governed by the international law trade regime. These medicines had patents on them which allowed the pharmaceutical companies who owned them to exclude other users and charge astronomical prices. Millions of AIDS sufferers especially those from the developing world simply could not afford to pay these prices. This thesis examines the response of the international legal regime to this dilemma. It argues that a hard law approach was unsuited to creating greater access to ARVs as this meant prioritising patent rights which always invariably led to cost implications for the user. Many of the people who suffered from AIDS in developing countries were therefore still left unable to afford these medicines. By contrast the thesis argues that a soft law approach has been more effective. Soft law unlike its hard law counterpart makes it easier for States to reach agreement due to its non-binding nature. This also makes it faster for countries to achieve a consensus over issues, which makes it preferable when dealing with public health pandemics, such as AIDS, where speed is of the essence. Soft law is also more flexible and easier to supplement, amend or replace when faced with changing circumstances. In pursuing this argument, the World Trade Organization regime and the United Nations regime from which the majority of conceptual responses to the access to ARV problems have originated are assessed. In doing so the research suggests that soft law initiatives have developed a humanitarian norm of access to ARVs so as to enhance the prospect of universal access programmes that give free ARVs to those who would have been unable to afford them otherwise.

Abstract Background: Obesity, in addition to being a serious condition in its own right, is causally associated with many chronic non-communicable diseases, and its prevention, identification and treatment is a public health priority. Results: The main findings of the present thesis were that 1) many drugs, used in the management of chronic disease, have an adverse effect on body weight with weight change of +10kg observed as a real side effect of some. 2) Identification and management of obesity is not a formal part of current practice in many secondary care clinics. While acknowledging the adverse health effects of obesity within their specialist areas, clinicians felt under-skilled and insufficiently resourced to provide effective management. 3) Improvements in iron status in pre-menopausal women can be achieved during weight loss, using eating plans that either include or exclude red meat. The data while in-conclusive suggest that a diet including red meat may confer greater benefits on iron status. Discussion: Weight gain is an adverse effect of many drugs used to treat chronic diseases. This should be discussed with patients prior to treatment and advice provided on how to avoid or minimise weight gain. NHS secondary care consultants are concerned about obesity and its impact on their patient’s health. Most have no weight management strategy and would like one. This will require additional training and resources. Excluding red meat did not adversely affect iron status in pre-menopausal women. A larger study is required for definitive health promotion advice. Conclusion: Pharmacotherapy is a significant factor in the rising prevalence of obesity. Weight management is not an integral part of patient care in secondary care clinic settings. The exclusion of red meat during weight management does not compromise iron status in pre-menopausal women with low iron stores.

Hypertension is a leading cause of death and disability worldwide. Despite effective treatment regimens the mortality among hypertensive subjects are much higher than that of normal individuals. Several studies have been carried out to identify prognostic factors that have predictive value for mortality in the general population. New biomarkers that are readily available and cost-effective are important in risk stratification and management of hypertension. While important prognostic information can be learned from routine blood tests that are often conducted in hypertension clinics, the usefulness of these markers in predicting survival are not studied in detail. The thesis aims to explain the relationship between such inexpensive and commonly available markers and survival in a hypertensive population. The thesis is divided into five main results chapters (chapters 3 to 7) based on studies conducted to assess the independent role of blood pressure variability (BPV), haematocrit, serum phosphate, serum electrolytes and indices of liver dysfunction or injury in predicting mortality in hypertensive patients. The study settings (Glasgow Blood Pressure Clinic) provided an opportunity to examine these relationships in a treated hypertensive cohort of more than 15,000, predominantly white population, from the West of Scotland. The hypertension clinic database was linked with the electronic records of General Register Office for Scotland. This electronic linking allowed extraction of primary cause of death data (if patients died during the course of follow-up) according to the International Classification of Diseases, 10th Revision, Version for 2007 (ICD-10), codes. The type of mortality was ascertained (namely; ischaemic heart disease, stroke, cardiovascular, non-cardiovascular and all-cause) from the ICD-10 codes. The independent relationships between predictor variables of interests and mortality were estimated after employing appropriate survival models. The main study findings are summarised below. Blood pressure variability and mortality: Long term average BPV is an independent predictor of mortality. Longitudinal changes in BPV also predict mortality independent of underlying mean BP. While sustained high variability increases mortality, sustained low variability decreases mortality in this hypertensive cohort. The findings indicate that BPV is likely a fundamental physiologic trait and it is a marker of early mortality. Visit-to-visit BPV is an important prognostic indicator of long-term mortality, and physicians should be made aware that long term clinic BPV should not be disregarded as random fluctuation between visits. Haematocrit and mortality: Haematocrit (Hct) is the proportion of blood volume occupied by red blood cells. It is associated with follow-up BP and is an independent predictor of mortality in the hypertensive population. There are distinct differences both in terms of the strength and magnitude of the association of Hct and mortality between men and women that have not previously been known. While Hct is associated with CV mortality in men ('U' shaped, non-linear), it is more closely associated with non-CV mortality in women ('U' shaped, non-linear). In the assessment and management of newly diagnosed hypertensive patients, Hct levels should be taken into consideration as an important risk predictor. Serum phosphate and mortality: Inorganic phosphate is an important mineral that is directly linked to energy metabolism, bone mineralisation, signal transduction, storage and translation of genetic information and maintenance of lipid membrane structure. A positive linear association between serum phosphate and mortality is reported in the present study. Deprivation status, serum calcium and serum alkaline phosphatase levels do not attenuate the mortality risk associated with serum phosphate in men and women. While serum phosphate is associated with CV mortality in men, it is more closely associated with non-CV mortality in women. Serum electrolytes and mortality: Electrolytes, especially sodium, chloride, potassium and bicarbonates, play a vital role in maintaining homeostasis within the human body. While the relationship with all-cause mortality is non-linear across the entire range of serum chloride, there is a linear increase in mortality with decrease in serum chloride level below 100 mEq/L. The relationship between serum chloride and mortality is independent of serum sodium and bicarbonate levels. While serum potassium shows a non-linear "U" shaped relationship with mortality, serum bicarbonate shows a positive linear association. Indices of liver dysfunction or liver injury and mortality: Serum albumin, bilirubin, alanine transaminase (ALT), aspartate transaminase (AST), gamma-glutamyl transferase (GGT) and alakaline phosphatase (ALP) are widely used markers of liver function or injury to liver cells. These markers of liver function or injury to liver cells independently predict mortality outcomes in the hypertensive population. While there is a linear association of both GGT and ALP with mortality outcomes, it is a more complex, non-linear and ‘U’ shaped association for AST. Both ALT and bilirubin show inverse linear association with mortality. Age and body mass index significantly influence the relationship between ALT and mortality. Strengths and limitations: The strengths of the studies conducted as part of this thesis include; a large cohort of nearly 15,000 hypertensive adults, a real life clinical setting, 35 years of follow-up with median survival time of 32 years, the ability to link predictor variables with differing causes of mortality outcomes, and adjustment for several potential confounding factors. Exclusion of individuals without predictor variables assessed at baseline and the bias introduced by the missing covariates in the adjusted Cox-proportional hazard models are the major weaknesses. Future recommendations: Although the above mentioned inexpensive markers predict mortality in hypertensive population, the mechanism involved in their association with mortality is not clear. Future studies are required to explain the missing links. Usefulness of inclusion of these markers in predicting mortality should be tested in an independent population.