The aim of the study was to estimate the effect of the GRampian ASthma Study of Integrated Care [GRASSIC] (for adult asthma patients currently attending hospital clinics) on the care of those patients not attending outpatient clinics. In order to do so, a method was devised for identifying random samples of adult asthma patients treated by general practitioners, using GP10 prescription forms. A two-phase postal and interview survey was carried out in Grampian, where the changes in clinic care were introduced, and Highland, where no changes were planned. Responses to the first postal questionnaire (in 1989), at the start of GRASSIC, were received from 1054 patients (728 from Grampian and 326 from Highland), and 1138 replies to the second (in 1991) (792 from Grampian and 346 from Highland). Interviews were carried out with a subset of 50 patients in Aberdeen and 25 in Inverness, after each postal survey. Detailed analysis of the responses demonstrated that GRASSIC did not have an effect on those patients not attending an outpatient clinic. However, changes in the care of patients treated in the community occurred over the two year period of the study.

The results of the literature review and survey show that tremendous changes have taken place in the United Arab Emirates both in its economic as well as in the provision of health care, since its independence in 1971.  The country has extensive primary health care services that are easily accessible.  The range of services provided includes health promotion, preventive, curative and maternity and child health services. However, the philosophy of primary health care is not generally accepted and the emphasis remains on providing  a curative service and the use of high technology medicine.  There are many other difficulties with the current system including a shortage of manpower; poor co-ordination between primary care and hospital based services; rising cost of health care provision; inadequate provision of health education programmes; inadequately or inappropriately resourced primary health centres; and the lack of reliable and good quality data on primary health care. Several recommendations are made: 1.  Creating a task force dedicated to primary health care and involving all stakeholders in order to identify gaps and deficiencies, make recommendations for improvement and ensure that the recommendations are being implemented. 2.  Emphasising the importance of primary health care in the overall provision of health care. 3.  Establishing a correct balance and a better co-ordination between primary, secondary and tertiary levels of care.  This should include an improvement in the referral and feedback system between primary care and hospitals. 4.  Ensuring the establishment of an effective health education programme aimed at emphasising the  value of primary health care, simple low-cost technology, health promotion and prevention services so minimising the dependence on the use of hospitals and high technology medicine.  This should take into account the different cultural, religious and social backgrounds of both the expatriate community as well as local inhabitants. 5.  Improving the provision of maternal child health care, screening, health promotion, prevention services and the availability of equipment, facilities and resources to enable primary care health professionals to carry out the assessment and management of most common and treatable conditions. 6.  Producing doctors, nurses and other health professionals who will promote health for all people and meet the needs of the society they serve.  This will require a greater collaboration and partnership between medical schools and the Ministry of Health.  7.  Developing a system of continuing professional development with staff training programmes for health professionals, to ensure the maintenance of their competence. 8.  Forming a professional organisation, such as a College or Institute of general practice, in order to identify the professional needs of general practitioners, to represent the specialty on professional matters and on all relevant medical decision making bodies, and to promote professional development at both national and international levels.

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Patients and staff who participate in PNC were surveyed by postal questionnaires and interviews to obtain a complete picture of the structures, processes and experiences which comprise it. 1249 newly delivered mothers and 648 health professional staff involved in PNC responded to the surveys (response rates 90.2% and 83.4% respectively). Maternal morbidity was reported by 85% of women in hospital, 87% at home in the first two months and 76% subsequently. Excess anxiety affected up to 27% of women, and depression occurred in around 16%. These factors influenced parental attitudes to their babies, as did aspects of babies' behaviour. 3% of women were readmitted to hospital for puerperal complications within the first two months, and 5% subsequently. At least one health problem occurred in 76% of babies in hospital, 82% in the first two months at home and 88% in the year thereafter, and the proportion treated increased with time. Readmission was necessary for 4% of babies in the first two months and 15% subsequently. Problems in PNC identified by respondents included lack of staff time, lack of continuity of care (resulting in conflicting advice), unrecognised maternal morbidity and need for support, high (and increasing) use of NHS services by babies, care focused on physical health problems rather than psychological and emotional ones, and deficiency in the quality of care after the first two months. Reorganisation of PNC so that the care of the patients (mother and baby) was its focus might enable the delivery of more effective and efficient care. A redefinition of the role of the midwife, greater autonomy and better professional recognition would increase job satisfaction and improve care. Forms of care which have been shown to be ineffective or harmful should be discontinued, and those which improve postnatal outcomes should be promoted.

In this study an economic analysis is conducted into the cost of the Scottish hospital sector from 1951 to 1981. The analysis is based upon data gathered from the Summarised Accounts of the Scottish Health Service, and additional published and unpublished data. The study suggests that many existing hypotheses on hospital cost inflation are inappropriate to the characteristics of the Scottish hospital sector, and that others have been overemphasised. The analysis presents a detailed account of changes in aggregate expenditure and, its components, showing these changes in current and constant prices and demonstrating the magnitude of the relative price effect. Using data on the changing conditions of service of hospital employees, the study then calculates an index of labour inputs to the hospital sector, which reveals that routinely published labour statistics considerably overstate the increase in working hours. Thus although wages and salaries have taken an increasing share of total hospital expenditure, the volume increase in labour inputs has been outstripped by that of non-labour inputs. In order to evaluate the hypothesis that hospital costs have increased as a result of the pay of hospital employees catching-up with other groups, the study compiles pay indices for the main hospital occupational groups and considers the influences on the patterns of settlement. The formal catching-up hypothesis is not supported by the evidence. Similarly, the study shows that the impact of compositional change in the hospital labour-force on total costs has not been significant, although substantial compositional changes are revealed. Finally, the study calculates the impact of demographic changes on hospital costs between 1951 and 1981, and concludes that, although the direct impact has not been great, such changes coupled to changes in rates of use may have brought about major long-term alterations in patterns of hospital care and resource allocation. Drawing on these and previous findings, the analysis is concluded with a discussion of policy and research implications.

Background. Implementation research is the scientific study of methods to promote the uptake of research findings in clinical practice. Cluster randomised trials are commonly adopted in implementation research, where interventions are generally targeted at health professionals or policymakers, in order to protect against contamination that would occur if individual patients were randomised. The application of cluster randomisation has important implications for design and analysis of trials evaluating implementation strategies. Case study: The Urological referral guidelines evaluation (URGE) has been used throughout this thesis, to explore the design and analysis issues of adopting a cluster randomised trial design in implementation research. URGE aimed to evaluate the effectiveness and efficiency of a guideline-based open access urological investigation service. This cluster randomised study adopted a 2X2 balanced incomplete block (BIB) design and collected data both prior to and following introduction of the intervention. The unit of randomisation was general practice and patients were recruited upon referral to secondary care. Aim: To investigate the implications of cluster randomisation for the design and analysis of trials evaluating implementation strategies. Objectives: This thesis has four distinct components. 1. A review of published cluster randomised trials in the field of implementation research. The methodological quality of these studies is assessed (Chapter 2). 2. An exploration of clustering within the URGE trial. Estimates of clustering and the imprecision in these estimates are considered for a number of endpoints, including process and outcome of care indicators and costs (Chapters 4 and 7). 3. The application of statistical methods in the analysis of cluster randomised trials. A number of approaches to the analysis of cluster randomised trials are described, applied and compared empirically. Incorporation of the BIB design and pre-intervention performance are also considered (Chapters 5 and 6). 4. Analysis of cost data collected from the economic evaluation conducted within the URGE trial. The analysis of skewed cost data collected within a cluster randomised trial design is considered (Chapter 7).

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