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This thesis offers a review of the historical development of telemedicine services in remote health care. It addresses the professional concerns in practising medicine in isolated conditions, and the advances in telecommunications technology since the telephone was invented. It also examines the application of telemedicine in remote environments across the world, such as in indigenous communities, remote industrial work sites and at scientific bases in Antarctica. At its most exotic, a review is offered of the health care for space crews. The literature review highlights a number of concerns about the state of the art knowledge on remote health care services. These concerns are the minimal training requirements of individuals who act as health care practitioners in the remote environment, the additional training requirement upon the advising medical practitioner, and the design of a system for the collection of clinical information from the patient. In response to the above a two year study was conducted. Quantitative and qualitative observation of remote health care consultations was undertaken. The environments studied were simulation cases occurring in the UK and Antarctica, and real cases presenting on oil installations in the North Sea. The study results answer the original concerns about the training levels, data collection and communications components of a remote health care service. In addition, they offer valuable input towards the design of a telemedicine model for remote health care. The telemedicine model is presented as a framework upon which future developments in the field of telemedicine may be approached.

In economic theory, the utility which an individual consumer obtains from a good is valued by the maximum amount s/he would be willing to pay for that good. On the face of it, therefore, it would seem that a measure of the benefits of a commodity based on maximum willingness to pay (WTP) offers great potential for policy makers. It provides a single measure of value which is rooted in economic theory. This thesis is concerned with valuing the benefits of public sector health care using the WTP approach. The aim of the thesis is to contribute to the development of WTP as a measure of the value of the benefits of health care. Potentially, such a measure would be of use in specific economic evaluations of health care alternatives (i.e. close substitutes) and in eliciting the strength of preference of the public with regard to the broader issue of health care priority setting. The contributions of the thesis are to theory and to the design of such WTP studies, with greater emphasis on the latter. Each of these is discussed in the following sections before going on to list the main recommendations for the future conduct of WTP studies which arise from the work presented. <I>Contributions to theory</I> The main theoretical contributions involve, first, bringing together the concepts of WTP and the nature of the commodity health care, second, examining this relationship within the contexts of patients' and the citizens' utility functions and, third, the examination distributional issues within the context of WTP.

This thesis describes the history of community pharmacy, and the current climate which has identified an extended role, particularly for 'over-the-counter' advice in response to symptoms and the reclassification of medicines. An electric methodology has been used to define current community pharmacy practice in Scotland, and to assess the attitudes of community pharmacists and GPs to an extended community pharmacy role. Attitudes of community pharmacists to medicines reclassification have been assessed nationally, and implications quantified. Clinical pharmacy guidelines for the treatment of dyspepsia have been developed and evaluated. A range of opinion formers have been interviewed to identify the different agenda which have contributed to medicines reclassification. Most of the more innovative tasks proposed are not yet commonly practised in Scotland. However most community pharmacists favour the extended role and the reclassification of medicines. Reclassification has little financial advantage for the community pharmacist, but would benefit the patient and the NHS. GPs were generally supportive of the extended role of the community pharmacist and the reclassification of medicines with a few caveats. These could be overcome by clinical pharmacy guidelines, which we demonstrated to have utility, patient acceptability and an educational value. Representatives of the medical and pharmaceutical professions, the government, the industry and the patient, revealed three agendas which have all influenced medicines reclassification. The government wish to shift the costs from the NHS to the patient. The industry wish to find additional markets and the pharmaceutical profession need a new paradigm to replace their largely redundant technical dispensing role. It is concluded that it is an opportune time for the community pharmacists to extend their professional role.

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