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Purchasing, providing and participating in mental health servicesThis thesis examines the implications of the changes introduced by the NHS and Community Care Act 1990 for mental health services. It focuses on two main issues. Firstly, the impact on mental health services of the 'market' system of purchasers and providers introduced by the 1990 Act. Second.ly, the extent to which the 1990 changes had led to any increase in user participation and involvement in the planning and delivery of psychiatric services. Analysis of the existing theoretical literature found that there had been little research which focused on the specific implications of health care 'markets' for mental health services. In addition, much of the work on the development of psychiatry had not focused on the role of the local context in influencing the nature of mental health service provision. In this thesis these issues are explored through a case study of the mental health services of one English county. Semistructured, qualitative interviews were und.ertaken with managers, professionals and individuals in purchaser, provider and voluntary sector organisations. People using community mental health services in the county were also interviewed. This contrasts with many previous studies which have tended to concentrate exclusively on users of in-patient services. The study found that local circumstances played a significant role in the relationships between those purchasing, providing and participating in mental health services. The imminent closure of a large Victorian psychiatric hospital and the uncertainty about which services would replace it had been a source of tension between the newly formed purchaser and provider organisations in the county under study. The lack of any strong existing groups in the local area representing users of mental health services was also significant. It meant that increased user participation in the county after the 1990 Act was reliant on initiatives by managers and professionals rather than organised pressure from user groups and users themselves. The variety of different local mental health agencies purchasing and providing mental health services in the county called for a degree of cooperation between organisations which conflicted with the competition encouraged by the 'market' system introduced by the 1990 Act. The focus, first, on psychiatric services in the examination of 'markets' and, second, the importance of the local context in mental health service development provides the basis for the study's contribution to theoretical and policy debates both about the 1990 Act and psychiatric services in general.
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Research and development policy in the English National Health Service: the implementation of the “Research for Health” strategyThe following thesis presents an analysis of power and control in the English National Health Service. Notably, it focuses upon power and control over knowledge; over defining what is 'valid' knowledge; over the production of that valid knowledge; and over how, what, when and where that knowledge is used in everyday clinical practice. The issue reaches to the heart of professional conception and definition and hence, control over professions themselves. The thesis attempts to demonstrate the relationship between the different professional groups in the NHS, through the analysis of national, regional and local documents, and interviews with managers, doctors, nurses, dietitians and physiotherapists in three case studies, the thesis shows the complex pattern of relations and behaviour at play. Particular attention is paid to Michael Power's notion of audit and the 'Audit Explosion', which provides a framework for the thesis, and to the work of Michel Foucault, especially his ideas about power, control and panopticism. These are used as a useful metaphor to understand and explain NBS research and audit in relation to the NHS professions. The thesis ends with a cross-case analysis which draws together the rich variety of data and concludes with an analysis of the wider sociological implications ofthe thesis.
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Donor identification and consent for deceased organ donation: summary of NICE guidanceOrgan donation plays a major role in the management of patients with single organ failure of the kidneys, liver, pancreas, heart, or lung, or with combined organ failure of heart and lung (such as in cystic fibrosis) or of kidney and pancreas (such as in diabetes). A shortage of transplant organs has resulted in long waits for transplantation. Currently about 500 people in the United Kingdom die each year because of a shortage of donated organs, and at 31 March 2011 almost 7000 patients were waiting for a kidney transplant1 and would be having costly dialysis with serious morbidity and impact on quality of life. This shortage of organs is partly the result of relatively low numbers of road traffic deaths (lower than in many countries) but is also the result of inefficiencies in the donor identification and consent processes. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on improving donor identification and consent rates for deceased organ donation.
