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The acquisition of iron is crucial for bacterial pathogenesis. In this thesis I describe the development and validation of a biosensor for heme in bacteria, an important host source of iron for human pathogens. I demonstrate that the co-expression of a phytochrome-based fluorophore (PBF), which utilises the heme-derived metabolite biliverdin IXα as a chromophore, with a heme oxygenase (HO) in Gram-negative bacteria results in heme-dependent near infra-red fluorescence. Using this PBF+HO reporter, I probe heme metabolism in the opportunistic human pathogen Pseudomonas aeruginosa and for the first time provide direct evidence linking the previously putative heme receptor HxuC to heme metabolism. Further, coupling of the heme biosensor to transposon mutagenesis and Fluorescence-Activated Cell Sorting was used to screen a P. aeruginosa transposon library leading to the identification of several putative novel components of heme metabolism. Finally, I demonstrate the potential of our fluorescent biosensor to be used to study heme metabolism and host-pathogen interactions in vivo using a live adult zebrafish model of infection. The PBF+HO heme biosensor allows the highthroughput, non-invasive study of bacterial heme metabolism in real-time and proves a useful tool for gaining further insight into iron-heme metabolism in bacterial pathogens.

Aim: To explore and understand parents' experiences of their child's genital ambiguity and the reconstructive surgeries for ambiguous genitalia that occurred in infancy and middle childhood. Background: The determination of sex and gender for a child born with ambiguous genitalia is an extremely complex medical and social process. Academic debate, professional practice, the law and increased political and ethical debate have all more recently challenged the evidence base for practice. Currently the 'optimal gender policy' and the 'informed consent policy' drive treatment options. Little research has been conducted to understand the significance gender ambiguity has in parents' lives and how the child's genital surgery affects parents. Methods: An exploratory design of narrative inquiry was chosen and data were collected through eighteen in-depth narrative interviews with a purposive non-random sample of fifteen parents of 11 children (aged 0-11 years). Findings: Narrative analysis resulted in three keystone stories which contained in total eight aggregate stories and twenty foundational stories. The three keystone story themes were firstly, parents' stories about their child. Secondly, stories about being a parent of a child with AG and finally stories about healthcare professionals. Interpretation and synthesis of the three keystone stories revealed three core elements fundamental to parents stories; shock protection and anxiety. Parents had to develop new skills in order to deal with the challenges of living with a child with AG. Parents endeavoured to find a sense of harmony from their experiences of shock, anxiety and the need to protect their child. Harmony is a concept that brought consistency and agreement together resulting in parents embracing their experiences holistically and giving their experiences meaning. Conclusion: Parents overcame the tensions inherent in their experience of their child's AG and found a sense of harmony which has not previously been described in the literature.

Mobilising knowledge from healthcare research into practice remains a global challenge. Alongside increasing recognition of the importance of knowledge mobilisation, academics are expected to have, and to demonstrate, impact from their work. One way in which they attempt to do so is to develop outputs, in addition to journal papers, such as toolkits and dashboards, which are defined here as products from healthcare research. Products from healthcare research may be developed with the aim of helping practitioners to mobilise research findings into practice. Despite their increasing ubiquity, the development of such products remains understudied, highlighting a gap in current understandings. This research contributes to addressing this gap, using boundary object theory as a lens through which to analyse the development of products from healthcare research. Boundary objects may be viewed as helping transform knowledge between different communities of practice. This research conceptualises products from healthcare research as designated boundary objects, and develops understanding of how they might emerge from their designated state into boundary objects-in-use. Drawing upon qualitative data generated from an exploratory study (20 semi-structured interviews and a focus group (n=11)) and four prospective, longitudinal case studies of research projects which aimed to develop products from healthcare research (38 semi-structured interviews, 83 hours of observation, analysis of ~300 documents), it addresses the research question How does the development of products from healthcare research influence their emergence as boundary objects-in-use? This research identifies that products from healthcare research may be developed because academics expect them to help mobilise research findings into practice. They may also be proposed in response to the 'impact agenda', and for symbolic purposes to try to secure grant funding in response to the perceived desires of funders. Three interconnected aspects may be necessary (but not sufficient) for designated boundary objects such as products from healthcare research to emerge as boundary objects-in-use. These aspects are: a perceived need for the product; clear end-users; and clear aims. The emergence of products as boundary objects-in-use is dependent upon an implicit understanding of end-users' needs. This understanding may be gained either by individuals with implicit understanding playing a key role in product development, or through engagement with end-users. Dissemination of the product may also contribute to the emergence of a boundary object-in-use. Plans for stakeholder engagement, dissemination and evaluation relating to product development within funding bids may be proposed for symbolic reasons to help secure their success. The high (and increasing) pressures upon academics to achieve certain research metrics, conceptualised here as the 'academic treadmill', in addition to the short term-ism generated by time-bound academic projects, make it difficult for them to meet the (over) ambitious targets laid out in research proposals. Existing accounts of boundary object theory propose that a new joint field needs to form between developers and end-users during use of the object in order for it to emerge as a boundary object-in-use, and assume that boundary objects will only be used if end-users have direct contact with boundary spanners in practice (people who successfully span boundaries). This research shows that end-users may use boundary objects even when they do not have direct contact with boundary spanners in practice, and contributes to boundary object theory by drawing on the empirical data to propose that where the boundary object in question is used at a distance from its developers (akin to a hand-over), the emergence of a boundary object-in-use requires the formation of a new joint field during its development rather than a new joint field of use. This research suggests that developing fewer, high quality products, which meet a need and summarise cumulative evidence, helping practitioners to improve care quality, is an ambition worth striving for.

Background: Little is known about the treatment pathways, transition and discharge of prisoner-patients detained in secure psychiatric services and how best to support and manage remittal back to prison. Remittals to prison now constitute just over 20% of discharges from medium secure services annually. Currently, there is no formal mental health care-pathway or national targeted post-discharge service for prison remittals in the United Kingdom, and there is need for formal guidance on follow-up and after care provision which may be appropriate for this group. This collection of studies aimed to produce essential data which would characterise prison remittals, their pathways through medium secure services and aftercare received post-remittal. Method: A mixed methodological design was adopted which utilised both quantitative and qualitative data collection methods. A national prospective cohort study with a one year follow-up was conducted to identify factors associated with remittal to prison. All prisoner-patients discharged over a 6 month baseline period were included subject to Section 251 of the NHS Act (2006). Collection of demographic, clinical and criminological characteristics alongside ratings on 4 standardised clinical measures was informed by data extracted from medical case notes and telephone interviews with collateral informants. These data were compared across discharge destination for individuals discharged into the community and those remitted to prison. A concurrent qualitative investigation was conducted to further explore the identified key areas of interest. This involved a focus group interview and series of semi-structured interviews. Prison remittals were followed-up in the prison estate at 12 months post-discharge. Data were extracted from individual patient medical case notes to complete a proforma covering access to prison mental health services, treatment / care received post-remittal and incidents of self-harm / attempted suicide, readmission, and release into the community. Results: There were 153 eligible prisoner-patients identified across 33 medium secure services. Comparative analysis revealed that prison remittals were 4 times more likely to have a primary diagnosis of personality disorder than community discharges and had a significantly shorter length of stay; patients with a length of stay of 6 months or less were 2 times more likely to be remitted to prison. Prison remittal scored lower for the presence of protective factors with the largest difference observed for presence of motivation for and attitudes towards treatment. Prison remittals were also rated as significantly higher risk of future violence and offending, with the largest difference observed for risk of future serious offending. Interview and focus group data allowed for exploration of how clinicians account for these observed differences and exposed the internal and external processes that guide prisoner-patient pathways through medium secure services. Overall, it appeared that different factors are taken into account depending on a prisoner-patients discharge destination, and many clinicians expressed their concern for the outlook of some patients post remittal. Eighty-nine prison remittals across 56 prisons were followed-up. It was identified that post-remittal aftercare is limited and that many patients present as vulnerable upon discharge, particularly those with a primary diagnosis of personality disorder. Discussion: Evidence on the needs of prisoners requiring inpatient psychiatric care is improving and, through the data presented in this thesis, arguments for how best to respond to these needs can be further developed. It is hoped that this research will act as a platform for further development and consideration as to how best to manage prisoners who require secondary mental health care and the extent to which the medium secure estate can provide a proactive role in the care and rehabilitation of these individuals.

Background: Primary care is seeing a rapid rise in diabetes cases which could potentially be prevented through lifestyle interventions. Some clinical trials indicate that diabetes risks can be cut by as much as 60% through lifestyle interventions; however very little is known about the practicalities of providing such services in primary care. Aims: to explore how diabetes prevention is conceptualised by patients and health practitioners within a primary care setting, as well as to understand the factors associated with diabetes prevention delivery by practitioners and uptake by patients. Methods: A narrative synthesis systematic review, including qualitative and quantitative evidence was completed, in addition to primary research. Four medical centres serving mixed urban city populations in the UK, recruited 32 'at risk' patients for routine appointment observations. Follow-up interviews with 30 patients and 20 professions (13 nurses, 2 health care assistants, 5 GPs) were completed. Thematic analysis, drawing on techniques of grounded theory, uncovered three major themes within the data. Results: The review examined 18 papers and found mixed evidence on the importance of diabetes prevention in primary care, but it pointed to the importance of understanding diabetes risks factors. Patient and professional factors impacting on prevention include patient knowledge, motivation, use/trust of healthcare, and professional factors include workload, resources, knowledge, and perceptions of patient motivation. The empirical study uncovered three major themes: The first theme focused on how patients made sense of diabetes and revealed that conceptualisations of diabetes risk was an important factor in prevention as it influenced experiences and interpretations of risk, as well as any preventative actions. This study provided novel insights into ways patients used knowledge sources such as co-constructed knowledge from health professionals, as well as family, and friends to make sense of diabetes risks, which in turn informed their views of candidacy and behaviour modifications. Claims to candidacy were mainly based on family history and lifestyle factors; however, a few patients were deemed 'unlikely candidates' in the absence of these factors. Within the second theme, patient factors affecting diabetes prevention, participants placed a high value on preventative services in primary care and this allowed for a preventative focus in consultations which focused on achievable lifestyle changes. However, there were several obstacles that impacted on lifestyle modification such as physical limitations and difficulties with engaging in change. Despite obstacles, many patients had a fear of developing diabetes and desire to stay healthy for the future, which acted as a motivator in tackling their potential 'diabetes in waiting'/risks. Finally, the third theme, professional views of prevention, professionals (mainly nurses and healthcare assistants rather than GPs) assumed the responsibility for preventative services although competing interests, lack of time, and motivation to change proved to be barriers to prevention. Opportunities for change arose from a new diagnosis of pre-diabetes or a patient's family history and professionals provided lifestyle advice depending on a patient's level of risk, health literacy and lifestyle. Despite challenges, this study points to the growing role of primary care professionals in engaging the patients in change, within the demanding workload of an already stretched primary care system. Conclusion: This study demonstrated that primary care can play an integral role in promoting healthy lifestyles for diabetes prevention as part of routine primary care appointments, despite challenges. This study is timely and fits with the introduction of the new National Diabetes Prevention Programme which advocates for primary care to play more central role in preventing diabetes. Key messages for policy and practice generated from this study surround ways to inform suitable diabetes prevention interventions that can be integrated into primary care. This study demonstrated that prevention should and could fit in this setting. Issues arising in this study, such as integrating prevention conversations into consultations, understanding risk perceptions and candidacy, as well as obstacles and motivators for both patients and providers should be considered in future programmes to maximise success.

Introduction: Six phase III randomised trials established the effectiveness of chemoradiotherapy as primary treatment for squamous cell carcinoma of the anus (SCCA) and over the last 30 years survival has progressively improved. However, variations in trial outcome reporting have limited between-study comparisons and hindered evidence synthesis, and despite considerable treatment-related morbidity no trial has comprehensively quantified late toxicity or quality of life. This thesis proposed to address these issues through the development of a core outcomes set (COS) “an agreed, standardised set of outcomes to be measured and reported, as a minimum, in all trials in a particular health area”. The project involved three phases described in subsequent chapters (i) outcome long-list generation through systematic review and semi-structured patient interviews; (ii) Delphi survey and (iii) face-to-face consensus meeting. Chapter 3 & 4: Systematic review (published in Colorectal Disease) identified 1243 outcomes from 101 trials and observational studies of chemoradiotherapy for SCCA. No outcome was reported in all trials and over half of outcomes were reported in less than five percent of studies. In 54% of studies no definition was provided. Reported outcomes were predominantly in the survival and disease activity domains; life impact and toxicity outcomes were reported infrequently. No core set of outcomes could be identified from the existing literature. Semi-structured interviews with 19 patients identified 56 outcomes including eight not identified in the systematic review. Thematic analysis identified how outcomes impact the lives of patients, including a novel description of symptom clusters in SCCA. Chapter 5: The long-list of outcomes generated from chapter 3 and 4 was used to populate a Delphi questionnaire. One hundred and forty-nine participants from 11 countries (patients 55; HCPs 94) completed both rounds of the Delphi. Twenty-three HCPs and 13 patients from four countries participated in the face to face consensus meeting where after discussion and anonymous voting the final COS of 19 outcomes was agreed. These were treatment response, local failure, regional failure, distant failure, disease progression, salvage surgery, overall survival, cancer-specific survival, disease-free survival, metastasis-free survival, progression-free survival, anal incontinence, faecal urgency, pelvic fistula, stoma, skin loss, physical function, sexual function, and health-related QoL (accepted for publication in Lancet Gastroenterology and Hepatology). Chapter 6: Three secondary methodological research questions were addressed. Systematic review of outcome domains in cancer COS informed the domain framework for the CORMAC project and contributed to the development of the outcome taxonomy recommended by COMET. Comparison of outcomes included in COS for site-specific cancers to those included in COS for cancer in general identified no emergent COS for cancer in general. A novel study using a simulated Delphi and think-aloud process demonstrated patients had good understanding of histograms in this context. Discussion: The findings in Chapter 3 and 4 demonstrate the lack of existing consensus on optimal trial outcomes in SCCA and that outcomes prioritized by patients are under-represented in existing studies. A core outcome set for trials of chemoradiotherapy for SCCA has been agreed through a methodologically rigorous and transparent consensus process involving key stakeholders. The steps required for implementation including agreement of recommend definitions and measurement instruments for outcomes in the COS are described.

Background: Telemonitoring (also termed telehealth, telecare, ehealth etc.) is promoted as a way to reduce healthcare costs and promote self-management in long term conditions such as COPD. Research suggests telemonitoring may be useful in COPD management, but barriers remain to its uptake and sustained use. Research has often been limited to testing technologies at a late stage and potential users' perspectives are not often considered. Aims/objectives: 1. Explore the barriers to using telehealth technologies from a user and potential user perspective: people with COPD (pwCOPD), their informal carers and health professionals (HPs). 2. Understand the challenges of living with and managing COPD to identify how telehealth models should be designed/existing models refined to better meet the needs of (potential) users. Methods: Multiple qualitative methods were used. This included a meta-synthesis of published papers that investigated users' experience of telehealth in COPD; semi-structured interviews and focus groups with HPs; focus groups and longitudinal interviews with pwCOPD and their informal carers. User involvement consisted of an advisory group (pwCOPD and HPs) that helped guide the research. Transcripts were analysed using a broadly thematic approach. Findings: Meta-synthesis: Findings indicate contradicting consequences of telehealth use. 1. It influenced moral dilemma of help seeking (increased dependency or improved self-care practices). 2. It transformed interactions (increased risk or reassured). 3. It reconfigured work practices (burdened or empowered). HP data: presented three overarching themes: 1. Telehealth was often implemented within a technology centred approach which failed to engage clinicians and did not result in efficiency savings. Recognised that telehealth implementation needed to focus on patient need before technology. 2. Organisational pressures and professional roles impact upon HPs' perception of telehealth. Telehealth undermined holistic care and threatened professionals' identity if it focused reductively on biometric monitoring. 3. Telehealth was not considered useful in 'complex' patients with high needs and considered more suitable in patients with fewer needs. Identified a need to tailor telehealth to patients' needs which was consistent with professional values of providing holistic support. PwCOPD and their informal carers' data: presented three overarching themes. 1. It identified how pwCOPD and their carers lived and responded to unpredictable illness trajectories and highlighted the work they did to manage illness at home. Identified reasons why they failed to seek timely help at times of acute illness: these were numerous and involved experiences of illness trajectory and healthcare. 2. PwCOPD and their carers carried out technical work for routine monitoring and at times of acute illness. Some did not consider technical work to be their responsibility. 3. People with mild illness expressed no felt need for telehealth and considered it a threat to their independence and identity; people with complex illness expressed a felt need for telehealth and perceived it would increase connectedness with clinicians and improve continuity of care. Some felt telehealth was not sophisticated enough to manage their complex illness and respondents did not want telehealth to replace current care. Discussion/conclusion: Patients and HPs hold different views regarding whereabouts in the illness trajectory telehealth would be considered useful. Greater recognition of the work that patients and their informal carers do to manage illness at home is needed to identify when patients need support at different times in their illness trajectory. Findings have implications for wider service support and organisational factors for supporting telehealth use, to identify where it may or may not be suitable. The study highlights a need for tailoring telehealth to patients' needs (which is more consistent with HPs' professional values of providing 'good care'). The findings provide valuable insights to inform telehealth solutions fit for reacting to uncertainty and changing trajectories of need in pwCOPD.

Research demonstrates that perspectives of health and illness vary by social and cultural context. This has implications for the ways in which people experience and respond to health and illness and becomes particularly important when people face major social and cultural change through migration. This is explored in this study through the relationship between health and place. The location for the study is a Chinese community centre, in which the centre members are first generation migrants from Hong Kong, China and Vietnam, aged 50 and over, who have spent the larger part of their lives living in the UK. The study uses the concept of therapeutic landscapes as an analytical lens through which to explore understandings of health and illness, issues of identity and belonging, and practices of wellbeing as they are enacted outside of formal healthcare settings. As an ethnographic study, the primary means of data collection has been through participant observation. This included regular attendance at the community centre to participate in activities and events over a period of ten months from August 2013 to May 2014. Twenty one formal interviews were also conducted with members of the community centre, the majority in English, and several in Cantonese. The migration stories of the participants in the study are explored as gendered experiences; that is, that the men and women experienced, and spoke about, migration differently. For the women in particular, their experiences of migration were recalled as a time of profound loneliness and isolation. Understandings of health and illness among the centre members are also explored. A shared understanding of health as a holistic and collective concept was expressed. In particular, they spoke about maintaining a positive attitude in the face of difficulties, about their own health in terms of family and social relationships, and the importance of being together and being active. The choices that they make around the use of Chinese and/or biomedicine are also explored within the context of this understanding. The experiences of migration and the understandings of health and illness are further explored through a consideration of the everyday practices, and associated materialities, that constitute the day-to-day life of the centre. These are explored as ways of re-connecting with the past and maintaining a sense of identity, but also as ways of negotiating both continuity and change at the same time. The role of the community centre in the lives of its members, and the ways in which they interact with one another in this particular place, is approached through the concept of therapeutic landscapes. The day-to-day activities, and the ways in which the centre members participate in these are presented as everyday practices of care; as the enactment of a particular understanding of health and wellbeing that helps to create a sense of identity and belonging at the community centre, which in turn contributes to the health and wellbeing of the centre members.

Background: Evidence from the employee perspective frequently suggests that unsupportive managerial relations present a considerable barrier to those with long-term health conditions (LTCs) both on their ability to sustain employment and manage their condition at work. However, little is empirically known about employers’ and managers’ experiences of supporting those with LTCs, or indeed about their perception of their supportive role in the social context of the workplace on which employees suggest they depend for workplace success. This presents a disparity in understanding the contribution of the management role in influencing the (re)entry process to employment for those with LTCs. This is important to explore in light of ongoing objectives by the UK Government to move people with LTCs off incapacity benefits and back into the labour force, as any successful return to work will largely be influenced by employers’ and managers’ readiness to support them. Method: A qualitative approach informed by Grounded Theory principles to guide data collection and analysis was taken for this 3½ year study (September 2009 to March 2013). 40 semi-structured in-depth interviews were conducted with employers and managers from a range of organisations in the North West of England and analysed thematically. Findings were interpreted in relation to a framework of sociological theories of emotion and work. Results: Regardless of industry type, sector and size or condition, several themes emerged which contributed to a sense of burden and tension for participants in supporting those with LTCs. These included discerning legitimacy and tangibility of conditions, having difficult conversations with employees and the influence of the employees’ personality on support. More significantly, all bar one participant typified their role as one of a difficult ‘balancing’ act of additional and often incompatible demands, pressures and feelings arising from managing a complex and emotive situation many considered non-normative to their everyday role. This was typified by feelings of conflict and emotional discomfort, interpreted as ambivalence, stemming from contradictions between and within the normative expectations of their social roles and appropriate feeling rules. For example between the obligations of the professional ‘public’ managerial role in providing value to the organisation, and philanthropic concerns for the welfare of the employee concomitant with their personal ‘private’ role as an individual. Interpreted from a combination of both spoken word and ‘unsaid’ gestures, is the emotion management conducted by managers to cope with negative feelings of ambivalence in a culture which favours rationality over emotionality. Conclusion: Overall, findings indicate that participants in this study concur with the employees’ perspective as to the importance of socially supportive managerial relations. However, it is theorised that managing the emotions of ambivalence serves to undermine manager’s capacity to translate intention to provide support into tangible action, and hence is reflected in the employee’s perception of unsupportive relations. It is suggested that this research could be used to inform the development of a potential intervention to support managers in their pivotal role in the return-to-work process, being beneficial for all stakeholders - the Government, employees and employers alike.

Background: Whilst the experience of chronic physical conditions is well documented and has been recognised as relevant for health policy and practice little is known about notions of recovery and prognosis from the point of view of those with long-term physical health conditions. The extent to which people consider the future outcomes of their conditions is relevant to health policy which seeks to engage people in shared decision making, care plans, and self-management. This gap in knowledge about lay perceptions of recovery and prognosis becomes more pronounced when compared with literature from the mental health field in which recovery is one of the dominant foci, is comparatively well researched and in recent years has fed into policy and management approaches.Aims: The aim of the thesis is to explore perceptions of recovery and prognosis with people with long-term physical health conditions and to compare these with perspectives on recovery and prognosis apparent in the mental health field.Methodology: Using qualitative methods, a two phased approach to data collection and analysis was undertaken. Phase 1 used secondary data analysis with two existing datasets to examine whether notions of recovery and prognosis were implicit in narratives about the experience of illness. Phase 2 built on the findings from phase 1 and utilised longitudinal, primary data collection in the form of narrative interviews undertaken at two time points (baseline and 12 month follow-up). The analysis in both phases involved a cross case thematic analysis to look for commonalities and differences across individuals. Data from phase 2 were also subject to a narrative emplotment of individual stories which were used to capture the longitudinal changes in patient perspectives over time.Results: There were similarities with findings from the mental health field (recovery as a complex, nonlinear journey, the input from friends and family, notions of burden and the impact of condition on sense of self). However, there were nuanced differences in relation to physical health conditions which related to expectations about mortality, the experience of time, the extent to which narratives were future oriented and the experience of stigma. The dual focus on mental and physical health recovery proved useful for understanding those experiences of multiple morbidities. The results were used to develop a model of recovery narratives based on two dimensions (expectations and responsibility) which gave rise to four typologies of narratives. The aim of this model was to further highlight and summarise the themes arising from the data analysis.Discussion: The results of this study highlight the importance of understanding notions of recovery and prognosis in order to better understand the experience of illness and self-management. The thesis challenges the blanket use of health promotion strategies for those with and without chronic health conditions and supports a shift in policy focus from improved choice and autonomy to what Mol (2009) refers to as ‘enhanced care’.

General practice emerged as a distinct medical discipline in the nineteenth century. As independent contractors, General Practitioners (GPs) have however largely been 'untouched' by centrally derived policy. As a result, the profession has possessed wide discretion in relation to the way they dealt with their patients. However, due to increasing concerns over the cost and quality of care within the NHS, general practice increasingly became a focal point for the attentions of central policy makers who sought to control aspects of frontline practitioner behaviour. In order to do attempt to align the frontline behaviour of GPs with such policy aims, policy makers turned to their main tool, the contract. In this thesis I am concerned with the most recent contractual changes (and its later variants) introduced in 2004. In particular, the study is concerned with the impact of the large element of Pay-for-performance (P4P) known as the Quality and Outcomes Framework (QOF) contained within the new contract. QOF rewards practices on the basis of meeting a number of targets in relation to clinical, organizational, and patient experience indicators. As a result of the scale and prescriptive nature of the targets, QOF had the potential to change the nature of GP work at the micro-level should GPs choose to follow this voluntary policy. Previous evidence in relation to GP responses to other prescriptive policies such as National Service Frameworks (NSFs) and clinical guidelines suggests that GPs responded as workers, specifically as street-level bureaucrats (SLBs) by selectively by choosing aspects of policies based upon the on the criteria of whether or not they made the practicalities of processing their daily workload easier. However, the evidence suggests that there were also instances of GP principal (those that (part-) own their practices) behaviour that did not conform to expected SLB behaviour but instead resembled behaviour that would be expected of those managers who are 'results oriented.' Based upon this evidence and the analytical possibilities the SLB framework provided, the theoretical view of GPs as frontline public sector workers or street-level bureaucrats (SLBs) was employed to understand the continuing perceived impact and responses of GPs to the new contract and in particular QOF. Unlike previous analyses of GPs as SLBs however, this study distinguished between GP principals and salaried GPs employed by the GP principal counterparts. Ultimately, the aim of the thesis was to address the question of whether or not the conceptualization and responses of GPs as SLBs was still relevant and useful post-contractual change. Data was collected (between Feb 2008 and Sept 2009) via semi-structured interviews. In total 62 first round interviews and 24 second round interviews were conducted and analysed thematically. The findings indicate that the financial incentives within the QOF appear to strongly influence the responses of GP principals and reflect their priorities as owners of, rather than workers in their organisations. In addition, it appears that the Evidence Based Practice (EBP) movement means that salaried GPs priorities are also aligned to those of their organisations as they believe most of the QOF to be evidence-based. As a result, the application of Lipsky's SLB framework to explaining GP behaviour in relation to QOF is less useful than previous applications.

Background: Much social network analysis in health related research has focused on the impact of social networks in the genesis of long term conditions and associated inequalities. However, there has been little research on the role of social networks in the management of such conditions. This is significant at a time when increasing policy emphasis is placed on individual self-care and assumptions are often made about social support, and familial support in particular. The management of chronic illness is complex involving the interplay of personal and contextual factors and comprised of a number of daily activities which include the ongoing negotiation of management into existing roles and the degree of individual engagement with self-management. Little is known about how these aspects interact to shape and influence management, what constitutes a social network for individuals with long term conditions and whether this changes over time.Methods: This study was embedded within the Whole Systems Informing Self-management Engagement (WISE) randomised control trial. It used a longitudinal qualitative design with initial face to face in-depth interviews, telephone follow-ups over a year and final face-to-face interviews where sociograms were also used to elicit network structure.Results: The findings suggest that who is in the social network, and the types of relationships which are present, influence how management practices are framed and the extent to which they are engaged with. Resources available to an individual through the network support, or undermine, engagement and changed over time. Networks included family, friends, GP, nurses and companion animals. The amalgamation of the different types of relationships that constitute the social networks are characterised by three typologies; the family focused network, the friend focused network and the health care professional focused network. These network types reflected where support was sought in times of crisis. In the absence of 'typical' sources accounts highlighted the substitutability of network members which was often narrowly sought from key individuals. Changes in illness management, either positive or negative, were framed around critical moments as they challenged existing norms of practice and involved significant network members. Further, co-morbid conditions placed an additional complexity to management and priorities were shaped by the recursive relationship with health services which seemingly influences patients' orientation in becoming either active assessors of health care or less engaged through being overwhelmed. Conclusions: This thesis challenges the notion of 'self'-management as an individual construct as many of the practices of illness management involved the support and/or negotiation of roles with others. Critical moments are a key point where normalised management practices are challenged and have particular relevance for future interventions which could foster these critical points to facilitate such changes in routines. Interventions and education need to reflect this wider setting in which chronic illness management occurs for the practices of management to become normalised into everyday routines.