The quality of diabetes care in the community: practice, policy and culture

Aim: Diabetes is an important barometer of health system performance. This chronic condition is a source of significant morbidity, premature mortality and a major contributor to health care costs. There is an increasing focus internationally, and more recently nationally, on system, practice and professional-level initiatives to promote the quality of care. The aim of this thesis was to investigate the ‘quality chasm’ around the organisation and delivery of diabetes care in general practice, to explore GPs’ attitudes to engaging in quality improvement activities and to examine efforts to improve the quality of diabetes care in Ireland from practice to policy. Methods: Quantitative and qualitative methods were used. As part of a mixed methods sequential design, a postal survey of 600 GPs was conducted to assess the organization of care. This was followed by an in-depth qualitative study using semi-structured interviews with a purposive sample of 31 GPs from urban and rural areas. The qualitative methodology was also used to examine GPs’ attitudes to engaging in quality improvement. Data were analysed using a Framework approach. A 2nd observation study was used to assess the quality of care in 63 practices with a special interest in diabetes. Data on 3010 adults with Type 2 diabetes from 3 primary care initiatives were analysed and the results were benchmarked against national guidelines and standards of care in the UK. The final study was an instrumental case study of policy formulation. Semi-structured interviews were conducted with 15 members of the Expert Advisory Group (EAG) for Diabetes. Thematic analysis was applied to the data using 3 theories of the policy process as analytical tools. Results: The survey response rate was 44% (n=262). Results suggested care delivery was largely unstructured; 45% of GPs had a diabetes register (n=157), 53% reported using guidelines (n=140), 30% had formal call recall system (n=78) and 24% had none of these organizational features (n=62). Only 10% of GPs had a formal shared protocol with the local hospital specialist diabetes team (n=26). The lack of coordination between settings was identified as a major barrier to providing optimal care leading to waiting times, overburdened hospitals and avoidable duplication. The lack of remuneration for chronic disease management had a ripple effect also creating costs for patients and apathy among GPs. There was also a sense of inertia around quality improvement activities particularly at a national level. This attitude was strongly influenced by previous experiences of change in the health system. In contrast GP’s spoke positively about change at a local level which was facilitated by a practice ethos, leadership and special interest in diabetes. The 2nd quantitative study found that practices with a special interest in diabetes achieved a standard of care comparable to the UK in terms of the recording of clinical processes of care and the achievement of clinical targets; 35% of patients reached the HbA1c target of <6.5% compared to 26% in England and Wales. With regard to diabetes policy formulation, the evolving process of action and inaction was best described by the Multiple Streams Theory. Within the EAG, the formulation of recommendations was facilitated by overarching agreement on the “obvious” priorities while the details of proposals were influenced by personal preferences and local capacity. In contrast the national decision-making process was protracted and ambiguous. The lack of impetus from senior management coupled with the lack of power conferred on the EAG impeded progress. Conclusions: The findings highlight the inconsistency of diabetes care in Ireland. The main barriers to optimal diabetes management center on the organization and coordination of care at the systems level with consequences for practice, providers and patients. Quality improvement initiatives need to stimulate a sense of ownership and interest among frontline service providers to address the local sense of inertia to national change. To date quality improvement in diabetes care has been largely dependent the “special interest” of professionals. The challenge for the Irish health system is to embed this activity as part of routine practice, professional responsibility and the underlying health care culture.

Language legislation in Ireland and the United Kingdom: Exploring the gaps between theory and practice

The central objective in this thesis is to explore the gaps between the normative justifications advanced for language rights and language legislative protection and the effective realisation of those rights and legislative provisions in practice. This objective is achieved by examining the scope and application of language rights and legislative provisions within language legislation in Ireland and the United Kingdom. Drawing on Canadian jurisprudence advocating for language rights to be recognised as “purposeful”, the thesis considers the extent to which Ireland and the United Kingdom have limited the acceptance of positive obligations as they relate to the provision of language services in the public sphere. In arguing that language rights are distinct in nature, the thesis suggests that in order for language rights to be effectively realised, an approach to language rights and language legislation more generally must be underpinned by a substantive vision of equality, otherwise language rights and legislative provisions merely amount to symbolic recognition and vacuous rhetoric as opposed to being substantive and enabling rights and provisions. Having said that, the thesis also recognises and elucidates the practical difficulties that arise in the realisation of language rights and language legislative provisions and in doing so seeks to stimulate further dialogue about the nature and limits of language rights and language legislation.

The Protection of Life During Pregnancy Act 2013: Suicide, dignity and the Irish discourse on abortion

Accepted Version

Civil Rights on the Cell Block: Race, Reform, and Violence in Texas Prisons and the Nation, 1945-1990

This study, "Civil Rights on the Cell Block: Race, Reform, and Violence in Texas Prisons and the Nation, 1945-1990," offers a new perspective on the historical origins of the modern prison industrial complex, sexual violence in working-class culture, and the ways in which race shaped the prison experience. This study joins new scholarship that reperiodizes the Civil Rights era while also considering how violence and radicalism shaped the civil rights struggle. It places the criminal justice system at the heart of both an older racial order and within a prison-made civil rights movement that confronted the prison's power to deny citizenship and enforce racial hierarchies. By charting the trajectory of the civil rights movement in Texas prisons, my dissertation demonstrates how the internal struggle over rehabilitation and punishment shaped civil rights, racial formation, and the political contest between liberalism and conservatism. This dissertation offers a close case study of Texas, where the state prison system emerged as a national model for penal management. The dissertation begins with a hopeful story of reform marked by an apparently successful effort by the State of Texas to replace its notorious 1940s plantation/prison farm system with an efficient, business-oriented agricultural enterprise system. When this new system was fully operational in the 1960s, Texas garnered plaudits as a pioneering, modern, efficient, and business oriented Sun Belt state. But this reputation of competence and efficiency obfuscated the reality of a brutal system of internal prison management in which inmates acted as guards, employing coercive means to maintain control over the prisoner population. The inmates whom the prison system placed in charge also ran an internal prison economy in which money, food, human beings, reputations, favors, and sex all became commodities to be bought and sold. I analyze both how the Texas prison system managed to maintain its high external reputation for so long in the face of the internal reality and how that reputation collapsed when inmates, inspired by the Civil Rights Movement, revolted. My dissertation shows that this inmate Civil Rights rebellion was a success in forcing an end to the existing system but a failure in its attempts to make conditions in Texas prisons more humane. The new Texas prison regime, I conclude, utilized paramilitary practices, privatized prisons, and gang-related warfare to establish a new system that focused much more on law and order in the prisons than on the legal and human rights of prisoners. Placing the inmates and their struggle at the heart of the national debate over rights and "law and order" politics reveals an inter-racial social justice movement that asked the courts to reconsider how the state punished those who committed a crime while also reminding the public of the inmates' humanity and their constitutional rights.

VIXEN, VIRGIN, AND GODDESS: PERFORMANCE PRACTICE AND THE BAROQUE HEROINE

This dissertation comprises performance of three soprano roles in Baroque musical theater pieces, recorded on compact disc. These roles are "Poppea" in The Coronation of Poppea (1642) of Claudio Monteverdi (a filly-produced staging of the 1989 Alan Curtis critical edition in English translation, with the Maryland Opera Studio at the Kay Theater, Clarice Smith Performing Arts Center, University of Maryland, College Park, Maryland, May 3 and 6, 2002; Ken Slowik, conductor); "Galatea" in Acis and Galatea (1718) of George Friederich Handel (a staged reading at Gildenhorn Recital Hall, Clarice Smith Performing Arts Center, University of Maryland, College Park, Maryland, May 29,2003; Edward Maclary, conductor); and "Miecke" (Soprano Soloist) in Mer hahn en neue Oberkeet (Peasant Cantata), BWV 212 (1742) of Johann Sebastian Bach (a staged and costumed performance with the Washington Bach Consort at Rachel M. Schlesinger Concert Hall, Alexandria, Virginia, February 2,2003; J. Reilly Lewis, conductor). In addition to performing these three roles, I was the stage director for the reading of Acis and Galatea. Close readings of the libretti, examination of contemporary guides to ornamentation, and research into production histories inform the improvisatory ornamentation found in these compact disc recordings.

The `Ulama' and the State: Negotiating Tradition, Authority and Sovereignty in Contemporary Pakistan

This dissertation is an account of how contemporary Pakistani ulama grapple with their political realities and the Islamic state of Pakistan. The central conceptual question that scaffolds my dissertation is: How do Pakistani ulama negotiate tradition, authority and sovereignty with the Islamic Republic of Pakistan? In engaging with this issue, this dissertation employs a methodology that weds ethnography with rigorous textual analysis. The ulama that feature in this study belong to a variety of sectarian persuasions. The Sunni ulama are Deobandi and Barelvi; the Shia ulama in this study are Ithna Ashari.

In assessing the relationship between Pakistani ulama and their nation-state, I assert that the ulama's dialectical engagements with the state are best understood as a dexterous navigation between affirmation, critique, contestation and cultivation. In proposing this manner of thinking about Pakistani ulama's engagements with their state, I provide a more detailed and nuanced view of the ulama-state relationship compared to earlier works. While emphasizing Pakistani ulama's vitality and their impact on their state, this dissertation also draws attention to the manners in which the state impacts the ulama. It theorizes the subject formation of the ulama and asserts the importance of understanding the ulama as formed not just by the ethico-legal tradition in which they are trained but also by the state apparatus.

Estoppel and the interests of the prospective beneficiary

Reviews case law concerning proprietary and testamentary estoppel. Examines two cases in which an elderly person made certain comments and encouraged an understanding between themselves and the claimants, that on death properties would be left to them, but where the requisite legal formalities were not undertaken. Illustrates the contrasting courts' approach, once estoppel has been established, in finding the appropriate remedy to satisfy and considers the challenges faced by the courts in differentiating between constructive trust and proprietary estoppel. [From Legal Journals Index]

Dazed and Confused: Accidental Mixtures of Goods and the Theory of Acquisition of Title

This paper explores the law of accidental mixtures of goods. It traces the development of the English rules on mixture from the seminal nineteenth century case of Spence v Union Marine Insurance Co to the present day, and compares their responses to those given by the Roman law, which always has been claimed as an influence on our jurisprudence in this area. It is argued that the different answers given by English and Roman law to essentially the same problems of title result from the differing bases of these legal systems. Roman a priori theory is contrasted with the more practical reasoning of the common law, and while both sets of rules are judged to be coherent on their own terms, it is suggested that the difference between them is reflective of a more general philosophical disagreement about the proper functioning of a legal system, and the relative importance of theoretical and pragmatic considerations.