Clinical Decision Making Skills for the Integrated Worker Essay
Clinical Decision Making Skills for the Integrated Worker
This assignment will define and analyse the need for a chosen service improvement within the pathway of mental health, as well as evaluating the suggested service. Demonstrating how this service can inform and benefit integrated practice, discussing the ways in which the agency’s statutory obligations and responsibilities impact on both individual and group decision making. The chosen service improvement for this assignment is the introduction of a mental health nurse into primary care services, for example, a GP Surgery. Focusing on service users with mental health issues in the community and therefore in the care of the local Primary Care Trust (PCT). There is an obvious need for movement towards better health and social care for individuals with mental health illnesses in primary care.
No Health without Mental Health: A Guide for General Practice (Department of Health, DoH, 2012, online), sets out what General Practitioners (GPs) can do to improve mental health and enhance care and support offered to those with mental health conditions in the community. This document also states that one in four GP consultations account for mental health problems (DoH, 2012, pg8, online). Treatments for those with mental health issues cost the NHS in the United Kingdom approximately £105 Billion per year (DoH, 2012, pg8, online). Primary care plays a pivotal role in caring for those with mental health illnesses in the community and in most cases this falls into the responsibility of the local GP surgeries.
Therefore GPs are ideally placed to identify signs of distress and those with risk factors for poor mental health (NHS Confederation, 2011, online). Primary care providers, more specifically GPs are usually the first point of call for an individual experiencing some form of psychological distress (DoH, 2012, pg13, online). It is essential there is early recognition and referral to any specialist mental health services required, saving time, money and individual distress in the long-run.
An area which remains problematic is the treatment of physical health care needs for those with mental health illnesses. Research continues to highlight that the physical health of those with mental illnesses is frequently poor and people with long-term physical conditions experience higher levels of mental health issues (Nash, 2010, pg2). It is ironic that a great deal of the research carried out is with individuals that are currently in contact with either health or social care services (Nash, 2010, pg2). This issue could be tackled within primary care services, as GPs especially can treat the whole person linking rather than separating physical and mental health (Knapp, 2011, pg3, online).
Professionals within the primary care sector could experience problems when trying to identify their role in relation to meeting the health needs of those with mental health issues, as well as offering interventions and support to those identified as high risk of developing mental health problems, such as, individuals with long-tem physical conditions (Nash, 2012, pg 10). Yamey (1999) found that a number of patients had actually been removed from GP registers at some point prior to accessing secondary mental health services. This causes suspicion that some mental health illnesses could be construed as a reason for being excluded from GP surgeries (Yamey, 1999). MIND (1996) carried out a survey which also showed that a large majority of individuals felt they had been treated unfairly by their GP due to their mental illness.
This could be a consequence of lack of understanding and minimal training in the area of mental health in the primary care sector. Although this research is dated, it is relevant as Government white papers and initiatives currently being introduced are still recommending that more specialised training in mental health is required for professionals throughout the primary care sector. Each of the initiatives aim toward improved integrated working and lower hospital admissions due to deteriorating mental health by providing early access to services and early recognition of mental health issues in primary care. This highlights the importance of the chosen service improvement, not only for individuals with mental health issues but for those at risk of developing mental illness and the NHS as a whole.
These recommendations are present in No Health without Mental Health: A Guide for General Practice (DoH, 2012, online), The NHS Outcomes Framework 2012/13 (DoH, 2011, online), and numerous others. It remains clear that professionals within the primary care sector are not receiving adequate training in mental health care. They do not have sufficient knowledge of mental health and many do not possess the general skills required day to day when working with mental health service users (DoH, 2012, pg5, online). This is supported by Good Medical Practice (2006),(General Medical Council, GMC) which sets out the principle guidance for GPs offers no mention of individuals with mental health issues, suggesting that this document is based solely on the general population and does not taking into account the differing needs of those with mental health issues.
A programme that was introduced in Wales in 2011 provides Mental Health First Aid Training to a large group of service providers including primary care. It teaches them to provide initial help to someone experiencing mental health problems, deal with a crisis situation or the first signs of someone developing mental ill health and guide people towards appropriate help (MIND 2011, online). This shows some progress towards increasing knowledge and awareness of mental health illnesses in a wider range of healthcare providers.
There is evidence to show that in GP practices without mental health professionals, brief training for primary care providers have substantial benefits for patients who are mentally ill (Ross et al, 2001). This supports the need for specialist training and the chosen service improvement, as a mental health nurse in a GP surgery would be specially trained to work with individuals with mental health illnesses and would have an awareness of the difficulties service users may face when accessing services.
There are many aspects that could present a barrier to mental health service users when accessing services. Communication difficulties can cause problems for individuals with mental health issues as they may not feel able to make themselves understood by healthcare professionals. They may suffer anxiety or panic disorders making it more difficult to communicate effectively. One of the most problematic areas in mental health and for those suffering mental health illnesses is stigma (Nash, 2010, pg10). Discrimination is not just confined to the general population as research has shown that healthcare professionals can hold stereotypical views towards their clients (Nash, 2010, pg10). This could prevent individuals from seeking help and support for both physical and mental health problems.
Some service users with mental health issues may have previously experienced some form of discrimination and had a negative experience when accessing primary care services. For example, experiences involving reception staff with bad attitudes or individuals being made to believe the physical symptoms they are experiencing are part of their mental illness (Nash, 2012, pg12). This shows that individuals with mental health issues suffer from inequality and discrimination regarding their healthcare reinforcing the need for improved access to primary care services. Previous negative experiences can cause individuals to fear returning causing them to avoid seeking help for a physical condition. Furthermore, if a person believes the may be mentally ill, they may avoid accessing any kind of support as they fear being labelled and discriminated against due to the stigma attached to having a mental health illness. Employing a mental health nurse in a GP surgery can bring services closer to eliminating barriers between primary care services and mental health, improving the healthcare of those in the general community suffering from some sort of mental illness.
The proposed service improvement supports the need for reducing health inequalities and barriers to those with mental health issues wishing to access services. Barriers to healthcare specifically Primary care services can include communication difficulties, lack of understanding from both service user and professional perspective and there may be inadequate support available to mental health service users when accessing their local GP surgeries. GPs may lack the interpersonal skills required to manage some symptoms of mental illnesses. Such as inappropriate sexualised behaviour that can be expressed during psychotic episode (Norman & Ryrie, 2009, pg711).The professional may feel uncomfortable and embarrassed when examining an individual and unaware of how best to deal with this situation.
Symptoms of mental illnesses can themselves often prevent individuals with a barrier to accessing services. An individual suffering depression will most likely lack motivation and volition (Norman & Ryrie, 2009, pg429) making it extremely difficult for them to self-refer or even care about their mental and/or physical health. Further supporting the need for the chosen service improvement as families, carers and friends of such individuals could support them in attending their local GP surgery enabling them to access specialist help at an initial stage of their illness. It may be necessary for a mental health nurse in a GP surgery to be advertised; as individuals cannot access services if they are unaware they exist. Booklets and leaflets could be made available to raise awareness of mental health issues and the support available to individuals, their friends and families’ informing the community that specialist help is available first hand within their local GP surgery.
Another barrier that is present in the provision of care by primary services and GP surgeries is the use of the medical model. The health professionals within a GP surgery adopt a medical approach when treating their patients. This aims to treat the medical illness and reduce the total number or patients attending the surgery. Although this is necessary within a GP surgery setting there remains a need to consider social factors when adopting the medical approach (Barbour, 1995, pg2). There are limitations when using the medical model, however as it can prevent healthcare professionals from treating patients individually in a person centred manner, treating only the obvious medical condition (Barbour, 1995, pg10). This could have a serious detrimental effect on an individual’s health and well-being, resulting in increased appointments with their GP causing more distress and prolonging their suffering.
This in turn increases the likelihood of an individual requiring crisis intervention and ultimately costs the NHS more in the long-run (Norman & Ryrie, 2009, pg172). The Royal College of General Practitioners (RCPG) ‘Roadmap’ (2007) document supports the need for adopting a model in which health and social care needs are considered in general practice (RCPG, 2007, pg1). There has been confusion around which professionals role it is to provide physical health care to the mental health population for many years (Phelan et al, 2001). Government policy recognises the importance in considering physical health care needs of those with mental health illnesses in both primary and secondary care settings (Newell & Gournay, 2009, pg 322).
General practice has transformed significantly over the past decade and current government policy is aiming to improve access to and the choice of services available to patients, expanding the role of a GP and improve quality of care overall (Gregory, 2009, Pg3, online). Government policy is implemented in the structure of clinical governance and is important in highlighting improvements that are required in a wide range of services within the NHS including mental health and primary care (NHS Direct, 2011, pg12, online). Clinical governance is described as ‘a system in which NHS organisations are accountable for continuously improving the quality of their services’ (Scally & Donaldson, 1998, online). It is a framework that ensures professionals continuously develop and improve the quality of the services they provide. Clinical governance involves the research and development, risk management, promotion of openness, education and training for staff, clinical effectiveness and clinical auditing of services within the NHS.
It is extremely important that high quality care is provided in healthcare and clinical governance ensures professionals are individually accountable for the quality of care they provide (South Tees NHS Trust, 2013, online). Buetow and Roland (1999, pg184, online) suggest ‘there is a barrier between managerial, organisational and clinical approaches to quality of care’ denoting that the aim of clinical governance is to bridge the apparent gap by allowing all professionals within an organisation involvement and ‘freedom from the control of managerialism’ (Buetow & Roland, 1999, pg189, online). Although this suggests the aim is to promote equality throughout organisations when it comes to quality of care. There remains a need for one individual or a small group of people to accept the role and responsibility and become the clinical governance lead or team (Buetow & Roland, 1999, pg189, online).
In a primary care setting such as a GP surgery this would entail being responsible for a large number of professionals who may have had little reason to communicate with each other previously. This could cause conflict within an organisations culture if the quality of care professionals provide is questioned. The Department of Health (2008) stated ‘the current system of NHS primary care does not ensure a consistent level of safety and represents insufficient quality across the country’.
Resulting in GPs becoming required to hold a licence which is reviewed and renewed every five years and to register with the Care Quality Commission (CQC) from 2011 (GMC, 2009, online). This ensures up to date practice, competence and assures the provision of quality care. Clinical governance enables services to show how targets have been met within their organisation and how they meet the needs of their patients, supporting the decisions made by professionals and teams within the organisation (Buetow & Roland, 1999, pg187, online).
All organisations have what is known as an organisational or agency culture. Agency culture is made up of numerous aspects including, values and beliefs, language and communication, policies and procedures and rituals and routines within an organisation. Each organisation has a varied culture with a different set of beliefs and norms. It could be a result of these norms that staff members may not be willing to embrace change or take time to attend extra training for specialist service user groups such as the mental health population. It may appear that the service gains results and targets are met therefore may not want to change anything. This places organisations at risk of neglecting areas for improvement. Changes within agency culture can become a challenging process especially when there is disruption to traditional working routines (NHS Direct, 2011, online). Staff within a GP surgery may have been led by one individual or a small group of the same GPs for a long period of time and may feel the services they provide are sufficient.
Newly qualified members of staff joining the workforce may feel their opinions and ideas are underappreciated or not even considered because the routines and procedures are already in place. An unwillingness to accept change could have detrimental effects on the mental health service user population. This is reflected in recommendations by government policy. No Health without Mental Health (DoH, 2012, online), Making it Happen (DoH, 2001, online) and Call to Action (DoH, 2011, online) each suggest recommendations for primary care services to develop the services provided to those with mental health illnesses and stress the importance of mental health promotion within primary care. The culture within a GP surgery may appear to be more superior to other NHS services as most GP surgeries are independently contracted and are not direct employees of the NHS (Gregory, 2009, pg 8, online). This enables them to provide enhanced services such as extended opening hours and specific services for those with learning difficulties (Gregory, 2009, pg 8, online).
The above are components of General Medical Services (GMS) whereas Personal Medical Services (PMS) enable GP surgeries to cater for the specific needs of the local population (Gregory, 2009, pg 5, online). This could include drug and alcohol services or mental health services if there were a large number of the local community presenting to their GP surgery with these issues. The cultures within each of these types of GP surgeries could be different completely. In a PMS GPs could have received specialist training in the areas large numbers of patients require support, resulting in patients feeling more valued and respected as well as staff members. GP surgeries can be seen as ‘providing a gateway to specialist care’ (Gregory, 2009, pg8, online). This view could be difficult to change. However by offering a wider range of services and treatment options, the gap between primary and secondary services as well as both an individual’s health and social care needs can be filled (Gregory, 2009, pg8, online).
This service improvement aims to improve the health and social care needs of individuals with mental health illnesses in the community. However, not only are there barriers in place that service users must overcome to access primary care services there remains a lack of collaborative working between health and social care services. This has consequences on the service user and other professionals involved in their care denying the individual of adequate holistic care. Professionals from different areas such as nursing and social work may be bound by differing statutory obligations which can affect their decision making and the care they provide. Starting with the professional body they are registered with as a professional such as the Royal College of Nursing (RCN) or the Health and Care Professions Council (HCPC), these give professionals a value base they must work from and develop continuously.
Legislation also has a huge impact on a professional’s decision making, for example the Mental Health Act (MHA, 2007). The law determines what a professional can and cannot do in a crisis situation. If a mental health nurse was based in a GP surgery they will have specialist training and awareness of the limits of their role determined by the MHA (2007), such as a patient being sectioned. They will be aware of who to contact if a patient is causing danger to themselves or others and need more suitable mental health care. If the mental health nurse was an Approved Mental Health Practitioner they could even have a role in detaining patients especially if a GP within the surgery was specially trained under the MHA (2007). This would save a lot of time and distress to individuals in crisis, members of the public and staff members.
There are other noticeable difference between health and social care and the standards of care provided. Social work would traditionally take a service-led approach to care whereas nursing has become more person-centred and individualised (SCIE, 2010, online). By using a person-centred approach the specific health and social care needs of patients with mental health issues are addressed (Hall et al, 2010, pg178). The service user is the centre of focus and care and support is planned around their specific needs. This is essential when caring for an individual with mental health issues as each condition, symptom and experience is different. Enabling an individual to be fully involved in every aspect of their care and make fully informed decisions regarding their treatment and social options.
Continuity of care and positive therapeutic relationships are essential when making an individual feel valued and at ease, allowing them to feel comfortable and more willing to engage with professionals. An individual with mental health issues may feel anxious about attending their GP surgery and may need motivation or encouragement to do so. Having a therapeutic relationship with a particular professional within that surgery could reduce a person’s anxiety levels (Kettles et al, 2002, pg64). The chosen service improvement would be useful for this purpose as a mental health nurse based within a GP surgery could build positive relationships with patients enabling them to develop trust and engage with services and professionals.
The mental health nurse would also take into account both the health and social care needs of the patients, decreasing the GPs workload and saving the practice money in the long run. They would also ensure the needs of the individual are fully met as satisfactorily as possible within primary care services or id required could refer them to the most suitable services available to them for their condition and needs. Whether they be health or social care needs. However this service improvement would only be successful with the cooperation and collaboration from GPs within the surgery. Joint decision making would be required as well an equal partnership between GP and mental health nurse.
The Personalisation Agenda (Social Care Institute for Excellence, 2010, online) (SCIE) emphasises the need for integrated working, and the need for involvement from a wide range of services, such as; health, social care, housing, transportation and leisure, to ensure service users receive a holistic, consistent and continuous care package (SCIE, 2010, online). The service user is put first rather than the service. This creates a person-centred rather than a service-led approach. A priority of the Health and Social Care Bill (2011) is improving integration within services. The Bill strives to provide better partnership, integration and collaboration across the government and all NHS services (DoH, 2011, pg1, online). There is evidence to suggest that integrating health and social care services saves a substantial amount of money (DoH, 2011, pg2, online). However in the current government climate there are financial pressures which may cause a barrier to effective integrated working (DoH, 2011, pg1, online). All aspects of the patient journey could benefit from effective integrated working resulting in a positive experience and all needs being met.
The suggested service improvement of a mental health nurse in a GP surgery supports integration as there would be a variety of professionals within one building making multi-disciplinary team meeting easier to arrange and joint decisions could be made quickly. However there are barriers to integrated working including the breakdown of communication between staff and different organisations having a detrimental effect on patients (Trevithick, 2009, pg123). However by working in partnership there is a reduced need for specialist services ultimately cutting costs and having a positive effect on many other aspects of an organisation. Such as boosting staff moral and enhancing patient experience (Erstroff, 2010).
If barriers to integrated working can be overcome more adequate care can be provided overall. A dual qualified practitioner in a GP surgery would be ideal allowing both health and social care needs to be addressed working in partnership with outside agencies and with patients to gain the best results, without the need for two professionals. It has been stated that services need to detect early signs of individual distress by working closely with primary care (Norman & Ryrie, 2009, pg172-173). By integrating the skills required in a mental health nurse and a social worker a more holistic approach can be taken.
The introduction of community care impacted on various professions including general practitioners, social workers and nurses (Malin et al, 1999, pg158). Nurses have become increasingly empowered over time and have become more involved in commissioning alongside GPs. Within General practice more of a purchase/provide relationship has been established (Malin et al, 1999, pg 159). GPs now have more power and control with funding and choice in the care they provide. However social workers may have felt deskilled by the purchase/provide divide (Malin et at, 1999, pg 159). The cultures of each professional’s organisation could cause conflict among a team. Employing a dual qualified social worker and mental health nurse in a GP surgery would eliminate the chance of conflict. It would become the responsibility of the dual qualified worker and the GP to work in partnership. There is evidence to support the need for the chosen service improvement. Mental health services are improving and developing continuously despite government cuts to funding, reflected in No decisions about us without us (DoH, 2012, pg6, online).
The document states that primary care services, specifically GPs who play a part in supporting those with mental health issues are not making a difference to the mental health of their local communities. This creates an opportunity for the role of a mental health nurse to develop. The Care Services Improvement Partnership (CSIP, 2006) suggest that nurses are capable of delivering services within primary care settings as they have acquired the specialist knowledge to do so (Norman & Ryrie, 2009, pg 651). There is a need to modernise, develop and integrate services, primary care being a target area. The suggested service improvement would be cost effective and would provide early community intervention also lowering individual and family distress. Integrated working is an essential component in developing health and social care services (Trevithick, 2009, pg109).
In conclusion there remains a need for improvements in the health care provided by primary care services to those with mental health issues. Statistics show that primary care services are the first point of contact for many individuals developing a physical or psychiatric condition (DoH, 2012, pg 6, online). The introduction of a mental health nurse into a GP surgery promotes integrated practice and modernises NHS services (DoH Factsheet, 2011, pg1, online), enhancing patient experience. There is evidence to show that this is an already effective role.
Primary mental health workers have been introduced in Children and Adolescent Mental Health Teams (CAMHS) supporting colleagues in primary care services providing crisis intervention and contacts to specialist services (Norman & Ryrie, 2009, pg543). Primary care mental health Graduates have also been implemented in parts of London providing a range of interventions (Norman & Ryrie, 2009, pg 457). The suggested service improvement of a mental health nurse in a GP surgery would benefit the mental health service user population enormously. If the National Service Framework mental health standards (NSF, 2012, online) are to be met mental health promotion within primary care must be a focus (Newell& Gournay, 2009, pg 257).
Barbour, A. (1995); Caring for Patients: A Critique of the Medical Model. California, Sanford University Press.
Estroff, J. (2010); Effective teamwork: Practical; lessons from organisational research. London: Blackwell Publishing.
Hall, A. Wren, M & Kirby, S. (2010); Care planning in mental health: Promoting recovery. Blackwell Publishing. Oxford.
Kettles, A. Woods, P & Collins, M. (2002); Therapeutic interventions for forensic mental health nurses. London: Jessica Kingsley Publications.
Malin, N. Manthorpe, J, Race. D & Wilmot, S. (1999); Community care for nurses and the caring professions. Philadelphia: Open University Press.
Nash, M. (2010); Physical health and well-Being in mental health nursing; Clinical skills for practice. England: Open University Press.
Newell, R. & Gournay, K. (2009); Mental Health Nursing; An evidence based approach. Philadelphia: Churchill Livingstone Elsevier.
Norman, R. & Ryrie, I. (2009); The Art and Science of Mental Health Nursing: A textbook of principles and practice. Berkshire: Oxford University Press.
Trevithick, P. (2009); Social work skills: A practice handbook. (2nd
Edition). England: Oxford University Press.
Wilson (1997); Cited in; Handy, C. (1993); Understanding organizations. Penguin Books Ltd. Middlesex. England.
Buetow, S. & Roland, M. (1999); Clinical governance: bridging the gap between managerial and clinical approaches to quality of care, Quality in Healthcare (8) 184-190 http://www.clinicalgovernance.scot.nhs.uk/documents/184.pdf Accessed on 28/01/2013
Care Service Improvement Partnership (2006); Designing Primary Care Mental Health Services: Guidebook. London: DoH. http://collections.europarchive.org/tna/20090610005017/http://dhcarenetworks.org.uk/BetterCommissioning/Commissioninge-book/ Accessed on 02/02/2013
Department of Health, (2012); National Service Framework: standards for mental health. London: DoH. http://www.eguidelines.co.uk/eguidelinesmain/external_guidelines/nsf/mentalhealth_nsf.htm#National_Milestones Accessed on 02/02/2013.
Department of Health, (2012); No decisions about us without us: A guide for people who use mental health services, carers and the public, to accompany the implementation framework for the mental health strategy. London: DoH http://www.mind.org.uk/assets/0002/1266/No_decision_about_us_without_us.pdf Accessed 01/02/2013
Department of Health, (2012); No Health without Mental Health: A Guide for General Practice. London: DoH http://www.dh.gov.uk/en/Healthcare/MentalHealthStrategy/index.htm Accessed 04/01/2013
Department of Health, (2011); Health And Social Care Bill Factsheet. C3 London: DoH.
http://www.dh.gov.uk/health/files/2012/02/C3-Promoting-better-integration-of-health-and-care-services.pdf Accessed on 01/02/2013
Department of Health, (2011); No Health without Mental Health: A cross government mental health outcomes strategy for people of all ages- a call to action. London: DoH. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123990.pdf Accessed on 31/01/2013
Department of Health, (2011); The NHS Outcomes Framework 2012/13. London: DoH http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131723.pdf Accessed 10/01/2013
Department of Health. (2009); Response to Consultation on the Framework for Registration of Health and Adult Social Care Providers and Consultation on Draft Regulations. London: DoH.
Accessed on 28/01/2013
Department of Health. (2008). The Future Regulation of Health and Adult Social Care in England: A consultation on the framework for the registration of health and adult social care providers: Partial Impact Assessment on Primary Care. London: DoH. www.dh.gov.uk/en/Consultations/Closedconsultations/DH_083625 Accessed on 28/01/2013
Department of Health. (2001); Making it Happen: A guide to delivering health promotion (Pg 54). London:DoH. http:[email protected][email protected]/documents/digitalasset/dh_4058958.pdf Accessed on 31/01/2013
General Medical Council (GMC). (2009); Licensing and Revalidation. www.gmc-uk.org/about/reform/index.asp
Accessed on 28/01/2013
General Medical Council (GMC). (2006); Good Medical Practice. http://www.gmc-uk.org/static/documents/content/GMP_0910.pdf
Gregory, S. (2009); General Practice in England: An overview. London: The Kings Fund. http://www.kingsfund.org.uk/sites/files/kf/General-practice-in-England-an-overview-Sarah-Gregory-The-Kings-Fund-September-2009.pdf Accessed on 28/01/2013
The Health and Social Care Act (2012)
Accessed on 01/02/2013
Knapp, M., MacDaid, D. & Parsonage, M. (2011); Mental Health Promotion and Mental Illness Prevention: The Economic case.London: DoH. http://eprints.lse.ac.uk/32311/1/Knapp_et_al__MHPP_The_Economic_Case.pdf Accessed on 12/01/2013
Lakhani, M., Baker, M & Field, S. (2007); The Future Direction of General Practice: A Roadmap. Royal College of General Practitioners, London, 1-84 http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/the_future_direction_rcgp_roadmap.ashx Accessed 10/01/2013
Mental Health Act (2007).
MIND. (2011); Time To Change Wales: Mental Health First Aid Training (MHFAT). Wales: MIND. http://www.mhfa-wales.org.uk/youth/en/course-details/the-ymhfa-action-plan.htm Accessed 10/01/2013
MIND. (1996); Not just sticks and stones: A survey of the stigma, taboos and discrimination experienced by people with mental health problems. London: MIND. http://www.leeds.ac.uk/disability-studies/archiveuk/MIND/MIND.pdf
NHS Direct. (2011); NHS Direct Business Plan 2011/12-2015/16. http://www.nhsdirect.nhs.uk/About/~/media/Files/FreedomOfInformationDocuments/OtherFreedomOfInformationDocuments/201106201_NHS%20Direct%20Business%20Plan2011-16.ashx Accessed on 28/01/2013
NHS Direct (2011); Cultural changes in the NHS.
Accessed on 31/01/2013
Phelan, M., Stradins, L., Morrison, S. (2001); Physical health of people with severe mental illness. British Medical Journal. 322: 443-444. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1120844/
Rost,K., Nutting, P., Smith, J., Werner, J & Duan, N. (2001); Improving depression outcomes in community primary care practice: A randomized trial of the QuEST Intervention. Journal of General Internal Medicine 16(3): 143-9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494878/
Accessed on 01/02/2013
Scally, G & Donaldson, J. (1998); Clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal 317(7150) 4 July pp.61-65. http://webarchive.nationalarchives.gov.uk/20081112112652/bmj.com/cgi/content/full/317/7150/61 Accessed on 28/01/2013
Social Care Institute for Excellence, (2010); Personalisation: A rough guide. London: SCIE http://www.scie.org.uk/publications/reports/report20.pdf
Accessed on 31/01/2013
South Tees NHS Foundation Trust. (2013); Clinical Governance: What is Clinical Governance? Harrogate: Mixd.