Does training practice nurses to carry out physical health checks for people with severe mental illness increase the level of screening for cardiovascular risk?

Abstract

Background:

Compared to the general population, people with severe mental illness (SMI) have a higher risk of developing cardiovascular disease (CVD). Authors of clinical guidelines advise annual screening for CVD risk factors with appropriate lifestyle counselling. There are seven recommended elements of this health check: blood pressure, body mass index (or waist circumference), blood glucose, serum cholesterol, diet advice, exercise recommendations and smoking cessation guidance.

Aim:

To establish whether training practice nurses increases the proportion of patients with SMI who are screened for CVD risk factors and given lifestyle advice in primary care.

Method:

A before-and-after audit of 400 patients on the SMI registers in five primary care centres in Northampton, England.

Results:

Following the training, the proportion of patients with SMI who received all elements of the health check significantly increased (pre-training: n = 33, 8%, 95% CI = 6–11; post-training: n = 60, 15%, 95% CI = 12–19; RR = 1.82, 95% CI = 1.22–2.72, p = .01).

Conclusion:

Training practice nurses about CVD prevention in people with SMI may be effective in increasing the proportion of patients in this group who receive a comprehensive health check.

Keywords

Cardiovascular disease physical health practice nurse primary care severe mental illness training

Introduction

Severe mental illness (SMI) includes diagnoses that usually involve psychosis, such as schizophrenia or bipolar disorder. SMI is classed as a long-term condition with a life expectancy that is reduced by 12–19 years (Chang et al., 2011; Laursen, 2011). The major cause of death is cardiovascular disease (CVD) (Hennekens, Hennekens, Hollar & Casey, 2005). Unhealthy diets, lack of exercise and weight gain, which all increase the risk of CVD, are common in people with SMI (Allison & Casey, 2001; McCreadie, 2003). Many patients in this group are treated with antipsychotic medications, some of which have been implicated in raising this risk (Fontaine et al., 2001).

Experts have advocated the need to improve CVD monitoring and the provision of lifestyle advice in people with SMI (Barnett et al., 2007; de Hert, Schreurs, Vancampfort & van Winkel, 2009; Kilbourne, Brar, Drayer, Xu & Post, 2007; Osborn et al., 2011). A Cochrane Effective Practice and Organization Care (EPOC) review did not identify any randomized trials that assessed the effectiveness of physical health monitoring in this group (Tosh et al., 2010). In the general population, authors of a systematic review have concluded that health checks did not reduce morbidity or mortality (Krogsbøll, Jørgensen, Grønhøj Larsen & Gøtzsche, 2012). All fourteen studies included were carried out before 1999; therefore it is possible that recent advances in the prevention of CVD may have improved the benefits of these checks (Thompson & Tonelli, 2012). In contrast to Krogsbøll et al.’s observations, a meta-analysis of nurse-provided or nurse-coordinated care management programmes for secondary prevention shows that they are highly effective in reducing CVD morbidity and mortality in patients with coronary artery disease (Clark, Hartling, Vandermeer & McAlister, 2005). Running nurse-led secondary prevention clinics in primary care incurs the cost of nurses’ time (Campbell et al., 1998). Consequently, general practitioners (GPs) may view them as expensive and be reluctant to resource them (Raftery, Yao, Murchie, Campbell & Ritchie, 2005). In a randomized control trial of health checks in 1,343 patients with coronary heart disease, the results showed that these costs were relatively low and were linked to health gains that were considerable in terms of deaths, life years lost and quality-adjusted life years (QALYs) (Raftery et al., 2005).

Since the introduction of a new payment contract in 2004 in England, the emphasis of practice nurse clinics has been focused on long-term conditions rather than general health checks. Annual clinics to review patients with diabetes, for example, have become routine (Hall, 2008). A recent randomized control trial of these clinics run by practice nurses showed equivalent results to GPs in respect of lipids, glucose and blood pressure levels and increased patient satisfaction (Houweling et al., 2011).

Authors of national guidance in England recommend that patients with SMI should receive a physical health check at least once a year (NICE, 2006, 2010). GPs in primary care are paid to provide CVD screening for this group every 15 months (BMA & NHS Employers, 2012). Between April 2004 and March 2011, payment was received if primary care practitioners documented that they had completed a review in people with SMI. There should have been evidence that the patient was offered screening, routine health promotion and prevention advice appropriate to their age, gender and health status, but these were not mandatory. This changed in April 2011; payment is now given for recording patients’ alcohol consumption, body mass index (BMI), blood pressure, glucose and high-density lipoprotein (HDL) cholesterol level (if over 40 years), and cervical screening within the last five years (if within national screening age).

Many GPs choose to screen people with SMI opportunistically for CVD risk when these patients attend primary care (i.e. for another reason), rather than inviting them for an annual health check by a practice nurse (Hardy, 2011; Reilly et al., 2012). As the GPs’ usual consultation times are short, it is difficult for them to provide adequate lifestyle advice (Phelan, Stradins & Morrison, 2001). A recent study showed that health education was not a common feature of consultations with the SMI group of patients in primary care (Reilly et al., 2012). When in a busy clinic, professionals may make assumptions, such as a patient with a normal BMI is eating well. These assumptions do not necessarily hold true; for example, a study examining the food diaries completed by people with schizophrenia found that the patient with the lowest BMI had the unhealthiest diet (Hardy & Gray, 2011). It is important to have discussions with patients about their lifestyle, to either encourage a change in unhealthy routines or to motivate them to maintain healthy behaviour (Miller, 2005; NICE, 2012). We envisage that creating a nurse-led clinic for people with SMI would provide sufficient time to achieve this effectively, but there is presently no evidence to support this argument (Hardy & Gray, 2010). Additionally, as practice nurses think that working with people with SMI is too specialized (Lester, Tritter & Sorohan, 2005), they will need training in order to deliver effective health checks for this group. An observational study using routinely collected data regarding the quality of chronic disease management in primary care indicated the benefits and importance of education, training and personal development of nursing staff (Griffiths, Maben & Murrells, 2011). It could be argued that mental health nurses are best placed to screen patients with SMI for CVD risk. Current evidence suggests that they often do not consider the physical health care of their patients as being central to their role, or perceive themselves as inadequately trained to provide this aspect of care (Bradshaw & Pedley, 2012). One study examining the attitudes of mental health nurses towards the physical health care of people with SMI (Robson, Haddad, Gray & Gournay, 2012) found that they were more positive if they had attended post-registration physical health training. However, an integrative literature review found that they are not routinely supported by physical health care education and training (Blythe & White, 2012). As many patients with SMI have no contact with secondary care services (Lester, Tritter & Sorohan, 2004), they would be missed if mental health nurses had the responsibility of carrying out all health checks.

The aim of this study is to establish whether training practice nurses increases the proportion of patients with SMI who are screened for CVD risk factors and given lifestyle advice in primary care.

Methods

Sample and procedures

This is a repeat audit monitoring how well primary care practitioners are meeting their duty to screen people with SMI for CVD risk factors and give them lifestyle advice. We will then have the information to decide how this might be improved. Practice nurses will take part in training to deliver health checks for people with SMI. The audit will be carried out before and after training as described below.

Audit standards

The standards for CVD screening and lifestyle advice were derived from published guidelines (de Hert et al., 2009; NICE, 2006, 2010). These were that all patients with SMI should, as a minimum, have their blood pressure, BMI (or waist circumference), blood glucose (or HbA1c) and cholesterol measured at least once a year. They should also be given advice about diet, exercise and smoking cessation annually.

Data collection

This was an audit that took place between September 2009 and August 2010 and was then repeated following the training of practice nurses between September 2010 and August 2011. Patients were identified from the SMI register of each of the participating practices. The SMI register is a list of people who have a diagnosis of schizophrenia, bipolar disorder or other psychosis. Each GP practice is required to hold a register for a range of long-term conditions of which SMI is one (Department of Health, 2002). We checked the SMI registers to make sure that if people without an appropriate diagnosis were included we could remove them. To ensure that we included everybody with SMI, we carried out a search on antipsychotic medications from the computer records. The diagnosis and history of identified patients were then checked by clinicians from each practice to determine whether they met the criteria for inclusion. Demographic information (age, gender) and evidence of whether screening and lifestyle advice had been given in the last year was extracted manually from the electronic patient records.

Data analysis

We used relative risk to calculate whether training made a difference to the level of screening and lifestyle advice given to people with SMI as a group. The t-test was employed to determine the difference between the mean number of interventions received by each individual patient with SMI before and after training. This analysis was done with SPSS, version 18.

Training

Developing the training

We developed a manual (Health Improvement Profile for Primary Care or HIP-PC) and a website (now at http://physicalsmi.webeden.co.uk). The manual provides practice nurses with clear guidance and a rationale to help them make decisions about individual patients (Hardy & Gray, 2010, 2011). The website can be used both for training and as a resource for practice nurses to access useful tools (e.g. letters, care plans, scales, HIP-PC), relevant information about SMI (e.g. medication, Mental Capacity Act, schizophrenia, bipolar disorder) and helpful links (e.g. leaflets, further information for health care professional, charities). The aim was to provide practice nurses with a greater understanding of SMI and the increased risk of CVD in this group, and confidence in carrying out these physical health checks.

Training

A two-hour foundation block of training was delivered at the practice nurses’ usual place of work. In order to ensure that the learning outcomes were achieved, the training consisted of group discussion and demonstration (carrying out a simulated health check). The link community mental health worker (CMHW) was invited to attend the training in an effort to improve communication between primary and secondary care. Following this training, the participants were found to be more likely to accept carrying out these health checks as part of their role and their motivation to work with the CMHW was enhanced (Hardy, 2012).

Ethical approval

The local regional ethics committee confirmed that this project was a service evaluation and therefore did not require its approval. Each manager from the participating practices gave written consent to take part in the audit.

Results

We invited 31 primary care centres in Northampton to take part in this project; five agreed. From the computer records we identified 400 patients from the SMI register. The number of patients (n = 400) in the first and second audit remained unchanged. However, we cannot assume that they were all the same patients as we did not record how many of them left or joined the practice during this time. That said, the turnover of patients in primary care in GP practices is generally very modest and therefore it is likely that only a few patients were different (Stokes, Dixon-Woods & McKinley, 2004). Table 1 shows that the demographic profile (age and gender) of the sample remained broadly similar between the two audits. Most of the participants were male and the majority were middle-aged.

Table 1.

Age distribution of participants.

Age category	16–35		36–55		56+
	n	%	n	%	n	%
First audit (n = 400)	96	24	176	44	128	32
Second audit (n = 400)	94	23	179	45	127	32

Table 2 shows the proportion of patients that had each element of a health check completed in the year before and after practice nurse training. In terms of CVD screening factors, in the first audit the most commonly assessed element was blood pressure: more than half of the patients that participated had this checked. BMI was recorded for a little under half of patients. Around a third of patients had had a blood test for cholesterol and glucose levels. One in five patients had all four risk factors checked.

Table 2.

Proportion of patients that had each element of a health check completed in the year before and after practice nurse training.

Completed at health check
Component of health check	Pre-training year(n = 400)	Post-training year(n = 400)	Relative risk (95% CI)
	n, % (95% CI)	n, % (95% CI)
CVD risk factors
Glucose	125, 31 (27–36)	179, 45 (40–50)	1.43 (1.19–1.72, p < .01)
Blood pressure	245, 61 (56–66)	300, 75 (70–79)	1.22 (1.11–1.35, p < .01)
Cholesterol	144, 36 (31–41)	177, 44 (39–49)	1.23 (1.04–1.46, p =.02)
Body mass index (BMI)	186, 47 (42–51)	219, 55 (50–60)	1.18 (1.03–1.36, p = .02)
All risk factors	79, 20 (16–24)	91, 23 (19–27)	1.15 (0.88–1.51, ns)
Lifestyle advice
Diet	50, 13 (10–16)	136, 34 (30–39)	3.06 (2.03–3.65, p < .01)
Exercise	56, 14 (11–18)	138, 35 (30–39)	2.46 (1.87–3.25, p < .01)
Smoking	219, 55 (50–60)	279, 70 (65–74)	1.27 (1.14–1.42, p < .01)
All three elements	43, 11 (8–14)	112, 28 (24–33)	2.60 (1.89–3.60, p < .01)
All elements of health check	33, 8 (6–11)	60, 15 (12–19)	1.82 (1.22–2.72, p = .01)

Table 3 shows the elements of the health check delivered to each patient before and after training. The mean number of interventions received by each patient for screening was fewer than two from a possible four in the first audit. In the second audit following training, there was a significant increase in the proportion of patients receiving each health check element. Three quarters of the patients had their blood pressure checked and over half had their BMI recorded. Just under half were given blood tests for glucose and cholesterol levels. There was no significant increase in the number of patients receiving all elements of CVD screening. The mean number of interventions received by each patient for screening was nearly two and a half from a possible four, which was a significant increase.

Table 3.

Elements of the health check delivered to each patient with SMI.

Elements	Before	After	Significance
	M (sd, 95% CI)	M (sd, 95% CI)
CVD screening (out of four)	1.83 (1.53, 1.68–1.98)	2.41 (0.47, 2.36–2.46)	t = -6.99, p < .05
Lifestyle (out of three)	0.85 (0.95, 0.76–0.94)	1.41 (1.41, 1.27–1.55)	t = -6.98, p < .05
Screening and lifestyle (out of seven)	2.69 (2.22, 2.47–2.91)	3.85 (1.37, 3.72–3.98)	t = -8.22, p < .05

Turning to lifestyle counselling, in the first audit just over one in 10 patients with SMI received diet and exercise advice and over half received smoking advice. Around one in 10 patients received all three elements of lifestyle guidance. From a possible three lifestyle interventions, patients received less than one. Following training there was a significant increase in the three elements of lifestyle advice given. Just over a third of patients received diet and exercise advice and around two thirds were given information about smoking. From a possible three lifestyle interventions, patients received nearly one and a half.

In the first audit, around one in 12 patients received a complete health check (all seven elements); this increased significantly following the training to more than one in seven. This is in fact almost a doubling of patients receiving a comprehensive health check. The mean number of both screening and lifestyle advice elements from a possible seven received by each patient increased from just over two and a half to nearly four.

Discussion

The aim of this study was to establish whether training practice nurses increases the proportion of the patients with SMI in their practice being screened for CVD risk factors and given lifestyle advice. Following training, all elements of CVD screening and lifestyle advice increased. Importantly, there was no decrease in any of the interventions.

The proportion of patients receiving cholesterol and glucose measurements increased from a third in the first audit to just under half in the second. Although this is a large increase, the actual numbers are low in comparison to the blood pressure and BMI measures. This is consistent with other studies (Eldridge, Dawber & Gray, 2011; Smith et al., 2007). Only a quarter of patients had glucose and cholesterol tested in the study by Eldridge et al., despite 100% having BMI and blood pressure recorded. Smith et al. measured glucose in approximately 75% of participants but only recorded HDL cholesterol in 22%. They report that obtaining fasting samples was not easily possible in an outpatient SMI cohort with its various limitations including timing of appointments and laboratory schedules. The nurses in our study may have experienced similar difficulties, as although it is unnecessary to fast for total cholesterol and HDL (Birtcher & Ballantyne, 2004; Lab Tests Online UK, 2012), the laboratory in Northampton requires it for HDL. Our training suggested recording blood pressure and BMI, and testing random glucose or HbA1c and total cholesterol in everyone. However, six months later there were changes to the targets for people with SMI in the GPs’ payment contract; these included measuring blood pressure and BMI for all, but only offering blood tests to patients over 40 and measuring HDL rather than total cholesterol (BMA & NHS Employers, 2012). Due to this change in contract, we cannot claim that the increases in blood pressure and BMI in the second audit were fully due to our intervention. Additionally, this may explain the fact that fewer patients had blood tests done than the other screening measures.

The research activity around the training may have increased awareness of the high CVD risk in people with SMI and encouraged health care professionals in the practices to offer screening to patients, rather than it being the effect of the training itself (the Hawthorne effect – Mayo, 1933).

More patients were given diet and exercise advice following training and these interventions were not targets of the payment contract. The level of smoking advice increased significantly despite this being a payment target when the first audit took place. These findings are consistent with those of Bernard, Lux and Lohr (2009) who reported that the training and education of nurses in primary care centres promote the use of prevention practices. This is important as the high prevalence of obesity and dyslipidemia in patients with SMI suggests that these patients may benefit from interventions that are focused more specifically on changing health behaviours (Brar et al., 2005; Graves & Miller, 2003). As only half of the patients taking long-term primary prevention medications following screening adhere to their treatment (Morisky, Ang, Krousel-Wood & Ward, 2008; Vrijens, Vincze, Kristanto, Urquhart & Burnier, 2008), promoting a healthy lifestyle is essential.

It is encouraging to observe that in the second audit there was a significant increase in the mean number of elements of the health check received by each individual patient, both for screening and lifestyle advice. However, more research is required to examine whether this has an effect on patient outcomes.

Although the training in our study incorporated the suggestion of developing a specific nurse-led clinic, we had no control of whether the five practices participating developed this as a service. Practice nurses who have completed training have fewer misconceptions about SMI and might be more likely to accept carrying out these health checks as part of their role (Hardy, 2012), but the organization of their overall workload is usually controlled by the GPs (McGregor, Jabareen, O’Donnell, Mercer & Watt, 2008).

Conclusion

Training practice nurses to deliver health checks for people with SMI increases the level of screening and lifestyle advice given to this group of patients. More research is needed to assess whether the organization of the practice nurse workload to include annual health checks for patients with SMI in addition to training will enhance this progress. In order to shift the culture of primary care, there is also a need to educate commissioners and GPs about the risks of CVD in this patient group.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

References

Allison

Casey

(2001). Antipsychotic-induced weight gain: A review of the literature. Journal of Clinical Psychiatry, 62 (suppl. 7), 22–31.

Barnett

A. H.

Mackin

Chaudhry

Farooqi

Gadsby

Heald

… Jones

P. B.

(2007). Minimising metabolic and cardiovascular risk in schizophrenia: Diabetes, obesity and dyslipidaemia. Journal of Psychopharmacology, 21, 357–373.

Bernard

Lux

Lohr

(2009). Healthcare delivery models for prevention of cardiovascular disease (CVD). London: The Health Foundation.

Birtcher

Ballantyne

(2004). Measurement of cholesterol. Circulation, 110, 296–297.

Blythe

White

(2012). Role of the mental health nurse towards physical health care in serious mental illness: An integrative review of 10 years of UK literature. International Journal of Mental Health Nursing, 21, 193–201.

Bradshaw

Pedley

(2012). Evolving role of mental health nurses in the physical health care of people with serious mental health illness. International Journal of Mental Health Nursing, 21, 266–273.

Brar

Ganguli

Pandina

Turkoz

Berry

Mahmoud

(2005). Effects of behavioral therapy on weight loss in overweight and obese patients with schizophrenia or schizoaffective disorder. Journal of Clinical Psychiatry, 66, 205–212.

BMA & NHS Employers (British Medical Association & National Health Service Employers). (2012). Quality and Outcomes Framework guidance for GMS contract 2012/13. Available from: http://bma.org.uk/practical-support-at-work/contracts/independent-contractors/qof-guidance

Campbell

Thain

Deans

Ritchie

Rawles

Squair

(1998). Secondary prevention clinics for coronary heart disease: Randomised trial of effect on health. British Medical Journal, 316, 1434–1437.

10.

Chang

C.-K.

Hayes

Perera

Broadbent

Fernandes

Lee

W. E.

… Stewart

(2011). Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS ONE, 6, e19590. doi:10.1371/journal.pone.0019590.

11.

Clark

Hartling

Vandermeer

McAlister

(2005). Meta-analysis: Secondary prevention programs for patients with coronary artery disease. Annals of Internal Medicine, 143, 659–672.

12.

de Hert

Schreurs

Vancampfort

van Winkel

. (2009). Metabolic syndrome in people with schizophrenia: A review. World Psychiatry, 8, 15–22.

13.

Department of Health. (2002). Disease registers in England. Oxford: Institute of Health Sciences.

14.

Eldridge

Dawber

Gray

(2011). A well-being support program for patients with severe mental illness: A service evaluation. BMC Psychiatry, 11, 46. doi:10.1186/1471–244X-11–46.

15.

Fontaine

Moonseong

Harrigan

Shear

C. L.

Lakshminarayanan

Casey

D. E.

Allison

D. B.

(2001). Estimating the consequences of antipsychotic induced weight gain on healthy mortality rate. Psychiatry Research, 101, 277–288.

16.

Graves

Miller

(2003). Behavioral medicine in the prevention and treatment of cardiovascular disease. Behavioral Modification, 27, 3–25.

17.

Griffiths

Maben

Murrells

(2011). Organisational quality, nurse staffing and the quality of chronic disease management in primary care: Observational study using routinely collected data. International Journal of Nursing Studies, 48, 1199–1210.

18.

Hall

(2008). Access to specialist nurses in diabetes care: A postcode lottery? Diabetes & Primary Care, 10, 8.

19.

Hardy

(2011). Will the changes to the QOF mental health indicators improve care for people with severe mental illness? British Journal of Wellbeing, 2, 18–21.

20.

Hardy

(2012). Training practice nurses to improve the health of patients with severe mental illness: The effect on beliefs and attitudes. International Journal of Mental Health Nursing, 21, 259–265.

21.

Hardy

Gray

(2010). Adapting the severe mental illness physical Health Improvement Profile for use in primary care. International Journal of Mental Health Nursing, 19, 350–355. doi: 10.1111/j.1447–0349.2010.00686.x.

22.

Hardy

Gray

(2011). The secret food diary of a person diagnosed with schizophrenia. Journal of Psychiatric and Mental Health Nursing, 19, 603–609. doi: 10.1111/j.1365–2850.2011.01826.x.

23.

Hennekens

C. H.

Hennekens

A. R.

Hollar

Casey

D. E.

(2005). Schizophrenia and increased risks of cardiovascular disease. American Heart Journal, 150, 1115–1121.

24.

Houweling

Kleefstra

van Hateren

Groenier

Meyboom-de Jong

Bilo

(2011). Can diabetes management be safely transferred to practice nurses in a primary care setting? A randomised controlled trial. Journal of Clinical Nursing, 20, 1264–1272.

25.

Kilbourne

Brar

Drayer

Post

(2007). Cardiovascular disease and metabolic risk factors in male patients with schizophrenia, schizoaffective disorder, and bipolar disorder. Psychosomatics, 48, 412–417.

26.

Krogsbøll

Jørgensen

Grønhøj Larsen

Gøtzsche

(2012). General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. British Medical Journal, 345. doi: https://dx-doi-org.web.bisu.edu.cn/10.1136/bmj.e7191.

27.

Lab Tests Online UK. (2012). HDL cholesterol test. Available from: http://www.labtestsonline.org.uk/understanding/analytes/hdl/tab/test

28.

Laursen

(2011). Life expectancy among persons with schizophrenia or bipolar affective disorder. Schizophrenia Research, 131, 101–104.

29.

Lester

Tritter

Sorohan

(2004). Managing crisis: The role of primary care for people with serious mental illness. Family Medicine, 36, 28–34.

30.

Lester

Tritter

Sorohan

(2005). Patients’ and health professionals’ views on primary care for people with serious mental illness: Focus group study. British Medical Journal, 330, 1122. doi: 10.1136/bmj.38440.418426.8F.

31.

McCreadie

(2003). Diet, smoking and cardiovascular disease risk in people with schizophrenia: Descriptive study. British Journal of Psychiatry, 183, 534–539.

32.

McGregor

Jabareen

O’Donnell

Mercer

Watt

(2008). Impact of the 2004 GMS contract on practice nurses: A qualitative study. British Journal of General Practice, 58, 711–719.

33.

Mayo

(1933). The human problems of an industrial civilization. New York: MacMillan.

34.

Miller

W. R.

(2005). Enhancing patient motivation for health behavior change. Journal of Cardiopulmonary Rehabilitation, 25, 207–209.

35.

Morisky

Ang

Krousel-Wood

Ward

(2008). Predictive validity of a medication adherence measure in an outpatient setting. The Journal of Clinical Hypertension, 10, 348–354.

36.

NICE (National Institute for Health & Clinical Excellence). (2006). Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. Available from: http://www.nice.org.uk/nicemedia/pdf/CG38fullguideline.pdf

37.

NICE (National Institute for Health & Clinical Excellence). (2010). Schizophrenia: Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. Available from: http://www.nice.org.uk/nicemedia/live/11786/43607/43607.pdf

38.

NICE (National Institute for Health & Clinical Excellence). (2012). Public health draft guidance: Physical activity: Brief advice for adults in primary care. Available from: http://www.nice.org.uk/nicemedia/live/13443/61554/61554.pdf

39.

Osborn

Baio

Walters

Petersen

Limberg

Raine

Nazareth

(2011). Inequalities in the provision of cardiovascular screening to people with severe mental illnesses in primary care: Cohort study in the United Kingdom. THIN Primary Care Database 2000–2007. Schizophrenia Research, 129, 104–110.

40.

Phelan

Stradins

Morrison

(2001). Physical health of people with severe mental illness. British Medical Journal, 322, 443–444.

41.

Raftery

Yao

Murchie

Campbell

Ritchie

(2005). Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: Follow up of a randomised controlled trial. British Medical Journal, 330, 707.

42.

Reilly

Planner

Hann

Reeves

Nazareth

Lester

(2012). The role of primary care in service provision for people with severe mental illness in the United Kingdom. PLoS ONE, 7, e36468. doi:10.1371/journal.pone.0036468 .

43.

Robson

Haddad

Gray

Gournay

(2012). Mental health nursing and physical health care: A cross-sectional study of nurses’ attitudes, practice, and perceived training needs for the physical health care of people with severe mental illness. International Journal of Mental Health Nursing. doi: 10.1111/j.1447-0349.2012.00883.x.

44.

Smith

Yeomans

Bushe

Eriksson

Harrison

Holmes

… Sullivan

(2007). A well-being programme in severe mental illness: Baseline findings in a UK cohort. International Journal of Clinical Practice, 61, 1971–1978.

45.

Stokes

Dixon-Woods

McKinley

(2004). Ending the doctor–patient relationship in general practice: A proposed model. Family Practice, 21, 507–514.

46.

Thompson

Tonelli

(2012). General health checks in adults for reducing morbidity and mortality from disease [editorial]. Cochrane Database of Systematic Reviews, 10, ED000047. Available from: http://www.thecochranelibrary.com/details/editorial/2723031/General-health-checks-in-adults-for-reducing-morbidity-and-mortality-from-diseas.html

47.

Vrijens

Vincze

Kristanto

Urquhart

Burnier

(2008). Adherence to prescribed antihypertensive drug treatments: Longitudinal study of electronically compiled dosing histories. British Medical Journal, 336. 1114–1117.