The Biopsychosocial Model Health And Social Care Essay

The Biopsychosocial Model Health And Social Care Essay In the preceding paragraphs many theoretical models were put forward, but it is now desirable to introduce a holistic model of causation, one that is more naturalistic than the simple linear reductionist models (Borrell-Carrià ³ et al., 2004). A comprehensive literature search showed that the most common and widely accepted holistic framework for treatment and rehabilitation is the biopsychosocial model. The popularity of this model can be seen by the frequency of its occurrence in online sources. A preliminary assessment of the biopsychosocial model was conducted using the Medline database, using the term biopsychosocial in the topics field. It is well recognised that use of the term biopsychosocial does not necessarily indicate an adoption of the biopsychosocial model, but at a minimum, it does reflect a recognition of the perspective (Suls Rothman, 2004). Figure 1.5: Frequency of citation of the term biopsychosocial using the Medline database. 4.1 The Biopsychosocial Model One of the famous landmarks articles, published almost thirty years ago by Engle (1977), questioned the biomedical interventions used in both psychiatry and medicine, and warned of a crisis in the biomedical paradigm (Alonso, 2004). Engle (1977) argued that a true medical approach should consider: (1) the patient; (2) the healthcare system; (3) the social context of the patients life; and (4) the psychological context (Mrdjenovich et al., 2004; Pereira Smith, 2005). The main proposition of the biopsychosocial model is that treatment interventions should be an interlinked system covering multiple dimensions (i.e. diagnostic and causative variables), taking into account biological, social, psychological and macro (e.g. socioeconomic status, cultural, ethnic) issues (Figure 1.6) (Burton et al., 2008). Any defect in one part of the system will affect another part of the system (Keefe et al., 2002). For instance, deterioration of a patient condition (biological effect) can negatively aff ect patients` emotional states increasing stress and anxiety level (psychological effect) affecting his/ her ability to work or perform his/her daily routine activities (social effect), which will then, subsequently, increase pain and/or disability levels (Keefe et al., 2002). Figure 1.6: A pictorial illustration of the biopsychosocial model. Adapted from Finlay (2009). The biopsychosocial model accentuate the importance of interacting and understanding the patient as a unique individual taking onto consideration their belief system in a moderate way that neither concentrate on the biomedical aspects or psychosocial aspects but rather illustrate their relationship together (Jones et al., 2002). In comparison between the biopsychosocial model and the earlier discussed models, it can be seen that the biopsychosocial model posits a much complex, multidimensional and broader approach of clinical care (Hadjistavropoulos Craig, 2004). Engles new paradigm has often been seen as a radical departure for medicine (Salmon Hall, 2003, p.1972). However, Lambert et al. (1997) stated that although the biopsychosocial model is a new approach, it is still conservative. This assessment was based on several perspectives proposed by the model. First, by underlying the need for good clinical decisions to respond to the eccentricities of each individual patient, it re-affirms the patients role, self identity and professional independence (Armstrong, 2002; Salmon Hall, 2003). Secondly, the model extends the responsibility of medical care to go beyond biological complications and encompass non-medical treatments as well (Baer, 1989). Physicians are required to connect with their patients in a relationship that involves not only the patients complaints and symptoms, but also their personalities and psychosocial lives (Salmon Hall, 2003). Conversely, patients are expected to be prepared to respond to the physicians and bring about the required changes in their lives to prevent and/or manage their illness (Salmon Hall, 2003). However, one of the issues that has been discussed in the literature is whether the concepts of the doctor-patient relationship and patient-centredness can affect and threaten the doctors authority. However, if the requirements for patient-centredness and a doctor-patient relationship are applied in a moderate and professional way, they do not threaten either the doctors authority or their responsibility, especially since physicians maintain their authority by virtue of their specialist knowledge and their responsibility for an accurate diagnosis and appropriate treatment (Salmon Hall, 2003). Taking on the considerations mentioned in this section lead to a perceived need for a study to determine the current methods followed in managing lower limb injuries (either in elective or emergency cases) and whether the biopsychosocial model is a better approach of treatment. 4.1.1 To what extent have the medical establishment and different research fields adopted the biopsychosocial model? The biopsychosocial model has been widely adopted and promoted in different domains, including medical schools, major medical organisations, social work departments, public health, counselling, and some fields of psychology (Kaplan Coogan, 2005). For example, the WHOs International Classification of Functioning, Disability and Health (ICF), which is a global framework of disability and rehabilitation, is based on the biopsychosocial model (WHO, 2001). Dowrick et al. (1996) conducted a study to explore whether the biopsychosocial model is based on rhetoric or reality. A semi-structured postal questionnaire was sent to 494 principal general practitioners. The questionnaire sought the practitioners views about what they believed to be relevant and appropriate to a practitioners skills and knowledge in general medical practice, and investigated whether these views are consistent with the biopsychosocial model. Only 41% (207) of the sample responded to the questionnaire, which is considered to be a low response rate (Church et al., 2001). The results showed that general practitioners embrace the view that physicians should incorporate a biopsychological model, rather than a biopsychosocial model, in their general medical practice. However, the results cannot be generalised because the study was conducted exclusively on members of a specific organisation. Therefore, the results can only be only applied to the specific population describ ed in the study. Similarly, Alonso (2004) also investigated the extent to which the biopsychosocial concept has been adopted by medical researchers. Using the Medline database, Alonso examined published articles in the period 1978-1982 (period a) and the period 1996-2000 (period b). Period a was selected because it covers the first five years since Engels conceptualised his new model, and the second period (period b) was determined by the date of Alonsos study (covering the five years before the study). The findings of the previous study showed that the conceptualisation of health in medical research, as characterised in articles written within the past two decades, has not changed. In other words, physicians are still reluctant to incorporate the biopsychosocial model, and often focus solely on traditional methods of treatment. Other studies (Dowrick et al., 1996; Cohen et al., 2000; Alonso, 2004; Kaplan Coogan, 2005) also concur with the findings of Alonsos original study, and conclude that the bi opsychosocial model has not been fully integrated into actual medical practice. Conversely, in an evaluation of published articles between the years 1977-1987 and 1988-1998, Hwu et al. (2001) found a considerable spread of medical research articles that did include social and psychological aspects in their definitions of health and medical care. In addition, a literature search also shows that several behavioural, medical and psychological phenomena have adopted the biopsychosocial concept (Kaplan Coogan, 2005), in areas such as schizophrenia (Kotsiubinskii, 2002; Schwartz, 2000), chronic fatigue (Johnson, 1998), antisocial behaviour (Dodge Petit, 2003), gastrointestinal illness (Drossman,1998), spinal cord injury (Mathew et al., 2001), and pain management (Truchon, 2001; Covic et al., 2003). Clearly, there are conflicting findings in the existing literature regarding the extent to which the biopsychosocial model has been integrated into the medical domain, indicating a need for future research. 4.1.2 Application of the biopsychosocial model in rehabilitation Several authors have argued that there is a considerable gap between the introduction of a new or revised model and the application of the proposed model in clinical practice (Linton, 1998; Muncey, 2000; Jones et al., 2002). The challenging factors surrounding changes in clinical practice have been reviewed by Muncey (2000), two of which are associated with physicians decision-making skills and knowledge. In addition, physicians reluctance, in some cases, to integrate new models into their clinical practice should also be taken into consideration (Silagy, 1998; Jones et al., 2002). Furthermore, because the current medical literature is often introduced at a basic scientific level, it is complicated for non-researchers to understand and transfer new models and theories to clinical settings (Jones et al., 2002). Jones et al. (2002) stated that in order to achieve successful application of a new pattern of behaviour and practice thinking, two elements are required. These are reflective, critical clinical reasoning (i.e. the decision-making process), and a suitable organization of knowledge in which the new model can be implemented. The significance of the biopsychosocial model is based on its capability to show the multitude of interactions between its elements (Jones et al., 2002). in addition, every individual element can then be further explored. However, this means that physicians need to further develop their clinical practice skills in terms of patient assessment and management, either physically or in terms of other factors that contribute to their patient`s illness (Jones et al., 2002). One of the elements that should be considered in the application of the biopsychosocial model is diagnostic reasoning, which mainly depends on the application of the scientific paradigm (or the empirico-analytical model) for decision-making and validation. This form of reasoning attempts to identify and test hypotheses relating to the nature of psychological and physical impairments and their functional disabilities (Jones et al., 2002). Narrative reasoning is another form of reasoning which is used to understand the patients own experience with their pain and illness (Mattingly, 1994; Jones et al., 2002). However, although this sounds like a simple method, in fact it is far more challenging than simply listening to patients own stories (Jones et al., 2002). Finally, it is essential to highlight the fact that the biopsychosocial approach is not only concerned with curing pathological defects, but also with helping people to regain their normal life activities (Burton et al., 2008). In addition, it is acknowledged that there may be a certain amount of reluctance regarding the adoption of the biopsychosocial model because of the hurdles in the way of its clinical application (Burton et al., 2008). Changing the way in which injuries are managed in clinical settings will require further investigation, since little attention has been paid towards identifying the current methods that are used to manage lower limb injuries (either in emergency or elective settings) and whether the biopsychosocial model is a better approach in managing such injuries. From the findings and the studies presented in this literature review, it can be concluded and hypothesised that enough clinical evidence exists to show that the biopsychosocial model is a better approach to managing lower limb injuries. On the other hand, the literature does not answer the basic question to whether the surgery is elective or emergency make a difference to the patient experience after injury, which necessitate the need for further investigate. 5.0 Conclusion Little attention has been given to the patients experience after lower limb surgery for example, comparing and contrasting the experiences of patients who have had elective or emergency surgeries, exploring physical, social and psychological aspects, and looking at whether methods of treatment and follow-ups are applied differently between elective and emergency surgeries. In addition, although various studies had focused on how the physical, social and psychological factors interlink together, no previous study has investigated the outcome of the application of the biopsychosocial model in managing patients after lower limb surgery as a result of injury, compared to those who were treated using other treatment approaches. Therefore, to address these issues, this study aims to explore and report the patients experience of clinical care of lower limb injury after surgery, comparing and contrasting the experiences of patients who have had elective or emergency surgeries, and investigating whether the biopsychosocial model is a better treatment approach for the management of lower limb injuries than other approaches. Thus, the current study is based on the following research questions: 6.0 Research question Primary research question: What are the differences between patients experiences and clinical approaches after elective lower limb surgery as a result of injury, compared with patients experiences after emergency lower limb surgery as a result of injury? Secondary research question: If a difference exists among patients experiences and clinical approaches between elective and emergency lower limb surgeries as a result of injury, how does this difference related to the current care pathway including the biopsychosocial model? 6.1 Aims and objectives The aim of this study is to develop a better understanding of patients experiences after a lower limb injury that is severe enough to necessitate surgery, and to compare medical services (after lower limb surgery) provided in emergency settings vs. elective settings. In addition, the study aims to investigate the efficiency of current methods of treatment and compare them with treatment methods derived from a biopsychosocial approach. Understanding the experience of lower limb injury from the patients perspective is essential for providing guidelines for appropriate and efficient medical services, and in the prevention of future complications for the patient. In addition, such an understanding will form a reference for future research studies. The objectives of this study are to explore and report: The difference in patients experiences of medical services for lower limb surgery provided in emergency settings and elective settings. Whether the current biomedical approach to managing lower limb injuries is efficient enough from the patients perspective. The importance of psychosocial factors for a patient with lower limb injury. The importance of implementing treatment methods derived from a biopsychosocial model approach. 6.2 Statement of null hypotheses The research is based on three null hypotheses: The primary null hypothesis states that there will be no difference in patients experiences in emergency and elective surgery settings for patients with lower limb injuries. The secondary null hypothesis states that there will be no difference between elective and emergency lower limb surgeries as a result of injury, and hence it does not relate to the current care pathway including the biopsychosocial model.

Essay on setting and work

Essay on setting and work Describe the Setting and the Work it does This report is commissioned by the Local Authority and is the result of a review a Phase One Childrens Centre who currently adopt and integrated model of working. The scope of the review was to identify benefits and limitations of an integrated approach. Furthermore, a brief exploration of the economic implications is provided and recommendations regarding future strategic structure and planning are detailed. Terminology A primary issue with multi-agency working is the inter-changeability and misuse of associated terminology (Morris, 2008; Walker, 2008). This report offers two distinct definitions of multi-agency working and clarifies the use of terms. The first definition describes multi-agency work as a range of different services which have some overlapping or shared interests and objectives, brought together to work collaboratively towards some common purpose (Wigfield Moss, 2001). The second definition contends that multi-agency work is about Bringing various professionals together to understand a particular problem or experienceIn this sense they afford different perspectives on issues at hand, just as one sees different facets of a crystal by turning it (Clark, 1993). These definitions share the ideology of different professionals from separate agencies working with a common goal and attempting to resolve an issue. It is essential to note the differences between multi-agency and multi-disciplinary work. Multi-agency work refers to two or more professionals from different agencies working together, whereas multi-disciplinary refers to the collaboration between different professionals from one agency. For example, (Walker, 2008) suggests that the professional working relationship between a teacher, nursery nurse and teaching assistant within a school is multidisciplinary because although their roles are different, they work within the education agency. However, the relationship between a Teacher, Social Worker and General Practitioner would be multi-agency because it encompasses different agencies (Education, Social Services and Health). (Wilson Pirrie, 2000) make further distinctions between multi-agency and inter-agency and argue the choice of terminology is determined by three factors- numerical, territorial and epistemological. This relates to the quantity of professionals involved, locations, and the amount of innovation in developing new ways of working which considers the philosophical foundations of each professional identity(Wilson Pirrie, 2000). Inter-agency may involve two professionals from different agencies whereas multi-agency involves a minimum of three (Wilson Pirrie, 2000). Furthermore, true multi-agency working requires professionals to enter each others professional environment, both physically and culturally, and establishing or re-establishing a novel and universal awareness and understanding (Coad, 2008; Walker, 2008; Wilson Pirrie, 2000). For the purpose of this report, the term multi-agency shall be adopted throughout and shall refer to two or more professionals from different agencies working collaboratively to address the needs of children and young people. Rationale The emphasis for multi-agency teamwork initiated following the death of Maria Colwell in 1973 (Walker, 2008) which resulted in significant changes to the structure of child services. However, the deaths of children with whom various agencies were involved continued. Such deaths include Jasmine Beckford (1984), Tyra Henry (1984), Heidi Koseda (1984) Kimberley Carlile (1986), Doreen Mason (1987), Leanne White (1992), Rikki Neave (1994), Chelsea Brown (1999), Victoria Climbià © (2000), Lauren Wright (2000) and Ainlee Labonte (2002). Despite enquiries into these deaths only a minority led to negligible changes in policy or guidance and only one led to a radical change in children services (Walker,2008). (Laming) (2003) highlighted significant failings on the part of agencies to work collaboratively to ensure the well-being of children and young people. Lamings (2003) recommendations were broadly adopted into the Every Child Matters agenda (DfES, 2003) which (Walker, 2008) suggests the g overnment were already considering implementing which suggests the it was implemented because it mirrored the ideological perspective of the government. However, van Eyk and Baum (2002) suggest that inquests have provided h3 evidence that agencies should be working together in a collaborative manner to safeguard children and therefore it is unsurprising that the government have adopted this ideological stance. Laming (2003) supports this by indicating the inseparability of the protection of children and wider support to families which has been widely accepted (Morris, 2008) and therefore the need for Local Authorities to have agencies working collaboratively is essential (Coad, 2008; Walker, 2008). Despite the development of legislation and policies, the death of Baby Peter in August 2007 was attributed to the failure of Social Workers and other professionals who had seen him approximately sixty times.   In November 2008 Lord Laming was commission by the government to conduct independent report on the progress being made by Local Authorities to work collaboratively to protect children. Key findings from Laming (2009) included: Social Workers are under-pressure deliver but inadequate training. The Day-to-day running of protection cases has significant problems. Managers are failing to lead by example with an over-emphasis on targets and process. The lack of a centralised Information Technology system is hampering progress. Administration is too complex and lengthy with a tick-box recording system. There is a lack of communication and joined-up working. Data protection laws are not clear nor understood resulting in information not being shared. There is a lack of funding in Social and Child Protection work. There has been a reduction in Child Protection Police Officers. Laming (2009) made the following recommendations: Directors of Childrens Services with no experience with child protection issues should appoint an experienced social work manger. All Local Authority Leads and Senior Managers should have child protection training. Social Work students should get more child protection training. Employers should face prosecution for failing to protect. Court fees for Care Proceedings should be reviewed (currently  £4000 per case) OFSTED inspectors must have experience of child protection Explicit targets should be developed for all frontline services A national agency should be developed to ensure the implementation of these recommendations. Legislation Under Section 17 of the Children Act 1989 the Local Authority has a duty to safeguard and promoted the welfare of children within their area and are in need.   Section 22(3) extends this to include children within care. As the local authority is constructed of many agencies there is an implicit requirement for agencies to work collaboratively. This is stipulated within Section 10 of the (Children Act, 2004) Children which is a development of Section 27 of the Children Act 1989. This places a duty on agencies to pro-actively work with each other to support children and their families.   However, there also conflicting social policies and legislation which may act to limit the effectiveness of multi-agency working. An example may be a single-mother under the care of Social Services because she is over-crowded in her house.   The assessment indicates this is the primary factor from concern and recommends better accommodation from the Housing Department.   The Governments Every Child Matters vision demands that all children be placed at the centre of social action. However, other laws conflict this.   Housing law does not need to consider the Children Act 1989 or 2004, nor does it force Local Authorities to consider the allocation of accommodation on a child-centred basis, but on the basis of reasonable preference (Shelter, 2005, p.www). This leaves the potential for one law to stigmatise with the other to maintain stigmatisation and conflict between agencies arising. Current Model of Inter-Agency Working Integrated Service Model The Integrated Service Model unites various agencies into one hub who deliver a range of services and integrated support children and families within a community. The team share a location, vision, agreed principles and philosophies in developing localised plans to improve outcomes for service-users. This is usually delivered from an early years setting such as a Childrens Centre. The facilities and services of the integrated team are funded by all agencies and out-sourcing funding from voluntary, community and government agencies is also available. Such services may include access to childcare, education, and counselling as well as advice on health, employment and benefits. Furthermore, practitioners actively and collaboratively engage in outreaching activities to identify and target in need families. Parents and children are given the opportunity to learn new skills, discuss their issues (formally and informally), and engage in communal activities. As services are localised it recognises each community is different and has unique needs. Therefore, activities will differ from hub to hub. Furthermore, there is a greater emphasis on co-working and co-training with skills between agencies being shared at a deeper level resulting in better practice and information sharing. However, the benefits of this model can be limited by local factors such as poor management or failing to identify local needs. Furthermore, getting all agencies involved requires an initial financial and personnel investment along with a clear and agreed strategy on how to merge services. Managing the differences in pay between practitioners and the power each agency holds needs to be considered at a macro-level to ensure fairness and consistency. A failure in this may result in practitioners feeling devalued or threatened. Atkinson et als (2001) study found this model is most effective when there is a case lead/manager responsible for co-ordinating services for families which ensures services are aimed at the service-user rather than the organisation or professional.   A review into outcomes for families with disabled children indicates that a key worker integrated model promotes better outcomes (Liabo et al,2001). Although Liabo et al (2001) acknowledge a lack of large scale and robust studies, an integration of the current evidence indicates families enjoy a better quality of life, lower levels of stress and quicker access to services. However, from a critical perspective a systematic review is required to minimise any bias. Although Watson et al (2000,2002) concur, they argue these are opinions rather than fact and call for localised research aimed at measuring outcomes to enable a synthesis of results. Alternative Models of Multi-agency Working Multi-agency Team The multi-agency team model is considerably more formal than the Multi-agency panel model currently employed. Practitioners are recruited as part of a singular team who share a common goal and a sense of team identity and are line managed by a team leader. However, links are maintained with home agencies through supervision and training. This team would share a base, although some practitioners would be required to work in two settings. Such an example might include a School Attendance Officer who would be based within the Local Service Team and at the school which can lead to confusion between job roles. As collaborative working is at the foundation of the approach there is inevitably a sharing of skills and knowledge with communication being uncomplicated. However, recruitment of staff is time-consuming and identification of people not only with the appropriate skills, but also to work collaboratively may be problematic. Also, as this will be new to the Local Authority, time and funding would need to be allocated for team building and development.   There is also a reliance on agencies sharing a good relationship and be willing to partake in meetings, conferences and strategy meetings in addition to service-user discussions. Measuring the Impact of Integrated Working The above has highlighted the implications for failing to work in an integrated manner and there is an assumption that effective integrated working actively contributes to the positive outcomes of Every Child Matters. Therefore this section focuses on studies and literature aimed at measuring the efficacy of integrated working. Cameron and Larts (2003) systematic review reaffirms the findings of Cameron et al (2000) that there is little evidence to confirm the benefits for service users of integrated working. Cameron and Lart (2003) are critical of the lack of evaluations aimed at measuring the effectiveness of multi-agency working and highlight the few that have are methodologically poor. Similarly, few studies have provided information regarding the effectiveness of different models. For example, Atkinson et al (2002) interviewed professionals to assess benefits of multi-agency working to service users. They identified quicker access to services leading to quicker diagnosis and treatment. Furthermore, they identified that professionals from different agencies communicated more effectively. However, this study collected the subjective views of professionals and failed to obtain the representative view of the service user.   Webb and Vuillamys (2001) study indicated a reduction in the exclusion of high risk pupils through the introduction of specialist support workers responsible for avoiding inter-agency disputes regarding responsibilities and resources. Webb and Vuillamy (2001) claim the support workers differentiated between school-focused agencies (such as educational social workers, educational psychologists and teachers) and external-agencies (such as Social Workers, Police and General Practitioners). This study reported a 25% reduction in exclusions. Webb and Vuillamy (2001) claim this has far-reaching consequences such as a reduction in crime, better educational and vocational attainment, however, this is broad assumptions based on the statistical link between exclusion and crime and is not proven within the study. Challis et al (2004) conducted a Randomised Control Trial (RCT) of 256 older people at risk of care home entry. The objective of the RCT was to redesign the decision-making process by assessing the value of obtaining a specialist clinician assessment prior to placing individuals into care homes. Participants were randomly allocated into two groups, the first received the standardised assessment process and second (experimental group) received a clinical assessment from a geriatrician or psychiatrist. The collaboration between the clinician and social worker was at the heart of this RCT. The experimental group continued to experience reduced deterioration mental and physical, had minimal contact with emergency services and carers reported lower levels of stress. Furthermore, NHS costs were lower and social services and the NHS benefited from merging skills, developing communication; and improved outcomes for users and carers. Despite the findings from these studies, the majority of studies focus on process rather than outcome, for example a Systematic Review by Cameron and Lart (2003) indicate factors which promote and hinder integrated working. This is supported by the Integrated Care Network (ICN) (2004) who contends that even when outcomes are considered this is narrowly focused and are difficult to measure in the short-term without evidence from a cohort study. The ICN (2004) believes emphasis needs to shift from structure and input to outcomes. Benefits of Multi-agency Working Inter-agency working is reported to improved the knowledge, skills and expertise of professionals (Sammons et al,2003) due to the increased opportunity for professionals development through working with other agencies (Atkinson et al, 2001,2002). This is supported by Townsley et al (2004) who indicate that the process of multi-agency working is having an effect on positive outcomes for families with disabled children. However, this incorporates the views of professionals rather than service users suggesting a subjective and biased view. The study by Atkinson et al (2002) also considers the views of professionals who suggested service users benefited from quicker access to services leading to quicker diagnosis and treatment. Furthermore, they identified that professionals from different agencies communicated more effectively. Challis et al (2004) conducted a Randomised Control Trial (RCT) of 256 older people at risk of care home entry. The objective of the RCT was to redesign the decision-making process by assessing the value of obtaining a specialist clinician assessment prior to placing individuals into care homes. Participants were randomly allocated into two groups, the first received the standardised assessment process and second (experimental group) received a clinical assessment from a geriatrician or psychiatrist. The collaboration between the clinician and social worker was at the heart of this RCT. The experimental group continued to experience reduced deterioration mental and physical, had minimal contact with emergency services and carers reported lower levels of stress. Furthermore, NHS costs were lower and social services and the NHS benefited from merging skills, developing communication; and improved outcomes for users and carers. Webb and Vuillamys (2001) study indicated a reduction in the exclusion of high risk pupils through the introduction of specialist support workers responsible for avoiding inter-agency disputes regarding responsibilities and resources. Webb and Vuillamy (2001) claim the support workers differentiated between school-focused agencies (such as educational social workers, educational psychologists and teachers) and external-agencies (such as Social Workers, Police and General Practitioners). This study reported a 25% reduction in exclusions. Webb and Vuillamy (2001) claim this has far-reaching consequences such as a reduction in crime, better educational and vocational attainment, however, this is broad assumptions based on the statistical link between exclusion and crime and is not proven within the study. Counter-Evidence Despite the findings from these studies, the majority of studies focus on process rather than outcome, for example a Systematic Review by Cameron and Lart (2003) indicate factors which promote and hinder integrated working. This is supported by the Integrated Care Network (ICN) (2004) who contends that even when outcomes are considered this is narrowly focused and are difficult to measure in the short-term without evidence from a cohort study. The ICN (2004) believes emphasis needs to shift from structure and input to outcomes. Cameron and Larts (2003) systematic review reaffirms the findings of Cameron et al (2000) that there is little evidence to confirm the benefits for service users of integrated working. Cameron and Lart (2003) are critical of the lack of evaluations aimed at measuring the effectiveness of multi-agency working and highlight the few that have are methodologically poor. Similarly, few studies have provided information regarding the effectiveness of different models. Facilitators to Multi-agency Working Evidence on Removing Barriers Barriers to Effective Multi-agency Work There are apparent dangers to encouraging inter-agency and multi-agency working. As (Walker, 2008) stipulates, different professions are likely to have unique values at their foundation which they may want to protect. To provide an example of different values, cultures and practices consider a social worker partaking in an interview with a police officer. The child who they are interviewing breaks down. The role of the social worker is to consider the well-being of the child (from a child-centred perspective), however, for the police officer it is to provide evidence to consider prosecution. Obvious barriers, conflicts and confusion can arise. (Coad, 2008) offers support to (Walker, 2008) and suggests the primary trigger for such issues is the lack of clarity of roles and authority in decision making. The lack of clarity regarding roles may lead to work duplication or providing advice which conflicts with that of another professional. However, this can be overcome through effective c ommunication between agencies and practitioners (Walker, 2008) and transparency regarding decision making processes (Coad, 2008). In addition, each agency will have its own language, terminology, budgets, targets, assessments and measurement criteria to which other professions may not fully understand. Overcoming the barriers presented is dynamic and complex. As expectations of politicians, academics and service users change so do the barriers which are presented. Therefore, in order to overcome such barriers a model of integrated thinking should be adopted with the development and deployment of a Childrens and Young Persons Strategy. This should be developed through the conduction of research to include all agencies, academic institutions training professionals, and the views of service users. This should be reviewed on a bi-annual basis to ensure it remains contemporary. Recommendations Conclusion Seeking funding utilises large amounts of managerial time and resources.

Impact of Credit Risk Management on Profitability

Impact of Credit Risk Management on Profitability Credit Risk arises because there is a possibility of a risk that the counterparty defaults on the loans and bonds held by the institution (Cornett) The Ultimate advantages of Credit Risk Management are being accepted by Financial Institutions now and Risk Managers are focusing on different Risk Management Models in looking for different Business Opportunities (Heinemann). However in general Financial Institutions that make Loans or buy bonds with long maturities are more exposed than Financial Institutions that make loans or buy bonds with short maturities. This means for example that banks, thrifts and life insurance companies are more exposed to Credit Risk than are money market mutual funds, since Banks and life insurance companies tend to hold longer maturity assets in their Portfolios than mutual funds. (Cornett) Basel is an agreement that requires the imposition of risk-based capital ratios on banks in major industrialized countries. Considering the weaknesses of the simple capital-to-assets ratio, members of Bank for International Settlements (BIS) along with U.S decided to implement two new risk-based capital ratios for all commercial banks under their jurisdiction in 1988. The BIS phased in and fully implemented these risk based capital ratios on January 1, 1993, under what has been known as the Basel Accord (now called Basel I). Credit risks of assets are included into Capital adequacy ratio into Basel Agreement of 1993. This was followed with a revision in 1998 in which market risk was incorporated into risk-based capital in the form of an add-on to the 8 percent ratio for credit risk exposure. In 2001, the BIS issued a consultative document, It was proposed in the basel-II or the new basel system that the operational risk should be the part of Capital requirements with effect from 2007 and updated the credit risk assessments in 1993 agreement. This agreement was adopted in June, 2004. (Cornett) Basel-II or the new basel system consists of three pillars which are discussed below, these three pillars play a vital role in the safety and soundness of the entire financial system. PILLAR 1 CREDIT RISK: On Balance Sheet and Off Balance Sheet (Standardized vs. Internal Ratings Based approach) MARKET RISK: Standardized vs. Internal Ratings Based approach OPERATIONAL RISK: Basic Indicator vs. Standardized vs. Advance measurement approach) PILLAR II Regulatory supervisory review so as to complement and enforce minimum Capital Requirements calculated under Pillar 1 PILLAR III Requirements on rules for disclosure of Capital Structure, risk exposures, and Capital Adequacy so as to increase Financial Institutions transparency and Enhance Market/Investor Discipline. Like in every other Country in Pakistan also the State Bank of Pakistan issued a Road Map or Guidelines for Implementation of Basel-II in Pakistan and the deadline issued by State bank for the completion was December 2006. PROBLEM STATEMENT Capital Regulation, Supervision and Market Discipline are the foundation of Basel-II, and to improve the Risk Management Procedures for bringing stability in the financial System, the Banks and Financial Institutions were required to establish an adequate setup and report to SBP the name and other Particulars of the Person responsible for Implementation before 31st May 2005 We will study the impact of Basel II on the credit risk management by considering two parameters i.e. NPLR and CAR. By studying these ratios, we find out that how Basel II is useful in management and reduction of risk and finally determine the role of credit risk management in increasing the profits of banks. RESEARCH QUESTION As per the background discussed earlier, out task is to research: The impact of credit risk management on the profitability of commercial banks in Pakistan. PURPOSE Our research will find out the importance credit risk management in the profitability of commercial banks in Pakistan and how Basel II helps in reduction of credit risk and management by using some techniques and methods that will control the amount of non-performing loans. The purpose of the research is to explain the impact of credit risk management on profitability of commercial banks in Pakistan, that what is the role of BASEL-II in the management and reduction of credit risk by controlling the amount of non performing loans through methods, Processes and limits imposed in BASEL II. JUSTIFICATION Our research will explain the influence of credit risk management on the profitability of commercial banks. This research will be very helpful for the banking industry in Pakistan as it is directly related to the profitability of banks. It will provide them with the guidelines that how they could manage and minimize the credit as per the rules and regulations provided in Basel document. SCOPE Our research is significant and important in a way that it will determine the dependency of profitability on credit risk management and it will study Basel I and Basel II and determine their difference and whether the regulations in Basel II puts any betterment in managing the risk. LIMITATIONS OF THE STUDY We are conducting our research on the private commercial banks of Pakistan based on the conventional banking system. It will help us on concentrating and focusing only on one sector of banking industry and determine valid and authentic results. Public sector banks, Islamic banks, investment banks, micro-finance banks are included in the research. Basel II was put into account from December 2006 that is why we have included the data from financial statements of 2007 to 2009 as we have studying the relation between profitability and credit risk management after Basel II is implemented. The study is limited to two independent variables for measuring credit risk management that are NPLR and CAR, and one dependent variable for measuring profitability which is ROE, the reason for choosing the above mentioned variables will be discussed in the methodology. LITERATURE REVIEW ROE PROFITABILITY INDICATOR ROE (Return on Equity) refers to the ratio of Net Income to the Total equity capital. ROE indicates that how much the bank has earned with the investors capital. It measures that how well and efficiently a company uses its investors funds to generate profit. It is used as a comparative too between two companies or banks. Its the ratio of net income and share holders equity. But in the Case of Bank ROE can be increased if the Capital decreases, but as the Capital decreases, the bank is exposed to risk of insolvency, and thats the reason that regulators continuously monitor the minimum capital requirements for Banks. ROA(Return on Assets) indicates that how efficiently the management uses its assets to generate income. Its the ratio of net income and total assets. Both ROA and ROE are expressed in percentage. CREDIT RISK MANAGEMENT INDICATORS According to a research of Risk management practices followed by commercial banks in Pakistan. It was identified that the major risk faced by banks in Pakistan as well as internationally is the Credit Risk. Because the core banking business is all about creation of Credit, through which commercial banks generate their Profits. When it comes to Credit Risk, the most important aspect are the financing decisions followed by the commercial banks, because ultimately it ends into Credit risk. The State bank has also introduced some tough regulations when financing individual as well as SMEs and Corporate Customers, such as obtaining the BBFS(Borrowers basic fact sheet) and other restrictions as mentioned in the Prudential Regulations. Now what indicates that Credit Risk is increasing for the Banks is the NPLR(Non Performing Loans Ratio) which indicates that the financing generated by the banks are not recovering and as such the Non performing Loans are increasing which ultimately leads to Credit Risk. (Nasr, 2009) CAPITAL TO ASSETS RATIO It measures the Ratio of a Banks Book value of core Capital to the Assets book value. The Lower this Ratio, the more highly leveraged the bank is. Primary or core Capital Banks common Equity (book value) and perpetual preferred stock plus minority interests in consolidated subsidiaries (Cornett). RISK IN BANKS As Banks perform different financial services to their Clients they face many types of risk. There are number of assets in a banks Portfolio which are subject to different types of risks, such as default or Credit Risk. As Banks expand their services, they are exposed to foreign exchange risk. When the Assets and Liabilities in the Balance Sheet of Banks mismatch, they are further exposed to a risk known as Interest Rate Risk. If financial institutions actively trade these assets they are further exposed to Market Risk or asset price risk. Increasingly FIs hold contingent assets and liabilities off the balance sheet which represents off balance sheet risk, Moreover some all Financial Institution and Banks are exposed to some degree of Liability or withdrawal which exposes them to Liquidity risk. Finally the Risk that the Bank may not have enough Capital reserves to offset a sudden loss incurred as a result of one or more of the risks they face creates insolvency risk for the Banks. ( HOUSTON, 2008) CREDIT RISK MANAGEMENT Capital Adequacy Ratio (CAR) is used by Regulators of Banking System to assess the Banks financial Position especially the Capital to Assets Ratio as it does not falls below the required level so the bank is stable enough against the losses. State Bank of Pakistan the Regulator of Commercial Banks in Pakistan Monitor the Capital Adequacy Ratio of Commercial Banks to Provide Protection to the Depositors. A minimum Capital Ratio affects the leverage of Commercial Bank since highly leverage commercial Banks are more towards the chance of Credit and Interest rate risk and ultimately falling into Bankruptcy There are major 2 types of Capital for Banks. Tier-I Capital is closely linked to banks book value of equity, reflecting the contribution of a banks owners. Tier two is a broad array of secondary capital resources, which includes the loan reserves upto 1.25 % of risk adjusted assets plus various debt instruments. BENEFITS OF CAPITAL ADEQUACY RATIO In the initial Phase capital adequacy ratio does not take into account different risk Profiles of different class of Money market instruments, since some assets are highly risky and some debt instruments are almost risk free, such as Government bonds, where as the some instruments such as loans granted to Individual by a commercial bank can result in a default which accounts for Risk. So the advantage of Capital adequacy is as it takes into account risk profiles of all investment. (Schweser, 2008) BANKING REGULATIONS IN PAKISTAN The banks in Pakistan works under the BANKING COMPANIES ORDINANCE, 1962 (L VII OF 1962) and THE BANKING COMPANIES RULES 1963 made under the ordinance. (As amended up to 30th June, 2007) (State Bank of Pakistan, 2007)) METHODOLOGY RESEARCH APPROACH While doing the research, we are focusing on our research task and not to go beyond our specified boundary. Thus, were using deductive approach. We are also referring previous researches and theories related to our field of interest because we are studying a general phenomena i.e. relationship between profitability and credit risk management in conventional banking system of Pakistan. We are using quantitative method of study. We analyze the data with the help of regression model and the annual reports of the selected banks. The regression output makes us answer our research question. RESEARCH RESIGN We are conducting the research based on two factors i.e. profitability of banks and credit risk management thats why the design of research is co-relational. Our research will explain the relationship between the two and how credit risk management affects the profitability of banks in Pakistan. RESEARCH STRATEGY We are identifying the impact of credit risk management on profitability and For it, we have adopted the strategy of taking help from the previous records, studies and researches in this field and the statistics and data required for performing the test is obtained from the annual reports of the respective banks available on their websites. SAMPLING The population for the research consists of 20 private commercial banks out of the 54 banks operating in Pakistan. All the 20 chosen banks are working under conventional banking system as we are only focusing on conventional banks and all other banks such as Islamic banks, investment banks, micro-finance banks and public sector banks are not included in our research. The reason for this is to appropriately focus on one sector. On the basis of random sampling, 15 commercial banks are selected: Habib bank Ltd, MCB Bank ltd, Allied Bank Ltd, United Bank Ltd, Standard Chartered, Bank Alfalah, Faysal Bank Ltd, Bank Al-Habib, NIB Bank ltd, My Bank, RBS, Atlas bank, Arif habib Bank, Habib Metropoliton bank, JS Bank and Askari Bank ltd. In this research we are establishing the relation between profitability and credit risk management after implementation of BASEL II in Dec2006, therefore data is obtained from annual reports of 2007 to 2009. There are total 30 observations for each of the var iable used in this research. DATA COLLECTION Data and statistics for the tests are obtained from annual reports of 2007 to 2009. Well consider credit risk management disclosure, financial statements and notes to financial statements within the annual reports of the sample banks. RESEARCH INSTRUMENTS No research instrument is required in our research because the data used to conduct tests is secondary obtained from the annual reports of the banks from 2007 to 2009. DATA ANALYSIS Multiple regression analysis is used in our research i.e. the relationship of one dependent variable to multiple independent variables. The regression outputs are obtained by using SPSS APPLIED REGRESSION MODEL Dependent variable ROE and independent variables NPLR and CAR are considered in our study and all of them are numeric type. Therefore, multiple linear regression model is applied. DEPENDENT VARIABLE In many of the previous researches, ROE is used for the profitability of banks, Therefore, we have also used it as the indicator of profitability in the regression analysis.. According to Foong Kee K. (2008) indicated that the efficiency of banks can be measured by using the ROE which illustrates to what extent banks use reinvested income to generate future profits. INDEPENDENT VARIABLE NPLR and CAR are the indicators of credit risk management and they chosen as the independent variables because credit risk management affects the profitability of banks. NPLR, in particular, indicates how banks manage their credit risk because it defines the proportion of NPL amount in relation to TL amount. NPL amount is provided in the Notes to financial statements under Loans section. And the total loan amount is provided in the balance sheet of the banks in their annual reports. TL amount, the denominator of the ratio, has been gathered by adding two types of loans: loans to institutions and loans to the public. Thus, calculation of the NPLR has been accomplished in following way: NPLR = (NPL amount) Ã · (TL amount) CAR, CAR is regulatory capital requirement (Tier 1 + Tier 2) as the percentage of Risk weighted asset. The bank has to maintain a specific percentage of CAR to manage their Credit risk according to requirement of State bank of Pakistan. The minimum requirement for Banks on consolidated as well as standalone basis has been increased to 10%. RELIABILITY AND VALIDITY While doing the research two concepts must be taken into account i.e. reliability and validity. Reliability refers that the data is consistent and whatever be the conditions, it would be remain same. But its not necessary that every reliable and consistent data is valid. If we have any systematic error in the instrument then every time it would be encountered in the measurement, thus the observations would be reliable but not valid. In our research, we have taken the data from the annual reports of banks available at their websites. These are the official reports made by the rigorous efforts by the management of banks and authenticated by the higher management; therefore the facts and figures in it would be valid as well as reliable and will help us in getting true results. CONCLUSION The aim of the study is to determine the impact of credit risk management on profitability. It is important to note that sample size represents 75% of the total population i.e. private commercial banks. That covers the major portion of the population, giving more accurate results. The results obtained from the regression model show that there is an affect of credit risk management on profitability on reasonable level with 41.8% possibility of NPLR and CAR in predicting the variance in ROE. So, the credit risk management strategy defines profitability level to an important extent. Especially, NPL amount appears to be adding the most weight to that than CAR. CAR is having negative impact on ROE, but on the other hand the significance value of CAR is 0.171which is greater than the p-value i.e. 0.05, which means that the value of coefficient for CAR is zero, making the affect of CAR on ROE nil. Only NPLR is significantly affecting the value of ROE. In the end it is to be recommended that bank should focus on maintaining and controlling amount of non performing loans to ultimately getting higher ROE, which ensures the better profitability.

The Laurel Falls Jump :: Personal Narrative Swimming Papers

The Laurel Falls Jump The water looked at least a mile away. How could I be up this high? It had only taken me minutes to hike up to this ledge. Maybe my weariness from the hike and swim had confused me, and I had not realized how long it took me to get here, or had the cliff actually gotten taller since the last time I was here? Whatever the reason, I knew this was higher than I wanted to be. How high was I really? Thirty feet, forty, one hundred feet even? What would Elaina think? Laurel Falls are beautiful waterfalls near Hampton, Tennessee about a thirty-minute drive from Johnson City. One of the best characteristics about Laurel Falls is that they are accessible and easy to find. This makes them a great place to take your friends, family, or girlfriend. Driving through Hampton, one can find a couple of different routes to take to the falls entrance. The first route is in close proximity with the town of Hampton. It is about a seven-mile hike one-way and has some treacherous trail to hike. The second route is much shorter. It is only about a mile and a half long and is a very manageable hike. The second route takes longer to get to because you have to drive farther into the mountains to reach the trailhead. Both routes connect with the Appalachian Trail. â€Å"From Johnson City, go northeast to Elizabethton. From Elizabethton, take RT 321 southeast to Hampton. In Hampton, follow signs to ‘Dennis Cove Recreation Area’. T his takes you onto Dennis Cove Rd. Go east on Dennis Cove Rd., winding up the mountain about 4-5 miles until it crosses the Appalachian Trail (AT), where there is a parking area on the left and an information sign. If you get to the Dennis Cove Campground, you have gone too far† (MikenMel). I had been to Laurel Falls many times before, and I thought that I knew a lot about them. Well I was in for a big surprise.

Internal And External Economies Of Scale :: Economics

Internal And External Economies Of Scale When a company reduces costs and increases production, internal economies of scale have been achieved. External economies of scale occur outside of a firm, within an industry. Thus, when an industry's scope of operations expand due to for example the creation of a better transportation network, resulting in a subsequent decrease in cost for a company working within that industry, external economies of scale are said to have been achieved. With external ES, all firms within the industry will benefit. Economies Of Scale In addition to specialization and the division of labor, within any company there are various inputs that may result in the production of a good and/or service: * Lower input costs: when a company buys inputs in bulk, say for example potatoes used to make French fries at a fast food chain; it can take advantage of volume discounts. (In turn, the farmer from which sold the potatoes could also be achieving ES if the farm has lowered its average input costs through, for example, buying fertilizer in bulk at a volume discount). * Costly inputs: some inputs, such as research and development, advertising, managerial expertise and skilled labor are expensive, but because of the possibility of increased efficiency with such inputs, can lead to a decrease in the average cost of production and selling. If a company is able to spread the cost of such inputs over an increase in its production units, ES can be realized. Thus, if the fast food chain chooses to spend more money on technology to eventually increase efficiency by lowering the average cost of hamburger assembly, it would also have to increase the number of hamburgers it produces a year in order to cover the increased technology expenditure. * Specialized inputs: as the scale of production of a company increases, a company can employ the use of specialized labor and machinery resulting in greater efficiency. This is because workers would be better qualified for a specific job, for example someone who only makes French fries, and would no longer be spending extra time learning to do work not within their specialization (making hamburgers or taking a customer's order). Machinery, such as a dedicated French fry maker, would also have a longer life as it would not have to be over and/or improperly used. * Techniques and Organizational inputs: with a larger scale of production, a company may also apply better organizational skills to its resources, such as a clear-cut chain of command, while improving its techniques for production and distribution. Thus, behind the counter employees at the fast food chain may be organized according to those taking in-house orders and those Internal And External Economies Of Scale :: Economics Internal And External Economies Of Scale When a company reduces costs and increases production, internal economies of scale have been achieved. External economies of scale occur outside of a firm, within an industry. Thus, when an industry's scope of operations expand due to for example the creation of a better transportation network, resulting in a subsequent decrease in cost for a company working within that industry, external economies of scale are said to have been achieved. With external ES, all firms within the industry will benefit. Economies Of Scale In addition to specialization and the division of labor, within any company there are various inputs that may result in the production of a good and/or service: * Lower input costs: when a company buys inputs in bulk, say for example potatoes used to make French fries at a fast food chain; it can take advantage of volume discounts. (In turn, the farmer from which sold the potatoes could also be achieving ES if the farm has lowered its average input costs through, for example, buying fertilizer in bulk at a volume discount). * Costly inputs: some inputs, such as research and development, advertising, managerial expertise and skilled labor are expensive, but because of the possibility of increased efficiency with such inputs, can lead to a decrease in the average cost of production and selling. If a company is able to spread the cost of such inputs over an increase in its production units, ES can be realized. Thus, if the fast food chain chooses to spend more money on technology to eventually increase efficiency by lowering the average cost of hamburger assembly, it would also have to increase the number of hamburgers it produces a year in order to cover the increased technology expenditure. * Specialized inputs: as the scale of production of a company increases, a company can employ the use of specialized labor and machinery resulting in greater efficiency. This is because workers would be better qualified for a specific job, for example someone who only makes French fries, and would no longer be spending extra time learning to do work not within their specialization (making hamburgers or taking a customer's order). Machinery, such as a dedicated French fry maker, would also have a longer life as it would not have to be over and/or improperly used. * Techniques and Organizational inputs: with a larger scale of production, a company may also apply better organizational skills to its resources, such as a clear-cut chain of command, while improving its techniques for production and distribution. Thus, behind the counter employees at the fast food chain may be organized according to those taking in-house orders and those