Imagine a routine primary care appointment. A patient with long-standing schizophrenia comes in to renew a prescription. Their mental health is discussed, medication reviewed, and perhaps blood pressure is checked. But are cholesterol, blood glucose, weight, alcohol use and smoking status assessed also – or do some of these slip through the cracks?
People living with severe mental illness (SMI) face a stark reality: they are 1.5 to 2.5 times more likely to develop cardiovascular disease (CVD) and more likely to die from it than the general population (Correll CU et al, 2017). High rates of CVD risk factors, such as smoking, obesity and diabetes, combined with the cardiometabolic side effects of antipsychotic medication and social disadvantage, all contribute to this excess risk (see Masuma’s Mental Elf blog, Reducing cardiovascular risk in people with severe mental illness).
In the UK, efforts to tackle these inequalities began in 2004 with the introduction of the Quality and Outcomes Framework (QOF), which financially incentivised physical health monitoring for people with SMI. From 2011, specific CVD risk factors—such as cholesterol, glucose and BMI—were incentivised, although not consistently. From 2014 onwards, incentive schemes began to diverge across the UK, with Scotland and Wales later abolishing QOF altogether.
Previous studies suggest that incentives can increase the recording of individual risk factors (Osborn DPJ et al, 2011; Wilson CL et al, 2017). What remains unclear is whether they have resulted in regular, comprehensive screening over time, and which patients are most likely to miss out.
This large UK study addresses that gap, examining nearly two decades of primary care data to explore long-term screening patterns and the patient characteristics associated with incomplete, or absent, CVD risk factor checks (Launders et al, 2025).
People living with severe mental illness (SMI) face a stark reality: they are 1.5 to 2.5 times more likely to develop cardiovascular disease.
Methods
Researchers used data from Clinical Practice Research Datalink (CPRD), a large UK primary care electronic health records database, to identify adults (aged ≥ 18) diagnosed with SMI (schizophrenia, bipolar disorder or other non-organic psychosis).
They examined records from 1 April 2000 to 31 March 2018 to assess how often six key CVD risk factors — blood pressure, cholesterol, glucose, body-mass index (BMI), alcohol consumption and smoking status — were screened each year. The team also examined individual-level screening patterns (e.g. never receiving screening, always complete screening) and explored which patient characteristics (such as age, sex or diagnosis) were associated with differences in screening. Follow-up started at the latest of 1 April 2000, primary care registration, or SMI diagnosis, and ended at the earliest of death, leaving the practice, age 100, or last CPRD data collection.
Results
Cohort characteristics
The study included 216,136 adults with SMI. Most were resident in England (86.5%), with smaller numbers in Scotland (6.5%), Wales (5.5%), and Northern Ireland (1.6%). Patients were followed for a median of 4.85 years (IQR: 2.43 to 9.72).
Population-level screening trends
Across the study period, screening rates for smoking and blood pressure increased steadily. In contrast, alcohol use, BMI, cholesterol and glucose screenings rose sharply around 2011–2012, coinciding with the introduction of financial incentives for individual CVD risk-factor monitoring. For BMI, cholesterol and glucose, screening dropped quickly after 2013–2014, aligning with the withdrawal of these incentives.
These overall patterns were broadly similar across most demographic groups. However, the jump in cholesterol and glucose screening after 2011 was mainly seen in people aged 40 years or older, the group targeted by incentivisation at that time. This suggests that financial incentives have little impact on those outside of the incentivisation criteria, such as those under 40. Between 2000 and 2014, screening increased across all four UK nations, but trends became less consistent from 2014 to 2018, reflecting diverging national policies.
Individual-level screening patterns and associated factors
Nearly all patients (93.9%) were screened for at least one CVD risk factor during the study. However, only 54.8% were screened for all six risk factors at least once during follow-up, and just 34.8% received all six checks within a one-month period. This suggests that comprehensive screening was not commonly included as part of a routine physical health check.
Before financial incentives for CVD screening were introduced (2004–2011), only 1.7% of patients received a complete set of screenings (all six CVD risk factors) every year. This number increased to 14.8% during the incentivisation period (2011–2014), but dropped back to 8.3% after the incentives were removed (2014–2018).
Factors influencing the likelihood of receiving no screening:
- During the 2014–2018 period, men, younger patients, individuals with other or missing ethnicity data (compared to White ethnicity), and those who had been formally excluded from incentivised screening because they were deemed unsuitable, declined consent, or did not respond) were more likely to receive no screening instead of irregular screening.
- Additionally, patients not prescribed antipsychotics or mood stabilisers, those diagnosed with other psychoses (compared to bipolar disorder), and those not on QOF registers incentivising screening for conditions such as atrial fibrillation, coronary heart disease, hypertension, peripheral artery disease, stroke, or diabetes also had a higher likelihood of missing screening.
- National differences were observed: patients living in Scotland or Wales were more likely to receive screening in the 2011-2014 period compared to those in England, but more likely to miss screening in the 2014-2018 period when both regions reduced incentives differently.
Young men who were not of White ethnicity were less likely to receive screening for cardiovascular risk disease than other patients with severe mental illness.
Conclusions
This study highlights a worrying gap in physical healthcare for people with SMI. While most patients received some cardiovascular risk screening, regular and comprehensive checks were uncommon, suggesting that routine physical health reviews are not being delivered consistently in primary care.
Financial incentives appeared to improve screening temporarily, but their effects were uneven and short-lived.
To genuinely reduce cardiovascular risk, screening needs to be embedded within broader, routine physical health checks, rather than driven by isolated incentives.
Importantly, targeted strategies are needed for groups most likely to miss screening. Without more integrated and equitable approaches, longstanding cardiovascular health inequalities for people with SMI are likely to persist.
While most patients received some cardiovascular risk screening, regular and comprehensive checks were uncommon, suggesting that routine physical health reviews are not being delivered consistently in primary care.
Strengths and limitations
This study has several notable strengths. Its very large sample size and use of routinely collected data from the CPRD allow for detailed analyses across a wide range of patient characteristics. This makes it possible to identify subgroups of people with SMI who are particularly likely to miss CVD risk factor screening. The CPRD is broadly representative of UK primary care, lending credibility to the findings within this healthcare context. A further strength is the authors’ decision to examine screening not only at a population level, but also longitudinally at the individual level, which provides a more meaningful picture of whether screening is regular and comprehensive over time.
However, several limitations warrant consideration. As with all studies based on electronic health records, the analysis relies on recorded data, which may not fully reflect what happens in clinical practice. Some screenings may have taken place but were not coded, leading to potential misclassification. From a clinical and service perspective, however, missing documentation still represents a gap in coordinated care and limits continuity of treatment. The requirement for at least one year of follow-up may also introduce selection bias, as more transient or disengaged patients—who may be at higher risk of missing screening—are less likely to be included. This could mean that the true extent of under-screening is underestimated.
Importantly, the study focuses on whether screening occurred, not on what followed. It does not assess whether screening led to effective interventions, such as smoking cessation support, blood pressure control, or statin use, nor whether it improved long-term cardiovascular outcomes. While the study convincingly shows associations between incentivisation and screening patterns, causal inference is limited. Changes in screening may also reflect broader shifts in clinical practice, staffing pressures, or parallel policy changes. Finally, while the findings are highly relevant to the UK context, differences in health system organisation and incentive structures may limit their applicability elsewhere.
This study focusses on whether screening occurred; not on what followed. It is not clear whether screening for cardiovascular disease led to effective interventions for people with SMI.
Implications for practice
This study should prompt reflection among clinicians, service planners and policymakers about how physical health care for people with SMI is actually delivered in practice. The findings suggest that, although CVD risk factor screening is common, it is often fragmented and opportunistic, rather than part of a coordinated, comprehensive physical health review.
For frontline clinicians, an important takeaway is that high screening prevalence does not necessarily mean good care. Blood pressure or smoking status may be recorded during routine contacts, but far fewer patients receive all recommended checks together. Without a structured review, it becomes difficult to connect screening results, assess overall cardiovascular risk, or take coordinated follow-up actions, such as offering lifestyle support, reviewing medications, or making referrals. Clinicians should therefore be cautious about relying on single indicators and instead ask whether patients are receiving complete and meaningful physical health assessments.
At a service and policy level, the study raises questions about the role of financial incentivisation. Incentives appear to increase screening activity (Khadjesari Z et al, 2017) but their effects are uneven and short-lived, and they may unintentionally prioritise certain groups while leaving others behind. Policymakers may need to reconsider whether current schemes reward the regularity and completeness of screening, rather than simply the presence of individual measurements. Incentives that support integrated annual physical health reviews may be more effective than those targeting isolated risk factors.
The findings also support a stronger role for mental health services in delivering or coordinating physical health checks. Many people with SMI have limited or irregular contact with primary care, and relying solely on GP-based screening risks widening inequalities. Integrating basic physical health monitoring and referral pathways within mental health services could help reach those who are currently missed. However, this approach will only work if there is clear communication and shared responsibility between primary care and mental health teams, to avoid duplication and ensure that results lead to action.
Ultimately, improving cardiovascular health for people with SMI will require shifting from opportunistic checks to integrated, person-centred physical health care; where screening is not an end in itself, but the starting point for meaningful intervention.
Screening for physical health problems in people with severe mental illness should not be an end in itself, but the starting point for meaningful intervention.
Statement of interests
Blogger Jingyi Wang – None.
Edited by
Laura Hemming.
Links
Primary paper
Naomi Launders, Caroline Jackson, Joseph Hayes, Ann John, Robert Stewart, Matthew Iveson, Elvira Bramon, Bruce Guthrie, Stewart Mercer, David Osborn. (2025) Prevalence and patient characteristics associated with cardiovascular disease risk factor screening in UK primary care for people with severe mental illness: an electronic healthcare record study. BMJ Mental Health 2025; 28:1–8.
Other references
Correll CU, Solmi M, Veronese N, et al. Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls. World Psychiatry 2017; 16:163–80. https://pmc.ncbi.nlm.nih.gov/articles/PMC5428179/
Khadjesari Z, Hardoon SL, Petersen I, et al. Impact of Financial Incentives on Alcohol Consumption Recording in Primary Health Care Among Adults with Schizophrenia and Other Psychoses: A Cross-Sectional and Retrospective Cohort Study. Alcohol and Alcoholism 2017; 52:197–205. https://pubmed.ncbi.nlm.nih.gov/28182195/
Mishu MP. Reducing cardiovascular risk in people with severe mental illness. The Mental Elf, 21 Oct 2020.
Osborn DPJ, Baio G, Walters K, et al. 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 2011; 129:104–10. https://pubmed.ncbi.nlm.nih.gov/21550783/
Wilson CL, Rhodes KM, Payne RA. Financial incentives improve recognition but not treatment of cardiovascular risk factors in severe mental illness. PLoS ONE 2017; 12:e0179392. https://pubmed.ncbi.nlm.nih.gov/28598998/
