Reviews of the association between psychotic disorder, the metabolic syndrome, diabetes, and antipsychotic drugs conclude that there is a need for active, routine physical health screening of patients' prescribed antipsychotic drugs. From published guidelines, we derived the audit standard that all such patients should, as a minimum, have their blood pressure, body mass index (BMI) (or other measure of obesity such as waist circumference), blood glucose (or HbA 1c ), and plasma lipids measured at least once a year. We conducted an audit of the clinical records of 1966 eligible patients under the care of 48 multidisciplinary, assertive outreach clinical teams in 21 mental health services across the United Kingdom. This revealed a recorded measurement within the previous year for blood pressure in 26% of the patients, obesity in 17%, blood glucose (or HbA 1c ) in 28% and plasma lipids in 22%, with all 4 measures documented in 11%. In the total national sample, 6% had a documented diagnosis of diabetes, 6% hypertension, and 6% dyslipidemia. Extrapolating from the prevalence of these disorders in similar populations suggests that for every patient with a known diagnosis of diabetes, another had not been recognized, for every known case of hypertension, 4 had been missed, and for every known case of dyslipidemia, 7 had been missed. The responses of the clinical teams to a questionnaire yielded information on obstacles to screening in routine practice, revealing uncertainty about whose responsibility this was, a lack of confidence about the interpretation of abnormal screening results, and limited access to basic equipment.

The quality improvement programme did not have a demonstrable impact on prescribing practice in the majority of services. Future efforts to align practice with clinical guidelines need to specifically target the culture and practice of p.r.n. prescribing.

General practitioners with special interests (GPSIs) have emerged in the UK as a government initiative aimed at improving access in specialities that traditionally have long waiting times for investigations and treatment. This represents, to some extent, a formalisation of existing working practices of general practitioners who had obtained specialist experience during hospital training. GPSIs are working in a wide range of clinical areas including coronary heart disease, drug abuse, echocardiography and sexual health. Similar changes at the primary-secondary care interface are taking place in other European health systems. Key issues in the development of these services include the assurance of high-quality health care, clinical governance and risk management, cost-effectiveness and impact on outpatient care, and the work and role of specialists. It is possible that these new opportunities for general practitioners and other health care professions will aid recruitment and retention of staff in primary care, enhance education and encourage commissioners of services to look carefully at unmet needs in their health economies. Further challenges include the need to train a cadre of practitioners and to provide the research evidence on which to base continued investment in this promising initiative.