Physical care of people with severe mental illness is an important clinical issue, as the potential health benefits of cardiovascular disease prevention for the general population are astonishing. Each year, cardiovascular disease kills about 20 million people, including 10 million prematurely (before the age of 65 years) and inflicts high morbidity, disability and socioeconomic costs. ^{Reference Fuster and Kelly1} This problem is more pronounced in schizophrenia, with standardised mortality rates (SMRs) of 2.7 for diabetes and 2.3 for cardiovascular disease. ^{Reference Osby, Correia, Brandt, Ekbom and SpareAn2}

Cardiovascular mortality increased in schizophrenia from 1976 to 1995, with the greatest increase in SMR in men from 1991 to 1996. ^{Reference Osby, Corriera, Brandt, Ekbom and SpareAn3}

In the current climate of austerity in the National Health Service and internationally, it is interesting to know that in high-income countries, preventing or postponing 100 cases has been reported as saving about US$1 million (£0.6 million, €0.7 million). ^{Reference Mozaffarian and Capewell4}

A few important issues have been highlighted by De Hert et al. ^{Reference De Hert, Vancampfort, Correll, Mercken, Peuskens and Sweers5} First, involvement of patients and carers in screening and monitoring of patients’ physical health is a vital part of patients’ and carers’ education and empowerment, which will be reflected positively in management and outcome. Second, their study raised the legitimate question of who should screen and monitor physical health: the psychiatrist or the general practitioner (GP). The care programme approach of 2008 indicates that mental health professionals should consider service users’ needs holistically and aim to improve their quality of life and their health. Assessments and care plans should identify and tackle the impact that mental illness symptoms and possible treatment programmes can have on physical health and the impact that physical symptoms can have on an individual's mental well-being. ⁶ I think the way forward is a proper collaboration through the local shared care protocol as the process should be initiated by psychiatrists and results should be communicated to GPs who would plan management through proper referral to different specialties.

De Hert et al rightly state that all previous evidence indicates that guidelines have an impact on real-life screening and that monitoring rates are minimal to poor.

The national Prescribing Observatory for Mental Health (POMH) ⁷ has included screening for metabolic syndrome in community patients receiving antipsychotics as a topic for its quality improvement programme. The POMH group conducted a retrospective case-note audit of patient's prescribed antipsychotic medication with a standard of yearly monitoring of blood pressure, measure of obesity, glucose and lipids. Results showed that between 0 and 41% (0 and 48% at re-audit a year later) of trusts were monitoring for all four aspects on an annual basis. Our study is consistent with these figures, with 40% conducting physical examinations and liver function tests (further details available from the author on request).

Scrutinising guidelines is a very important issue but what is more important, as De Hert et al's article indicated, are clear, comprehensive, inclusive and up-to-date local policies and procedures to implement physical health check-ups, with an initial assessment of risk factors and identification of people with metabolic problems with a view to referring them to a metabolic clinic for management, and to continue to monitor patients who are on atypical antipsychotics regularly, at least annually. It has been reported that establishing a metabolic clinic and managing patients at risk has improved physical check-ups and referral to GPs for abnormal results by 25% in the re-audit. ^{Reference Gumber, Abbas and Minajagi8} All efforts should be directed towards patient and carer involvement, education and promotion of healthy living.