More than 20 years ago, early intervention services were developed and implemented throughout the UK; they provided a novel conceptualisation of psychosis and promised better outcomes. Rightly, there are movements towards extending services to those at risk of psychosis. Reference Shah, Jones, van Os and McGorry1 However, this revolution in care has not reached those at the other end of the chronological spectrum of psychosis, namely those with chronic and protracted illness. For instance, many people with chronic schizophrenia in the UK remain largely unseen by the services meant to support them. Although effective medications, psychosocial interventions and clear management guidelines exist for ‘treatment-resistant’ illness, challenges remain. Yet, despite this knowledge and the availability of treatments, long-term care – the necessary ingredient for effectively managing chronic disorders in medicine – remains fragmented and reactive. This editorial proposes a pragmatic redesign as part of the wave of forthcoming changes in managing clozapine and chronic schizophrenia, using the regulatory changes to expand – not shrink – the care provided.
Blood-monitoring procedures are finally being modernised, in line with a recent international Delphi consensus recommending contemporary absolute neutrophil count (ANC) thresholds and risk-based monitoring, including discontinuing routine ANC testing beyond 2 years in stable patients. Reference Siskind, Northwood, Pillinger, Chan, Correll and Cotes2 In the USA, the Food and Drug Administration has removed the clozapine REMS programme; ANC monitoring remains in labelling, but prescribers and pharmacies no longer need REMS enrolment or ANC reporting to obtain supply. The European Medicines Agency has issued a Direct Healthcare Professional Communication announcing updates to product information: ANC-based rules and a reduction in monitoring frequency after the early high-risk period.
It is a matter of time before the UK will adopt similar approaches. My concern is that people on clozapine without active psychosis would be discharged to primary care. Whereas in principle this appears to be a laudable goal, the risk for those diagnosed with schizophrenia is ultimately that of greater exclusion and less access to newer and potentially more effective interventions. They will be added to the care gap we choose not to see, specifically, those two-thirds or more of people with serious mental illness who are not in contact with secondary care. Reference Reilly, Planner, Hann, Reeves, Nazareth and Lester3
It is my view that these forthcoming changes should trigger service expansion and reconceptualisation for patients with chronic schizophrenia, similar to those experienced when early intervention was implemented, and that they should not result in a contraction of the care that is provided. For example, capacity released by fewer administrative steps and routine bloods should be redeployed into case-finding, timely initiation of clozapine, Reference Howes, Vergunst, Gee, McGuire, Kapur and Taylor4 wider assessment and treatment of non-psychotic symptoms and better management of physical health. There are four steps that could be implemented immediately.
Reducing barriers to clozapine
Clozapine remains the most effective option for treatment-resistant schizophrenia, with growing evidence that earlier prescription leads to greater benefits. However, clozapine underuse and wide regional variation persist in the UK; roughly only one-third of those eligible for clozapine actually receive it. Reference Whiskey, Barnard, Oloyede, Dzahini, Taylor and Shergill5 Clozapine’s economics are favourable when services initiate it appropriately and then retain patients. Real-world mirror cohort work has shown clinical improvement and lower costs after community initiation, with reduced admissions and bed-day use compared with the period before clozapine commencement. Reference Butler, Pillinger, Brown, Borgan, Bowen and Beck6 Underuse of clozapine is a false economy; it shifts costs on to crisis services and beds. Wider implementation of clozapine community initiation services, Reference Beck, McCutcheon, Bloomfield, Gaughran, Reis Marques and MacCabe7 with a particular focus on supporting early intervention teams, would be a sound reinvestment of the expertise from clozapine clinic teams.
Cognitive and negative symptom assessment
Standardised tools for rating symptom severity are rarely used in routine psychiatric practice and are mostly confined to specialist services, Reference Varvari, Mancini, Zauchenberger, McGuire and McCutcheon8 a gap that is most evident for negative and cognitive symptoms despite their marked impact on long-term functioning. Without structured assessment, these domains are often underestimated, leading to inconsistent recognition of needs, variable access to support and incomplete treatment plans. This creates difficulties when patients must demonstrate functional impairment for government financial support (‘benefits’), as lengthy forms focus on physical disability and capture poorly the cognitive slowing, planning difficulties and amotivation common in schizophrenia. It is increasingly hard to justify discharging patients to primary care without a standardised evaluation of these symptoms, given their relevance to daily life. Wider adoption of brief tools such as the Brief Negative Symptom Scale and Montreal Cognitive Assessment would improve documentation, support fairer access to assistance and strengthen care planning.
Access to psychological therapies
Psychological therapies for people with chronic schizophrenia remain limited, with services still mostly focused on relapse prevention and positive symptoms. This overlooks interventions with evidence of improvement in symptoms linked to long-term disability. Cognitive remediation can strengthen attention, memory and executive functions, with downstream gains in daily living and employment. Structured behavioural approaches and non-pharmacological interventions for negative symptoms show meaningful benefits but are rarely offered in routine care. Trauma-focused therapies remain similarly underprovided, despite high rates of trauma exposure, both pre- and post-onset of psychosis. The capacity released by the reduction in clozapine monitoring could be reinvested to ensure these treatments are available within community mental health teams (CMHTs), broadening routine care and addressing unmet needs.
Improving screening and treatment of physical health
Physical health remains the most persistent and preventable source of excess mortality in people with psychotic disorders. Reference Fernandez-Egea, Flanagan, Taylor, Gaughran, Lawrie and Jenkins9 However, systematic assessment and follow-up remain inconsistent across services. Although primary care has responsibility for routine cardiometabolic screening, models that rely solely on general practitioners have repeatedly shown their limits for those with chronic schizophrenia, who often struggle to navigate fragmented pathways, attend multiple appointments or advocate for appropriate investigations. Co-located physical health teams within mental health services can close this gap by providing structured, repeated screening; identification of cardiovascular risk factors; and initiation or coordination of evidence-based treatment. They can also offer specific support for lifestyle change and medication optimisation, areas in which people with schizophrenia experience major inequities.
Is this feasible? A secondary-extended clinic in practice
We have a long tradition of academic-led clinics providing cutting-edge assessment and treatment for people with chronic psychosis, but the real test is whether this level of care can be replicated across routine services in the National Health Service. There are some experiences that suggest it can be done. In Cambridgeshire, a small sub-team within the CMHT has operated a specialised clozapine clinic for 15 years; this is built around a dedicated staff group and a long-term, continuous-care approach and supports initiation while providing sustained follow-up for stable patients who are often overlooked in generic clinics. Its remit extends beyond psychosis, with structured attention to cognitive and negative symptoms and systematic management of physical health, which has also enabled substantial research activity.
Concentrating clozapine expertise improves initiation and retention, reduces crisis-driven care and strengthens professional confidence, while offering guidance to colleagues across the wider team and continuity of care to patients. Standardised processes limit unwarranted variation, and clearly defined cohorts with shared measures make research and commercial trials feasible in routine practice. This model, which is valued by patients for its continuity and holistic focus, could be implemented across CMHTs with modest restructuring. A similar model using the potential resources resulting from the probable changes in regulations could help to improve the care of people with chronic schizophrenia.
The current system leaves many people with chronic schizophrenia without sustained specialist care, timely clozapine, or adequate monitoring of physical, cognitive and negative symptoms. Regulatory changes now offer a chance to reverse this. Embedding secondary-plus clinics within CMHTs would refocus capacity on these core tasks, reduce crisis-driven care and restore continuity. The Cambridge experience shows that this model is feasible and valued. The priority now is broader adoption, in which the new scenario leads to expansion not retreat.
Funding
E.F.-E. is supported by the 2022 Medical Research Council/National Institute for Health and Care Research (NIHR) Clinical Academic Research Partnerships award (MR/W029987/1), and all research at the Department of Psychiatry in the University of Cambridge is supported by the NIHR Cambridge Biomedical Research Centre (NIHR203312) and the NIHR Applied Research Collaboration East of England. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Declaration of interest
E.F.-E. has received consultancy honoraria from Boehringer Ingelheim (2022), Atheneum (2022) and Rovi (2022–2025), speaker fees from Adamed (2022–2025), Otsuka (2023) and Viatris (2024) and training and editorial honoraria from the Spanish Society of Psychiatry and Mental Health (2023–2025). E.F.-E. is deputy editor of the British Journal of Psychiatry but did not participate in the review process or decision-making for this paper.
eLetters
No eLetters have been published for this article.