BackgroundPatients with severe mental illness (SMI) die 10-20 years earlier than the general population. They have a higher risk of cardiovascular disease (CVD) yet may experience lower cardioprotective medication prescribing.AimTo understand the challenges experienced by GPs in prescribing cardioprotective medication to patients with SMI.Design and settingA qualitative study with 15 GPs from 11 practices in two Scottish Health Boards, including practices servicing highly-deprived areas (Deep End).MethodSemi-structured 1:1 interviews with fully-qualified GPs with clinical experience of patients with SMI. Interviews were transcribed verbatim and analysed thematically.ResultsParticipants aimed to routinely prescribe cardioprotective medication to relevant patients with SMI but were hampered by various challenges. These included: lack of funding for chronic disease management, insufficient consultation time, workforce shortages, IT infrastructure and navigating boundaries with mental health services. Patient-related challenges included: patients’ complex health and social needs, their understandable prioritisation of mental health needs/existing physical conditions and presentation during crises. Participants emphasised continuity of care as fundamental in engaging this patient group in effective cardiovascular health management. A cross-cutting theme was the currentGP workforce crisis leading to ‘firefighting’ and diminishing capacity for primary prevention. This was particularly acute in Deep End practices, which have a high proportion of patients with complex needs and greater resource challenges.ConclusionAlthough participants aspire to prescribe cardioprotective medication to patients with SMI, professional, system and patient-level barriers often make this challenging, particularly in deprived areas due to patient complexity and the inverse care law.