HoNOSty: does HoNOS provide a good enough measure of outcome?

Sugarman et al highlight an important aspect of mental healthcare in their paper which analyses the use of Health of the Nation Outcome Scales (HoNOS) in assessing change among psychiatric patients. ¹ Although they demonstrate that it is possible to measure outcomes using a suitable instrument, their data also reveal the limited utility of such a ‘blunt instrument’ and they provide an honest account of its shortcomings, recommending that it should not be used alone. Indeed, the tiny degrees of change indicated in their results have little meaning for real-life clinical practice.

Historically, measuring clinical outcomes in psychiatry was discarded as anathema ² despite the availability of a variety of simple, quick and meaningful scales in many major conditions: the Beck Depression Inventory and the Hamilton scales for depression and anxiety being examples. It is essential that clinicians engage with the use of outcome measures, especially in light of the drive towards the use of outcomes in commissioning services, payment by results and the public availability of information about health providers that is now being published online.

A further demand, shaped by the Next Stage Review ³ and various National Institute for Health and Clinical Excellence guidelines, is for measures to underpin the shared care of patients between primary and secondary care services. The concept of remission is of use here and has been well established in connection with depression ⁴ but with few other mental disorders. Recent work on schizophrenia has provided a well-argued case for remission criteria to support shared care of patients with this disorder. The instrument, derived from the Positive and Negative Syndrome Scale, takes 10 minutes to administer and provides a simple, meaningful result for clinicians, patients and carers. Remission criteria have the additional advantage over HoNOS of being specific to the challenges experienced by patients with these disorders, both as an objective snapshot of the state of an individual's illness and as a marker of their long-term stability. ⁵

The use of dynamic markers such as remission scores to measure progress is actively encouraged in the World Health Organization's Mental Health Gap Action Programme. ⁶ If new models of healthcare are to be evaluated properly and the engagement of stakeholders facilitated, validated assessment of patient change will need to be performed to ensure both continued success and continued funding.