What is, or are, HoNOS?
They are 12 simple scales on which service users with severe mental
illness are rated by clinical staff. The idea is that these ratings
are stored, and then repeated- say after a course of treatment or
some other intervention- and then compared. If the ratings show a
difference, then that might mean that the service user's health or
social status has changed. They are therefore designed for repeated
use, as their name implies, as clinical outcomes measures.
What does HoNOS stand for?
Health of the Nation Outcome Scales
What do the scales cover?
A wide range of health and social domains- psychiatric symptoms,
physical health, functioning, relationships and housing:
- Overactive, aggressive, disruptive or agitated behaviour
- Non-accidental self-injury
- Problem drinking or drug-taking
- Cognitive problems
- Physical illness or disability problems
- Problems associated with hallucinations and delusions
- Problems with depressed mood
- Other mental and behavioural problems
- Problems with relationships
- Problems with activities of daily living
- Problems with living conditions
- Problems with occupation and activities
How are they scored?
All scales follow the format:
0 = no problem
1 = minor problem requiring no action
2 = mild problem but definitely present
3 = moderately severe problem
4 = severe to very severe problem
Each scale is rated in order from 1 to 12. Do not include
information rated in an earlier item except for item 10 which is an
overall rating. The rating is made on the basis of all information
available to the rater (whatever the source) and is based on the
most severe problem that occurred during the period rated (usually
the two weeks leading up to the point of rating).
The HoNOS system is not a standardised clinical assessment and
cannot be a substitute for one.
When are HoNOS ratings made?
The minimum required is that a rating is made at the start of each
episode of care and at the end. Most services using HoNOS also
require ratings at any regular review (like the English Care
Programme Approach review), when there is a major change in the
patient's status (for instance, an admission to or discharge from
hospital) and, for long episodes of care, at every 6 months or so.
Are there different systems for different service-user
There are several versions
HoNOS for working age adults
HoNOS65+ for older people
HoNOSCA for children and adolescents
HoNOS-Secure for use in health and social care settings secure
psychiatric, prison health care and related forensic services,
including those based in the community)
HoNOS-LD for learning disabilities
HoNOS-ABI for acquired brain injury
How long does it take to complete HoNOS ratings?
The ratings are made when all the information (e.g. from an
assessment, informant view, GP, notes, investigations) is
available. Once staff are trained in the use of the scales, the
actual 12 ratings take, on average, an extra 4 minutes or so. If a
multidisciplinary group of staff make a collective rating it can
How easy is it to train in HoNOS use?
Clinical staff will require one day training initially, and a
half-day re-training every 2 years to maximise inter-rater
reliability. Multi-team, multidisciplinary training is of great
value in stimulating discussion, and is recommended.
Who can make HoNOS ratings?
Any qualified mental health care professional working with people
with severe mental illness who has undergone official HoNOS
training. Unqualified staff can be provided with training that
gives them an understanding of the scales that will enable them to
contribute to multidisciplinary team discussions about HoNOS
What is done with the scores?
They are stored in the notes, and should be used to support care
planning. For instance, if, after assessment, the non-accidental
self injury scale (Scale 2) is scored at more than 1, it may be
necessary to justify omission of any plan to reduce suicidal risk.
In some services, charts of HoNOS scale scores are made for
individual service users, on which details of intervention and
other events are added, so that the scores form part of the story
of how things are going. This can sometimes surprise or puzzle
staff or lead to further assessment and intervention- for instance,
if a scale score remains obdurately high. These charts will become
routine once an electronic patient record becomes fully
In some services, scores can be entered into an information
system, aggregated and the results used to help staff look at
changes in their whole caseload in relation to the sorts of
service-users they are dealing with and the interventions they use.
The same is true for teams, or whole services.
Adding up the scores of all 12 scales may not be particularly
informative, as they are so wide in their coverage. Marked
improvements in one domain may be cancelled out by deterioration in
another, and it looks as if nothing has changed.
What part do the service-users' views play in this process? Is
it user-centred? And what about carers and other stakeholders?
HoNOS ratings are made by staff, and reflect the staff's view of
the situation, although in many ratings, service-users' views are
taken into account. Service users, carers, referrers, commissioners
and others may have quite different reasons for being interested in
outcomes, quite different desired outcomes, and quite different
approaches to how to measure outcomes. The HoNOS system is not
designed to cover all aspects of outcomes; merely those that relate
to staff views.
Are there any obvious gaps in the scales?
Yes. For instance, in HoNOS and HoNOS65+ elation must be rated
under the "other" scale (8). There is no place to rate spiritual or
existential difficulties. But the HoNOS system was designed with
severe mental illness in mind and to be brief. It cannot be all
things to all situations.
What's to stop staff deliberately rating higher initially, and
then lower, to show a spurious improvement?
Nothing but their honesty. However, most services implementing
HoNOS ratings will also implement quality control systems
including, for instance, independent assessments and ratings of a
sample of service users to check the degree with which this
tendency is occurring. The results of these "validation" checks can
then be incorporated into the aggregate analysis.
Surely staff will disagree so often that it will all depend on
who does the rating rather than the service-user's real level of
HoNOS was designed to maximise inter-rater reliability and there
are published data about this.
However, like all such ratings, HoNOS ratings are subjective and
prone to some disagreement. Like the validation quality checks
mentioned above, services using the HoNOS system can arrange to
check this by, for example, getting all staff to rate the same
video of a service user.
What is the HoNOS system not designed for?
- it does not predict risk; it is a measure of the preceding
- it is not a standard interview or assessment
- it does not produce a medical diagnostic label
- it is not designed for use in primary care
- it is not designed specifically for use in clinical trials; it
is to be used by clinicians who know the service-user well.
On their own, HoNOS ratings- even repeated- say little about
whether an outcome is related to the care provided. Outcomes
assessment includes also the intervention used, and the context of
the situation- for instance, the diagnosis, or other events which
might have a bearing on change. HoNOS is thus necessary, but not
sufficient, for routine clinical outcomes assessment.
What is the difference between HoNOS and HoNOS65+?
The scales are identical, and scored in the same way, so are
directly comparable. The HoNOS65+ glossary
detailed than that for HoNOS, and is particularly aimed at common
situations in old age psychiatry.
Can scores be used against staff?
Every tool for building can be used for destruction. But the HoNOS
system, including careful analysis of context and intervention, can
strengthen the case for better resources for people with severe
mental illness and the staff who deal with them.
Isn't HoNOS just another piece of paper?
Nearly all bureaucracy is introduced with the aim of improving
patient care, and the HoNOS system is no exception. But the
difference with HoNOS is that if clinicians are not seeing the
results fed back to them, and seeing the results relevant to their
service-users and their interventions, then it is not working and
the service systems that support HoNOS use should be reviewed and
What will my service gain from using the HoNOS system?
Clinicians can build up a picture over time of their service-users'
patterns of response to interventions and events that might not be
easy to achieve without measurement. If ratings are incorporated
into care plans then objectives can be quantified. Managers can
examine differences between outcomes between different teams and
interventions on similar service-user groups. Commissioners can
move from a purely activity/structure approach to a more rational
purchasing model involving health gain. Routine outcomes
measurement involves more than HoNOS or other repeated measures,
and development of systems for coding interventions and context
move services into a reflective and evidence-based culture that has
many other tangible and less tangible benefits. This process
"tests" crucial clinical governance systems (e.g. training,
information and supervision systems).