B R I T I S H J O U R N A L O F P S Y C H I A T R Y ( 1 9 9 9 ) . 174.
3 8 9 - 3 9 4
Validation of the Health of the Nation
Outcome Scales
PAUL BEBBINGTON, TERRY BRUGHA. TREVOR HILL, LUCY MARSDEN
and SUZANNE W I N D O W
Background The Health ofthe In the Health of the Nation Strategy
of ti^^ outcome scales( ~ ~ ~were 0 s ) (Department of Health, 1991) the United
Kingdom government identified national
developed to assess the outcome of severe
targets for improving mental health in
mental disorders in relation to the Health England. In an attempt to quantify improve-
ofthe Nation Strategy for England. ment, the Royal College of Psychiatrists'
Research Unit was commissioned to develop
Aims TOvalidate the HoNOS. the Health of the Nation Outcome Scales
(HoNOS) (Wing et al, 1996, 1998). These
Method One hundred and fifteen
form a simple, brief and clinically acceptable
patients were assessed by keyworkers instrument comprising 12 five-point scales
using HoNOS, and by research workers (0-4);eight items are clinical, four social.
using SCAN, SBS, and SRPS, and A guide for raters includes a glossary of item
definitions. Since the initial development of
completing HoNOS in the light ofthis
HoNOS, the UK government and the Health
additional material.These assessments of the Nation targets have changed. Never-
were repeated after 6 weeks. theless, the introduction of effective routine
assessment in the secondary mental health
Results The performance of HoNOS services is likely to remain a priority.
in the hands of keyworkers was generally The scales passed through extensive
poor, in relation both to the research piloting and field trials organised by the
workers' rating of HoNOS and to the Royal College Research Unit, culminating
in the fourth (final) version for assessing
criterion instruments.Performancewas
outcome in severe mental illness. Reliability
particularly poor when the change in was very good for items, sub-scores and
scores was used as a measure of outcome. total score. Initial validation relied on com-
paring HoNOS scores with clinical judge-
Conclusions There are serious ments of improvement and with two other
problems in using HoNOS as a routine instruments, the Global Assessment of
measure ofclinical status in busy Functioning (GAF) and the Brief Psychiatric
Rating Scale (BPRS) (Wing et al, 1998).
psychiatric services. Its performance
On the basis of this work, the Planning
is probably related to the training and and Priorities Guidance for 199718 encour-
experience of keyworkers. Sequential aged health authorities to establish a basis
ratings are not a good method for for the introduction of HoNOS (NHS
assessingoutcome. Managers and planners Executive, 1996). However, this may be
premature: the piloting exercise was limited
should be cautious in adopting HoNOS,
because the validating instruments were
but it is worthy ofconsideration in themselves not sufficiently comprehensive,
developing a suite of locally agreed and some of the items in HoNOS were in
outcome measures. any case derived from them.
The basic question remains unanswered:
Declaration of interest This study can HoNOS be used by busy psychiatric
was entirely funded by the Department of keyworkers to assess clinical status and
progress in a useful and meaningful way?
Health.
In our view this requires comparison of
HoNOS with established, 'gold standard',
clinical instruments based on detailed and
laboriously gathered information. The cur-
rent paper describes an extensive validation
of HoNOS in an ordinary clinical setting,
and summarises a more detailed technical
report to the Department of Health (avail-
able from the first author upon request).
METHOD
Two sites were involved in the study. The
London site was the psychiatric in-patient
wing serving the Islington catchment area,
an innercity area north of the Thames. In
Leicestershire, patients came from two
hospital wards and the corresponding four
community teams covering urban and rural
parts of the county.
Following initial assessment, a cohort
of patients in the two separate services
was followed up after a six-week interval.
The assessment at each time point included
the completion by keyworkers of HoNOS,
which were filled in after routine clinical
information had been gathered. This was
followed by the evaluation of patients by
research workers, using detailed and stand-
ardised clinical instruments. HoNOS were
also completed by the research workers,
using the more detailed information they
had obtained in the course of their research
assessments. Thus the researchers' HoNOS
were intended to reflect the actuality of the
patient's state and situation rather better
than those completed by the keyworkers.
This design permitted the assessment of
HoNOS as completed in an ordinary
clinical context, and including the effects
of change with time.
The patients chosen had a range of
conditions: psychosis; severe affective disor-
der; depression; secondary cognitive impair-
ment; or incapacitating neurotic disorders.
All were either newly admitted to an acute
psychiatric ward or recently engaged by a
community psychiatric team; there were 57
patients in London and 58 in Leicestershire.
In addition to the 12 constituent items,
rated on a scale of 0-4, HoNOS provide
summed subscores relating to Behaviour,
Impairment, Symptoms and Social function-
ing, and a total score. The instrument takes
approximately two or three minutes to fill
in.
The comparison instruments between
them covered psychiatric symptoms, social
behaviour, and role performance. Schedules
for Clinical Assessment in Neuropsychiatry
(SCAN), Version 1.0 (Wing et al, 1990;
World Health Organization, 1992a) is a
detailed semi-structured, standardised inter-
view that allows a description of neurotic
and psychotic symptoms, and classifica-
tion according to ICD-10 (World Health
Organization, 19926). Ratings of symptoms
are guided by a detailed glossary, and the
research interviewers underwent a week-
long training course. The Social Behaviour
Schedule (SBS) (Wykes & Sturt, 1986;
Wykes & Hurry, 1991) has been extensively
evaluated for its reliability and validity.
The SBS was developed specifically for use
with patients suffering from severe psychi-
atric disorder. It records relatively severe
disruptions of social behaviour. Interrater
reliability is good, and inter-informant and
test-retest reliability are also reasonable
(Wykes & Sturt, 1986). The information
needed to complete this assessment was
obtained from the patients' keyworkers.
Less severe disorders can also be asso-
ciated with significant disability that might
be recorded in HoNOS. For this reason the
SBS was supplemented with the Social Role
Performance Schedule (SRPS) (Hurry &
Sturt, 1981).This semi-structured interview
has good reliability and there is evidence of
its construct validity (Hurry et al, 1983,
1987). It was completed in collaboration
with the patients. An adapted version of
the Leicester Housing Schedule (LHS)
(Wheatley, 1998) was used to provide addi-
tional information required for comparing
with HoNOS ratings.
Validation is complicated by the fact
that the HoNOS items are not precisely
equivalent to those in the reference instru-
ments, and there are variations in the defi-
nition of individual levels of the items in
the different instruments. Imperfect agree-
ment between HoNOS and the reference
instruments might thus be the result of
imperfect content overlap rather than of
the poor practical performance of HoNOS.
We thus developed complex algorithms
linking HoNOS items to those from our
chosen reference instruments whose con-
tent was clearly related. We refer to the
computed items equivalent to the HoNOS
items as item equivalents. Algorithms are
available from the first author.
Research personnel and training
In London, two full-time research assistants
were employed, one a trainee psychiatrist
and one a psychologist with considerable
research experience. In Leicester, three re-
search staff were employed: one full-time
project manager, one part-time research
assistant, and one pan-time research inter-
viewer. A trainee psychiatrist worked closely
with the Leicester team. The research work-
ers were trained in the use of the HoNOS by
the Royal College of Psychiatrists' Research
Unit. The clinical staff were subsequently
trained by the local researchers to use
HoNOS. Because of service demands, the
training of keyworkers in London was less
intensive.
Procedure
Two sets of HoNOS were completed, one by
the patient's keyworker and one by a re-
searcher. The keyworkers were encouraged
to use all information available to them. A
research worker then met the keyworker, to
administer the SBS and the LHS, and the
patient, to carry out the SCAN and SRPS.
Researchers completed their own HoNOS
after the assessment interviews. Patients were
followed up after approximately six weeks.
If they were still in-patients, the nurse key-
worker again provided the HoNOS. For pa-
tients who had been discharged, the relevant
community keyworker filled out the HoNOS.
Analysis
We had two basic sources of comparison
for the keyworkers' HoNOS scores. The
first was the HoNOS completed by the
research workers. Comparisons could be
made at the level of total score, sub-score
and individual items.
Our second set of comparisons was the
criterion instruments. We used the item
equivalents from these to derive total and
sub-scores equivalent to those from the
HoNOS. We made comparisons of these
and at the item level. The criterion
instruments could also be used directly to
generate their own overall scores and sub-
scores, and these could also be related to
the HoNOS scores and sub-scores. Thus,
SCAN gives an overall symptom score,
and also sub-scores relating to neurotic
items, depression, mania and psychotic
items that can be related to the HoNOS
Symptoms sub-score. The SBS can be used
to generate an overall score for social
behaviour, but its items can also be divided
into groups to provide summary scores that
can be related to HoNOS sub-scores for
Behaviour, Symptoms and Social function-
ing. The SRPS items all relate to the
HoNOS sub-score of Social functioning.
These various scores from the criterion
instruments were related to the HoNOS
total score and sub-scores.
Agreement was calculated at induction
and at follow-up, for each site separately.
However, we also evaluated the degree of
change in HoNOS between induction and
follow-up as a measure of its clinical utility,
since scales purporting to measure outcome
should be capable of registering change over
a six-week period. Finally, we examined our
results for systematic bias in keyworkers' rat-
ings in relation to those of the research work-
ers and to the HoNOS equivalent items.
RESULTS
Even in our severely ill group of patients,
most HoNOS items were endorsed only at
the 'minor' or 'mild' levels. The mean scores
had improved by the time of follow-up,
although this was not by a huge margin. This
is because the initial mean scores were not
high and overall room for improvement was
restricted (details available from the firm
author upon request).
The HoNOS sub-scores and total scores
obtained by keyworkers and research work-
ers were compared, as shown in Table 1. In
general, the correlations were adequate.
Those for follow-up scores, and in particu-
lar for HoNOS total score, were, in general,
more acceptable and satisfactory.
In Table 2 we compare HoNOS sum-
mary scores obtained from keyworkers and
research workers with those derived from
the item equivalents based on criterion instru-
ments. The correlations of the research work-
ers' HoNOS scores with the computed scores
were generally very good and, in almost all
cases, better than those of keyworkers. The
performance of the Impairment sub-scale
seems to have been the worst, although in
the initial interview the performance of the
Symptoms sub-scale was not good either.
In Table 3 we summarise the agreements
between keyworkers and research workers
on individual HoNOS items, and the agree-
ments of each set of workers with the item
equivalents computed from the reference in-
struments. The levels of agreement indicated
by kappa (Cohen, 1960) are traditionally
divided into <0.20 (poor); 0.21-0.40 (fair);
0.41-0.60 (moderate); 0.61-0.80 (good);
20.81 (very good). The agreement between
keyworker and research worker was gener-
ally low. When the keyworkers' and research
workers' HoNOS item ratings were com-
pared with the equivalents calculated from
the criterion instruments, the performance
of the research workers was once again
rather better, both initially and at follow-up.
 V A L I D A T I O N OF H o N O S

In order to assess overall item perfor- and Social functioning subscores in We tested for systematic bias in key-
mance, we examined all 196 measures of HoNOS. Many of these correlations were workers' and research workers' ratings by
agreement relating to individual items substantial and significant, but there were comparing mean HoNOS total scores and
between keyworkers and research workers still appreciable inconsistencies: several sub-scores as generated by the keyworkers
and between keyworkers and item equiva- analyses showed virtually no correlation and researchers. Although the additional
lents (details available from the first author (Bebbington et al, 1998). information available to the research
upon request). No item had a mean kappa
value above the 'fair' level. Eight items
can be regarded as having 'fair' agreement
(items 1-3, 5, 6, and 9-1 1). The remainder
fell into the 'poor' range. There are particu-
lar problems with item 8, which is a catch- Sub-score Initial data Follow-up data
all, with several different possible symptoms
London
included. However, items 4 (Cogrutive pro-
A (Behavioural problems)
blems), 7 (Problems with depressed mood),
B (Impairment)
and 12 (Problems with occupational activ-
ities) also performed badly. Item 8 covers a C (Symptoms)
number of additional symptom areas, in- D (Social functioning)
cluding anxiety, eating disorders, sleep dis- Total score
orders, sexual problems, and a section for Leicester
rating problems not specifically covered. A (Behavioural problems)
There were very few positive endorsements
B (Impairment)
of eating, sexual and 'other' problems.
The agreement about whether these pro- c (Sym-1
blems should be rated was very variable, D (Social functioning)
but in view of their rarity, it is difficult to Total score
make any definitive statements. Examples Total
of anxiety and sleep disorders did occur fre- A (Behavioural problems) 0.59 0.58
quently enough for an overall view of the b (Impairment) 0.52 0.39
performance of item 8 in relation to these
C (Symptoms) 0.22* 0.56
sub-items. The item performed badly,
D (Social functioning) 0.59 0.58
although it was marginally better for
Total score 0.43 0.70
anxiety than for sleep disturbance.
In Table 4 we examine the relationship All ye rignifkant at the I% kvel, except (dgnifkamat the 5% kvd), and "(where Pd.064).
between the total scores provided by each
of the criterion instruments, and the Tkbh 2 Key* a d research worked ratings. Correlations of HoNOS sub-scores and total scores
HoNOS scores and subscores. The most with the equivalents derived by computation from the aitwkn i n r u u m
consistent correlations were, as predicted,
between the Social functioning sub-score HoNOS scores
of HoNOS and the SBS and SRPS total
scores. The correlations of the other Behavioural Impairment Symptoms Social Total score
HoNOS subscores were mvial and non- (A) (B) (C) functioning (D)
significant, except in the London follow-
up data. There were few correlations lnttial data
between the SCAN total score and the London
HoNOS sub-scores and total score. Ke).worker
The implication is that the best perform- ReKvchworker
ing part of the HoNOS is the Social func- Leicester
tioning sub-score. The performance of the
Keyworker
other sub-scores against the 'gold standard'
Research worker
instruments is inconsistent and generally
poor. The HoNOS total score correlates Follow-up data
best with measures of social behaviour and London
performance. HoNOS appears inadequate Keyworker 0.36- 0.20 0.36- 0.W 0.45-
as a measure of symptoms in these analyses. Research worker 0.76- 0.41- 0.67- 0.7P 0.7F
As described above, we used the items

-
Leicester
of the SBS to generate subscores which Keyworker 0.6 1 * 0.42- 0.61- 0.67- 0.71-
were approximately equivalent to the s u b
Research worker 0.7W 0.45- 0.7F 0.6F 0.9 1
scores in HoNOS. We were able to do this
for the Behavioural problems, Symptoms
D E B D I N G T O N E T AL

workers enabled them to rate items more We chose the criterion instruments ment and that of the instrument being
accurately, there was no overall tendency because they were detailed, standardised tested. One cannot, therefore, expect a vali-
to rate items either higher or lower than and clinically based. They all have good dation exercise to be underwritten by
the keyworkers did. The lack of bias in psychometric properties. However, no perfect agreement. Our intention was that
these independently collected ratings is re- criterion instrument is perfect, and there the chosen criterion instruments should,
markably clear (details available from the will always be some divergence between between them, be equivalent to the concep-
first author upon request). the conceptual basis of a criterion instru- tual domain of HoNOS. Thus, the Social
If HoNOS are truly to reflect outcome,
the changes in scores between induction Table 3 Summary of measurn of a g r e m t on HoNOS h s
and follow-up should correlate with the
score changes calculated from the reference
Kappa value London Leicester
instruments. The reference instruments
provided two scores for such comparison: Initial Follow-up Initial Follow-up
the computed equivalent scores and the
scores and subscores obtained directly from Keyworkersand research workers
the reference instruments. In fact, using
0-0-20 (F) 5 6 0
change scores is an extremely stringent test 0.21-0.40 (fair) 6 2 6
of validity because it compounds the error
0.40-0.60 (moderate) 0 3 6
component of both initial and follow-up
0.604.80 (good) 0 0 0
scores. For this reason we present data relat-
ing only to correlations between HoNOS Keyworkers'rcores and the computed criterion instrument equivalents compared
scores and the computed equivalents, as 04.20 (POW) 5 8 7
the content overlap is thus maximised. 0.21-0.40 (fair) 6 2 4
In Table 5, we show the results of these 0.41-0.60 (moderate) I 2 I
correlations for the HoNOS rated by the 0.61-0.80 (good) 0 0 0
keyworkers and by the researchers. The per-
formance of HoNOS in the hands of the Researchworkers'scores and the computed criterion instrument equivaknts compared
keyworkers was particularly poor in Lon- 0-0.20 (poor) 5 3 7
don and only a little better in Leicestershire. 0.21-0.40 (fair) 4 4 I
The performance of the research workers, 0.41-0.60 (moderate) 3 3 4
as assessed in this way, was once more 0.61-0.80 (good) 0 I 0
noticeably superior to that of the keyworkers.

Table 4 ComhtionofkryworkcrHdJOSsub-rcore,adtodru~uwithtoul~oreronvitcrkn
DISCUSSION
instruments
Limitations of the study
The intention of HoNOS is that they should Criterion instruments HoNOS scores
be acceptable, feasible, reliable and valid
when used by ordinary clinical staff in Behavioural Impairment Symptoms Social A, B+D Total
or* clinical practice. This basically problems (A) (B) (C) functioning (D) score
requires them to perform in imperfect
conditions, something of a tall order. The London (initial data)
validation of an instrument like this is SBS -0.08 0.08 0.06 0.42" 0.26 0.23
particularly stringent as it implies that the SRPS -0.11 0.17 0.18 0.3F 0.23 0.24
error in ratings is small, despite the imperfect SCAN -0.17 -0.09 -0.02 0.00 -0.12 -0.12
circumstances in which they are made. In the Leiaster (initial data)
ordinary clinical situation, the information SBS 0.21 0.09 0.08 0.47. 0.500 0.44"
available to a keyworker is likely to be in- SRPS 0.04 0.11 -0.02 0.44" 0.40. 0.3V
complete, sometimes very much so. These
SCAN 0.26 -0.05 0.06 -0.17 0.00 -0.0 1
are the circumstances in which keyworkers
in our study completed their ratings. Thus, London (follow-up data)
we were testing the keyworkers' ability to SBS 0.51" 0.29 0.54" 0.25 0.49ff 0.51"
approximate to the 'real' picture, given the SRK 0.35- 0.26 0.490 0.45" 0.480 0.490
imperfect state of their knowledge. It could SCAN 0.08 0.03 0.54- 0.32* 0.36" 0.42"
be said that our study was a d y one of Leicester (follow-up data)
the performance of the keyworkers making SBS 0.24 0.22 0.20 0.31 0.45" 0.44-
the rating, but because the instrument is SRPS 0.17 0.13 0.29 0.5F 0.47- 0.470
supposed to be capable of accommodating
SCAN 0.08 0.20 0.32* 0.04 0.1 1 0.28
the limitations of raters in clinical situations,
it was properly a test of the instrument itself. *P <0.0% "P <0.01.

W e 5 Spearman correlation of xae changes with computed equivalents
Behavioural problems Impairments Symptoms Social functioning T d
Keyworker
London
Leicester
Research worker
London 0.46- 0.1 1 0.32; 0.63- 0.52-
Leicester 0.54- 0.36- 0.64** 0.13 0.41-
Role Performance Schedule has items which although we do feel that our item equiva-
relate purely to the four items in the Social lents correspond quite closely to the
functioning section of HoNOS. The SBS HoNOS items. In our view, they are closer
covers the Behavioural problems, Symptoms to being a validation criterion than the
and Social functioning sections of HoNOS. research workers' direct HoNOS ratings.
SCAN, on the other hand, relates primarily HoNOS is a simple instrument, intended
to the Symptoms items (6-8). However, it to be quick and easy to use by busy clini-
does also share content with the Behaviour- cians. Nevertheless, its use does require
a1 problems covered by HoNOS items 1-3. some training, however limited. The train-
Because of this imperfect overlap between ing of research workers and keyworkers in
the instruments, one would not expect the current study was constrained by the
more than good agreement between total busy services in which the study took place.
scores on any one of the reference instru- The training of keyworkers was more rigor-
ments and on HoNOS. The validation exer- ous in Leicester than in London, where the
cise can be amplified however by resorting service was particularly busy and it was
to analyses based on sub-scores. difficult to arrange for keyworkers to put
The rationale for using HoNOS ratings aside the necessary time. Because of
by the research workers as a test of validity changes in keyworkers, the initial and
is that the research workers had access to follow-up interviews were not always done
the criterion instrument ratings before by the same person. Moreover, the key-
making their HoNOS ratings.' In practice, workers were not equivalent at the two
this meant they had a wider knowledge sampling times. Primary nurses on the ward
base against which to rate the HoNOS. are not the same as community-based
The discrepancy between keyworkers' and keyworkers (in seniority, knowledge of
research workers' HoNOS ratings could patients, etc.). This may account in some
be due to the keyworkers' relative clinical part for the poor results we obtained.
inexperience, or to the keyworkers having The results from the research workers
less information available to them. In either indicate how HoNOS might perform when
case, the research workers' ratings are likely used by experienced clinicians with detailed
to be more valid than the keyworkers'. As information, and when initial and follow-up
we thus assign unequal status to the ratings assessment are made by the same person.
involved in the comparison, it is more a test Thus, the circumstances of our validation
of validity than of reliability. study are particularly informative about
Because of the incomplete overlap the limitations of HoNOS and the pro-
between criterion instruments and HoNOS, cedural aspects of its use.
we constructed item equivalents based on
the individual items in the three reference
The performance of Ho NOS
instruments that corresponded most closely
to the HoNOS glossary definitions. The general Pattern of our results suggests
aim of doing this was to get as close as poss- that HoNOS does not provide a good
ible to the conceptual domain of HoNOs. assessment of symptoms, and performs best
ne resulting algorithms were complex, as a measure of social functioning. Even this
may be an artefact, insofar as the SBS is
completed from interviews with informants,
I. In fact, this was not always the case in Leicester as the in case the This tends to
taskofcompleting criterion measures was often divided maximisf2 similarities, and may mean that
up among different research staff. there are inadequacies in the SBS ratings,
VALIDATION O F H o N O S
corresponding to the inaccuracies in the
keyworkers' HoNOS ratings. SCAN, on
the other hand, is based on direct evalu-
ation of patients' symptoms.
There are three types of output from
HoNOS: total score, sub-scores and ratings
on individual items. For the originators,
this represents a gradient of utility, with
the total score being the most useful (Wing
et al, 1996). In the hands of our key-
workers, the performance of the instrument
also followed this gradient, being just about
acceptable for total score, and very poor for
individual items. The items for which
agreement was particularly poor were 4
(Cognitive problems), 7 (Problems with
depressed mood), 8 (Other mental and
behavioural problems), and 12 (Problems
with occupation and activities). It is of
interest that keyworkers (who were mostly
nurses, although some were social workers)
had particular difficulties with two of the
three items relating to Symptoms.
These difficulties with individual
HoNOS items almost certainly relate to
the fact that most can be rated in relation
to several different circumstances and
phenomena. This is a necessary process of
conflation, to render the instrument suc-
cinct enough to be practicable in busy
clinical situations, but the downside is that
accuracy of rating is lost.
The use of HoNOS as an outcome
measure depends on repeated applications
to generate change scores. The HoNOS
change scores obtained from the keyworkers
performed poorly in relation to the com-
puted equivalents, whereas the performance
of the research workers was considerably
better. W e n the patient is discharged
between ratings, the keyworker's role in
ordinary clinical services will often be trans-
ferred to someone else. In consequence, the
necessary information for making the
ratings will reside with different raters,
who may apply different rating thresholds,
unless unusual steps are taken to ensure
rating by the same person. In the current
study, although follow-up keyworker
ratings were often made by different
people, the follow-up research worker
ratings were always made by the person
conducting the initial assessment. This
contrast is reflected in the relative perfor-
mance of HoNOS as an outcome measure
in the hands of the keyworkers and of the
research workers.
Our results are in considerable contrast
to the reliability studies between raters in
the HoNOS Research in Development
B E B B I N G T O N E T AL

Report ( W i g et al, 1996, 1998). In these

studies, both raters had access to virtually
identical information, given that they were
together at the time when the information
was presented. It is not surprising, under
these cimmstances, that the correlations o b ThmakdveuBedHoN(36b~-knplkPtkns~rr5Pd#l
tained were high on virtually all items, sub- to-
scores and total scores (Wing et al, 1996).
Our findings indicate both the limita-
tions of HoNOS and how its usefulness
mght be improved. The first issue is that of
training. One of the most illustrative results
was the failure of keyworkers to rate de-
pressed mood accurately. In our experience
of training clinicians, we found that de-
pressed mood is not easy to rate and
requires considerable attention from the trai-
ner. Historically, evaluation of symptoms
and the formulation of diagnoses have been
very much the province of psychiatrists,
-- -
although this expemse is now more wide-
PAUL BEBBINGTON. PhD, LUCY MARSDEN, MSc, University College London Medical School. Department of
spread. Nevertheless, it is possible that the Psychiatry and Behavioural Sciences;TERRY BRUGHA. MD, TREVOR HILL. BSc. SUZANNE WINDOW: BSc,
poor performance on these items may reflect University of Leicester Section of Social and EpidemiologicalPsychiatry, Leicester General Hospital, UK
a general lack of training in this area among
these professional groups. Clinical experi- Correspondence: Professor Paul Bebbington. Royal Free and University College Medical School,
ence and knowledge is no substitute for Department of Psychiatryand Behavioural Sciences, Archway Campus.Whittington Hospital, Highgate
Hill. London N19 5NF
specific training but may be an important - -

precondition for adequate rating of HoNOS. (First received 6 April 1998. final revision 24 August 1998. accepted 2 December 1998)
In fact, the widespread introduction of
HoNOS would serve more than one pur-
pose. The original intention was to measure
outcome in relation to Health of the Nation that would complement the recently fostered NHS (1996) Planningand Priwities ~~
targets for mental illness. Our results suggest
culnw of care msunderlines the C NHs, 199718. L e k Department of Health.

serious problems in using the instrument in
this way. Completion by individual keywor-
kers is likely to lead to serious imprecision,
and one way of dealing with this is to make
the ratings in multidisciplinary care plan-
ning reviews, so that the maximum infor-
mation and expertise can be brought to
bear. Even so, it is not clear over what period
outcome should be measured, and whether
the inevitable acute episodes characteristic
of many patients with severe mental illness
should be excluded from overall consider-
ation. Attempting to use the outcome of
patients as a measure of the pedormance
of individual keyworkers (as has apparently
been suggested) is likely to lead to biased
ratings for obvious reasons. It might be
feasible to use the scales to establish
comparative case loads in different service
locations, but only in broad-brush tenns,
as the training needed to establish true com-
parability would be extensive and expensive.
Nevertheless, we do not think the instru-
need to improve the training of keyworkers
in making clinical such training
should be general, in =lation to the appraisal
of mental and social status, and also specific,
in relation to using HoNOS.
Finally, consideration should be given to
whether further investment should be made
in improving the savcture of the instrument.
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P Bebbington, T Brugha, T Hill, L Marsden and S Window
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