Since the publication of the Health of the Nation Outcome Scales (HoNOS) in 1996, they have demonstrated adequate reliability, validity, clinical utility and sensitivity to change. England, Australia, and New Zealand, have also mandated the HoNOS for routine monitoring and outcome measurement across their mental health services at a national level.
Whilst recognising this basic soundness, two decades of training, use and analysis, together with advances in psychiatry and mental health services, resulted in a recognition that updates to the glossary are required to improve use of the HoNOS. The Royal College of Psychiatrists (RCPsych) elected to undertake a limited review (rather than a full redevelopment and revalidation) that aimed to use expert opinion to improve the utility of the HoNOS: remaining true to its original aims and maintaining comparability with existing datasets, whilst improving rater experience by removing ambiguity and inconsistency in the glossary.
In 1993 the UK Department of Health commissioned the Royal College of Psychiatrists’ Research Unit (CRU) to develop scales to measure the health and social functioning of people with severe mental illness. The initial aim was to provide a means of recording progress towards the Health of the Nation target ‘to improve significantly the health and social functioning of mentally ill people’
Development and testing over three years resulted in an instrument with 12 items measuring behaviour, impairment, symptoms and social functioning (Wing, Curtis & Beevor, 1996). The scales are completed after routine clinical assessments in any setting and have a variety of uses for clinicians, researchers and administrators, in particular health care commissioners and providers. The scales were developed using stringent testing for acceptability, usability, sensitivity, reliability and validity, and have been accepted by the NHS Executive Committee for Regulating Information Requirements for entry in the NHS Data Dictionary. The scales also form part of the English Minimum Data Set for Mental Health.
The use of HoNOS is recommended by the English National Service Framework for Mental Health and by the working group to the Department of Health on outcome indicators for severe mental illnesses.
HoNOS is the most widely used routine clinical outcome measure used by English mental health services. The CRU conducted a survey of NHS mental health services in England in 2000 and found 34 services had implemented the use of HoNOS in one or more service settings. A further survey by the Department of Health in 2002 found that 61 trusts were using HoNOS in their services with 5 having implemented the use of the scales across the whole service.
More information on training: HoNOS Working Age Adults training (pdf)
The Royal College of Psychiatrists which developed HoNOS, provides the following to support its implementation HoNOS supplies order form (pdf)
- Scoresheet An A4 sheet for recording background patient information and the HoNOS score.
- Glossaries A small, handy folding reference guides for the rating of HoNOS.
- Labels Self-adhesive score sheet labels to affix to case notes or other documents. There are nine labels on each A4 sheet.
- Final Report This is the final report which details the HoNOS research and development from July 1993 to December 1995. The report has three parts:- An executive summary; Five chapters detailing the design criteria specified by a panel of consultants,
four phases of testing and the final conclusions and Five appendices that contain all other material needed for the use of HoNOS, such as the final HoNOS glossary, chart and score sheet, HoNOS trainers' guide and self-completion of HoNOS for patients.
Contact: Emma George via firstname.lastname@example.org
The HIG65+ glossary is a tabulated verison of that originally published by the Royal College of Psychiatrists' College Research Unit. It had been refined and clarified between 1997 and 1999 by members of the HoNOS65+ Development Group of the former Lewisham & Guy's Mental Health NHS Trust; the first Trust to fully implement HoNOS65+.
- HoNOS65+ version 3 (pdf)
- Spanish version of HoNOS65+ glossary (pdf)
- Spanish self-rating version of HoNOS65+ (pdf)
- Dutch version of HoNOS65+ glossary (pdf)
- French version of HoNOS65+ glossary (pdf)
- Greek version of HoNOS65+ glossary (pdf)
- Italian version of HoNOS65+ glossary (pdf)
These are 12 scales that are used to rate older adult mental health service users. Together, they rate various aspects of mental and social health, each on a scale of 0-4. They are designed to be used by clinicians before and after interventions, so that changes attributable to the interventions (outcomes) can be measured. The scales are as follows:
- Behavioural disturbance
- Non-accidental self injury
- Problem drinking or drug use Cognitive problems
- Problems related to physical illness or disability
- Problems associated with hallucinations and/or delusions or false beliefs
- Problems associated with depressive symptoms
- Other mental and behavioural problems
- Problems with social or supportive relationships
- Problems with activities of daily living
- Overall problems with living conditions
- Problems with work and leisure activities - quality of day time environment
Each scale is rated as follows:
- No problem
- Minor problem that is non-clinical: i.e. would not normally lead to intervention
- Mild problem (that would justify intervention
- Moderate problem
- Severe problem
Contact: Emma George via email@example.com
Health of the Nation Outcome Scales for Children and Adolescents was developed for children and adolescents (under the age of 18) in contact with mental health services. The use of HoNOSCA has been fully supported by the Department of Health and was employed in the Audit Commission survey of child and adolescent mental health services in 1998.
- HoNOSCA glossary (pdf)
Contact: Emma George via firstname.lastname@example.org
HoNOS-secure version 2b is the latest version of what was previously known as HoNOS-MDO*. It is specifically designed for use in health and social care settings such as secure psychiatric, prison health care and related forensic services, including those based in the community. Parts of the original HoNOS can be hard to interpret in secure settings, and this scale meets that need.
In 2002, Dr Philip Sugarman and Lorraine Walker developed the first version of HoNOS-secure within St Andrew’s Group of Hospitals. (St Andrew’s Group of Hospitals is now known as St Andrew’s Healthcare). The ‘MDO scale’ was developed into 7 security scales so that the completed score sheet provided a profile of 19 severity ratings, a total HoNOS score and a separate security score. The title was changed from ‘MDO’ (Mentally Disordered Offenders) to ‘secure’ to include all users of secure services.
HoNOS-secure version 2 was developed in late 2004 by simplifying the original instructions and making some changes to the wording of the security scales (based on detailed feedback from users and a review of rating reliability). The aim was to create a more ‘user friendly’ tool. In version 2b, developed February 2007, the scales are unchanged but the instructions have been simplified based on feedback received at training sessions.
The 7 security rating scales are:
- A = risk of harm to adults or children
- B = risk of self-harm (deliberate or accidental)
- C = need of building security to prevent physical escape
- D = need for a safely staffed living environment
- E = need for escort on leave (beyond the secure perimeter)
- F = risk to individual from others
- G = need for risk management procedures.
Like the previous versions, HoNOS-secure version 2b is not a risk assessment tool. It allows the outcome of clinical risk assessment to be rated in terms of need for care and need for clinical risk management procedures.
*HoNOS-MDO consisted of an amended version of the 12 original HoNOS scales and a single ‘MDO scale’ that set out the overall need for level of secure care. It was piloted by the Kent Forensic Psychiatric Service across Regional Secure Units in the South Thames Region. Results showed a very high inter-rater reliability and also good reliability in using HoNOS and HoNOS-MDO interchangeably in those settings.
HoNOS-Secure glossary and scoresheet
Contact: Sanjith Kamath, Executive Medical Director via email@example.com.
Health of the Nation Outcome Scales for People with Learning Disabilities are designed for use with people with a learning disability with mental health needs irrespective of the degree of their disability. HoNOS-LD has been tested for inter-rater reliability, convergent reliability, validity to change and acceptability in a national pilot study. Results demonstrate a good inter-rater reliability and a level of sensitivity to change that was acceptable to clinicians working in the field.
- HoNOS-LD Training flyer (pdf)
Contact: Emma George on 020 3701 2611 or via firstname.lastname@example.org.
Health of the Nation Outcome Scales for Acquired Brain Injury was derived largely from HoNOS65+ by a group of brain injury psychiatrists interested in developing a version HoNOS more suited for this group of people.
Contact: Dr Simon Fleminger, The Maudsley Hospital London via email@example.com.
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Garralda, M.E., Yates, P. & Higginson, I. (2000) Child and adolescent mental health service use. HoNOSCA as an outcome measure. British Journal of Psychiatry, 177:52-8.
Glover, G.R., Sinclair-Smith, H. (2000) Computerised information systems in English mental health care providers in 1998. Social Psychiatry and Psychiatric Epidemology, 35 (11): 518-522.
Hatfield, B., Spurrell, M., & Perry, A. (2000) Emergency referrals to an acute psychiatric service: demographic, social and clinical characteristics and comparisons with those receiving continuing services. Journal of Mental Health, 9 (3): 305-17.
Keys, R. (2000) HoNOS: does it have a role to play in mental health services? Mental Health Practice, 3 (7): 22-24.
McClelland, R., Trimble, P., Fox, M.L., Stevenson, M.R. & Bell, B. (2000) Validation of an outcome scale for use in adult psychiatric practice. Quality in Health Care, 9 (2): 98-105.
Preston, N.J. (2000) The Health of the Nation Outcome Scales: Validating factorial structure and invariance across two health services. Australian & New Zealand Journal of Psychiatry, 34 (3): 512-519.
Rushforth, D., Brooker, C., Winstanley, J. & Repper, D. (2000) The use of HoNOS in the evaluation of partial hospitalisation in mental health day care. Health of the Nation Outcome Scales. Clinical Effectiveness in Nursing, 4 (3): 121-127.
Slade, M., Thornicroft, G., Beck, A., Bindman, J. & Wright, S. (2000) Assessment: from Theory to Practice. British Journal of Psychiatry, 176, 394-395.
Trauer, T. (2000) Update from Down Under. British Journal of Psychiatry, 176, 393- 394.
Trauer, T. (2000) Comment. Australian & New Zealand Journal of Psychiatry, 34 (3): 520-521.
Wing, J.K., Lelliott, P., & Beevor, A.S. (2000) Progress on HoNOS. British Journal of Psychiatry, 176, 392-393.
Allen, L., Bala, S., Carthew, R., Daley, S., Doyle, E., Driscoll, P., et al. (1999) Experience and application of HoNOS65+. Psychiatric Bulletin, 23, 203-206.
Amin, S., Singh, S.P., Croudace, T., Jones, P., Medley, I. & Harrison, G. (1999) Evaluating the Health of the Nation Outcome Scales. Reliability and validity in a three-year follow-up of first-onset psychosis. The British Journal of Psychiatry, 174, 399-403.
Bebbington, P., Brugha, T., Hill, T., Marsden, L & Window, S. (1999) Validation of the Health of the Nation Outcome Scales. The British Journal of Psychiatry, 174, 389-394.
Brooker, C., Molyneux, P., Deverill, M. & Repper, J. (1999) Evaluating clinical outcome and staff morale in a rehabilitation team for people with serious mental health problems. Journal of Advanced Nursing, 29 (1): 44-51.
Bruce, J., Watson, D., van Teijlingen, E.R., Lawton, K., Watson, M.S. & Palin, A.N. (1999) Dedicated psychiatric care within general practice: health outcome and service providers’ views. Journal of Advanced Nursing, 29 (5): 1060-1067.
Burns, A., Beevor, A., Lelliott, P., Wing, J., Blakey, A., Orrell, M., Mulinga, J. & Hadden, S. (1999) Health of the Nation Outcome Scales for Elderly People (HoNOS 65+). Glossary for HoNOS65+ score sheet. The British Journal of Psychiatry, 174, 435-438.
Burns, A., Beevor, A., Lelliott, P., Wing, J., Blakey, A., Orrell, M., Mulinga, J. & Hadden, S. (1999) Health of the Nation Outcome Scales for Elderly People (HoNOS65+). The British Journal of Psychiatry, 174, 424-427.
Chaplin, R. & Perkins, R. (1999) HoNOS: A cautionary tale of their use in a rehabilitation service. Psychiatric Bulletin, 23 (1): 20-21.
Charlwood, P., Mason, A., Goldacre, M., Cleary, R. & Wilkinson, E. (eds) (1999) Health Outcome Indicators: Severe Mental Illness. Report of a working group to the Department of Health. Oxford: National Centre for Health Outcomes Development.
Culiford, L., Goff-Beardsley, S. & Atkinson, T. (1999) Usefulness of HoNOS. Psychiatric Bulletin, 23 (9): 571.
Dalal, B., Larkin, E., Leese, M. & Taylor, P.J. (1999) Clozapine treatment of long-standing schizophrenia and serious violence: A two-year follow-up study of the first 50 patients treated with clozapine in Rampton high security hospital. Criminal Behaviour & Mental Health, 9 (2): 168-178.
Gowers, S.G., Harrington, R.C., Whitton, A., Lelliott, P., Beevor, A., Wing, J. & Jezzard, R. (1999) Brief scale for measuring the outcomes of emotional and behavioural disorders in children. Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). The British Journal of Psychiatry, 174, 413-416.
Gowers, S.G., Harrington, R.C., Whitton, A., Beevor, A., Lelliott, P., Jezzard, R. & Wing, J.K. (1999) Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA): Glossary for HoNOSCA score sheet. The British Journal of Psychiatry, 174, 428-431.
Issakidis, C. & Teesson, M. (1999) Measurement of need for care: A trial of the Camberwell Assessment of need and the Health of the Nation Outcome Scales. Australian & New Zealand Journal of Psychiatry, 33 (5): 754-759.
James, M. & Kehoe, R. (1999) Using the Health of the Nation Outcome Scales in clinical practice. Psychiatric Bulletin, 23 (9): 536-538.
MacDonald A.J.D. (1999) HoNOS 65+ glossary. British Journal of Psychiatry, 175, 192.
Mozley, C.G., Huxley, P., Sutcliffe, C., Bagley, H., Burns, A., Challis, D. & Cordingley, L. (1999) ‘Not knowing where I am doesn’t mean I don’t know what I like’: cognitive impairment and quality of life responses in elderly people. International Journal of Geriatric Psychiatry, 14 (9): 776-783.
Orrell, M., Yard P., Handysides, J. & Schapira, R. (1999) Validity and reliability of the Health of the Nation Outcome Scales in psychiatric patients in the community. The British Journal of Psychiatry, 174, 409-412.
Pirkis, J., Burgess, P. & Jolley, D. (1999) Suicide attempts by psychiatric patients in acute inpatient, long-stay inpatient and community care. Social Psychiatry & Psychiatric Epidemiology, 34 (12): 634-644.
Rossi, F., Blaco, R., Castelli, C., Civenti, G., Cocchi, A., Contini, A., Erlicher, A., Lanzara, D., Lora, A., Marcandalli, S., Morosini, P., & Pisapia, D. (1999) Cost of psychiatric patients by disability groups. EPIDEMIOL PSYCHIATR SOC, 8 (3): 198-208. (Italian)
Salvador-Carulla, L. (1999) Routine outcome assessment in mental health research. Current Opinion in Psychiatry, 12, 207-210.
Sharma, V.K., Wilkinson, G. & Fear, S. (1999) Health of the Nation Outcome Scales: a case study in general psychiatry. British Journal of Psychiatry, 174, 395-398.
Shergill, S.S., Shankar, K.K., Seneviratna, K. & Orrell, M.W. (1999) The validity and reliability of the Health of the Nation Outcome Scales (HoNOS) in the elderly. Journal of Mental Health, 8 (5): 511-521.
Slade, M., Beck, A., Bindman, J., Thornicroft, G. & Wright, S. (1999) Routine clinical outcome measures for patients with severe mental illness: CANSAS and HoNOS. The British Journal of Psychiatry, 174, 404-408.
Trauer, T. (1999) The subscale structure of the Health of the Nation Outcome Scales (HoNOS). Journal of Mental Health, 8 (5): 499-509.
Trauer, T., Callaly, P., Hantz, P., Little, J., Shields, R. & Smith, J. (1999) Health of the Nation Outcome Scales. Results of the Victorian field trial. The British Journal of Psychiatry, 174, 380-388.
Trauer, T., Callaly, T. & Hantz, P. (1999) The measurement of improvement during hospitalisation for acute psychiatric illness. Australian & New Zealand Journal of Psychiatry, 33 (3): 379-384.
Wing, J.K., Curtis, R.H. & Beevor, A.S. (1999) Health of the Nation Outcome Scales (HoNOS): Glossary for HoNOS score sheet. The British Journal of Psychiatry, 174, 432-434.
Wing, J.K., Curtis, R.H. & Beevor, A.S. (1999) Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). Glossary for HoNOS score sheet. The British Journal of Psychiatry, 174, 432-434.
Wing, J., Lelliott, P. & Chaplin, R.H. (1999) Reliability and validity of HoNOS (multiple letters). Psychiatric Bulletin, 23 (6):375.
Yates, P., Garralda, M.E. & Higginson, I. (1999) Paddington Complexity Scale and Health of the Nation Outcome Scales for Children and Adolescents. The British Journal of Psychiatry, 174, 413-416.
Ashaye, O., Adebisi, A., Newman, E. & Dhadphale., M. (1998) Resettlement and the Health of the Nation Outcome Scales (HoNOS) in the elderly. International Journal of Geriatric Psychiatry, 13 (8): 568-570.
Ashaye, O., Mathew, G. & Rigby, E. (1998) HoNOS in long-stay patients with learning disabilities. Psychiatric Bulletin, 22 (5): 306-308.
Blair, G. & Deaney, C. (1998) Inner-city general practice population of people with schizophrenia. Psychiatric Bulletin, 22 (4): 221-225.
Cheah, Y.C., Parker, G., Hadzi-Pavlovic, D., Gladstone, G. & Eyers, K. (1998) Development of a measure profiling problems and needs of psychiatric patients in the community. Social Psychiatry & Psychiatric Epidemiology, 33 (7): 337-344.
Goldney, R.D., Fisher, L.J. & Walmsley, S.H. (1998) The Health of the Nation Outcome Scales in psychiatric hospitalisation: A multi-centre study examining outcome and prediction of length of stay. Australian & New Zealand Journal of Psychiatry, 32 (2): 199-205.
Wing, J.K., Beevor, A.S., Curtis, R.H., Park, S.B.G., Hadden, S. & Burns, A. (1998) Health of the Nation Outcome Scales (HoNOS): Research and development. British Journal of Psychiatry, 172, 11-18.
Allan. S., & McGonagle, I. (1997) A comparison of HoNOS with the Social Behaviour Schedule in three settings. Journal of Mental Health, 6 (2): 117-124.
Ashaye, O., Mathew, G. & Dhadphale, M. (1997) A comparison of older longstay psychiatric and learning disabilities inpatients using the Health of the Nation Outcome Scales. International Journal of Geriatric Psychiatry, 12 (5): 548-552.
Boot, B., Hall, W. & Andrews, G. (1997) Disability, outcome and case-mix in acute psychiatric in-patient units. British Journal of Psychiatry, 171, 242-246.
Brooker, C., Molyneux, P., Deverill, M. & Repper, J. (1997) An audit of costs and outcome using HoNOS-3 in a rehabilitation team: A pilot study. Journal of Mental Health, 6 (5): 491-502.
Elphick, M., Anthony, P., Lines, C. & Evans, H. (1997) Mental Health: casemix outcome resource needs: Summary Report. The National Casemix Office: Winchester.
Elphick, M., Anthony, P., Lines, C. & Evans, H. (1997) Mental Health: casemix outcome resource needs. The National Casemix Office: Winchester.
Taylor, J.R. & Wilkinson, G. (1997) HoNOS vs GP opinion in a shifted out-patient clinic. Psychiatric Bulletin, 21 (8): 483-485.
Carlisle, D. (1996) Economies of scales. Nursing Times, 92 (50): 38-39.
Goldney, R.D., Fisher, L.J., Walmsley, S., Kent, P. & Cooper, A.W. (1996) A pilot study of the Health of the Nation Outcome Scale as a measurement of outcome in a private psychiatric hospital. Australasian Psychiatry, 4 (6): 319-321.
Jeffries, M. (1996) A culture of effective efficiency. NHS Magazine. Autumn (6): 12-13.
Wing, J.K., Curtis, R.H. & Beevor, A.S. (1996) HoNOS: Health of the Nation Outcome Scales: Report on Research and Development July 1993-December 1995. London: Royal College of Psychiatrists.
- Health of the Nation Outcome Scales (HoNOS) © Royal College of Psychiatrists 1996
- Health of the Nation Outcome Scales (HoNOS 2018) © Royal College of Psychiatrists 2018
- Health of the Nation Outcome Scales for Elderly People (HoNOS 65+) © Royal College of Psychiatrists 1999
- Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) © Royal College of Psychiatrists 1999
- Health of the Nation Outcome Scales for Acquired Brain Injury (HoNOS ABI) © Royal College of Psychiatrists 1999
Copyright in the Health of the Nation Outcome Scales (HoNOS, HoNOS 65+, HoNOSCA and HoNOS ABI) is owned by the Royal College of Psychiatrists. Commercial copying, renting, and adaptation are prohibited.
The following acts may not be performed without the consent of the Royal College of Psychiatrists:
- Copying the work
- Renting or otherwise issuing copies of the work to the public.
- Adapting the work [e.g. changes to the wording of items, scaling of items, addition or deletion of items or changes in the order of items].
This guidance is intended to clarify what extensions to the conditions the Royal College of Psychiatrists (RCPsych) will allow and under what circumstances they expect to be approached to gain explicit permission.
Where HoNOS is used copyright should be acknowledged with the following statement:
Health of the Nation Outcome Scales (HoNOS) © Royal College of Psychiatrists 1996
The HoNOS glossary
The RCPsych does not permit the reproduction or copying of the HoNOS glossary. All organisations or individuals should seek permission from the RCPsych to reproduce the glossaries or include the glossary descriptions within electronic health records.
The RCPsych allows without express permission the free use, copy and reproduction of HoNOS scoresheets for use in NHS-funded care. Use, copy or reproduction of HoNOS scoresheets for any other purpose should be with the explicit permission of the RCPsych.
The RCPsych allows without express permission NHS organisations and other providers of NHS funded care to include HoNOS scoresheets in electronic healthcare records and other computerised clinical systems.
Where possible, original fonts and layouts should be used. The inclusion of HoNOS within commercial ‘for profit’ software systems will require the explicit permission/license of the RCPsych.
Written HoNOS training materials
The RCPsych allows the copying and reproduction of training materials supplied as part of its accredited training only within the organisations who have commissioned that training. All other organisations should seek the explicit permission of the RCPsych to undertake any reproduction, issuing copies to the public or making adaptations in any way.
Permissions should be sought from the RCPsych for any reproduction, rental, lending or adaptation of the Training DVD. The use of the training DVD is permitted by accredited trainers and organisations who have commissioned training for trainers. All other commercial or public exhibition of the DVD is prohibited without the express permission of the RCPsych.
Other HoNOS publications
The permission of the RCPsych should be sought to undertake any acts associated with copyright law in relation to any other HoNOS publications of the RCPsych.
Contact for Australia: Rosemary Dickson, Network Coordinator, Australian Mental Health Outcomes and Classification Network (AMHOCN) on Rosemary.Dickson@health.nsw.gov.au or Tim Coombs, AMHOCN Consultant on firstname.lastname@example.org
About the Mental Health Clustering Tool
The MHCT has been developed in partnership between the Department of Health, the Royal College of Psychiatrists Centre for Advanced Learning and Conferences and the Care Pathways and Packages Project (CPPP) as a means of allocating clients to Care Clusters which in turn supports care planning and enables Mental Health Payment by Results (MH PbR). The MHCT retains the Health of the Nation Outcome Scales (HoNOS) and thus supports providers and commissioners in measuring health and social care outcomes in mental health without the need to collect additional data.
HoNOS was published by the Royal College of Psychiatrists (RCPsych) in 1996 and is now the most widely used outcome measure in specialist mental health services in England and overseas. The RCPsych has over 20 years experience of training clinical staff in the use of the HoNOS, working with staff teams to train them as trainers and with Trusts to develop and support Trust wide training and implementation plans.
To support mental health service providers and commissioners in implementing MH PbR, the following training courses are available:
- Mental Health Clustering Tool – Foundation One Day Training Course. Delivered directly to all staff who will be involved in assessment and clustering
- Mental Health Clustering Tool – Train the Trainers Two Day Course. Designed to help organisations train staff and implement MHCT . For organisations which have no previous experience of using HoNOS
- Mental Health Clustering Tool – Train the Trainers Course One Day Update Course. Designed to help organisations train staff and implement MHCT. For organisations which HAVE previous experience of using HoNOS
- Bespoke courses on request to suit your specific organisational needs (NB. HoNOS only training courses are available on request)
More information on training: Mental Health Clustering Tool (pdf)
Contact: Emma George on email@example.com