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The Royal College of Psychiatrists Improving the lives of people with mental illness

Frequently Asked Questions About HoNOS


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:
  1. Overactive, aggressive, disruptive or agitated behaviour
  2. Non-accidental self-injury
  3. Problem drinking or drug-taking
  4. Cognitive problems
  5. Physical illness or disability problems
  6. Problems associated with hallucinations and delusions
  7. Problems with depressed mood
  8. Other mental and behavioural problems
  9. Problems with relationships
  10. Problems with activities of daily living
  11. Problems with living conditions
  12. 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 groups?

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 take longer.

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 ratings.

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 developed.


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 problems?

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 period only
  • 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 is more 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 improved.

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).
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