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Managing outcome performance in mental health using HoNOS: experience at St Andrew's Healthcare

  • Philip Sugarman (a1), Lorraine Walker (a1) and Geoff Dickens (a2)
Abstract
Aims and Method

Modern mental healthcare providers must demonstrate service-level clinical effectiveness to key stakeholders. We introduced two performance indicators of clinical effectiveness based on outcome data from routinely collected Health of the Nation Outcome Scales (HoNOS) and HoNOS–secure assessments across St Andrew's Healthcare, a charity providing in-patient services in Northampton and Essex. We present outcome data from the period 2004–2007.

Results

The indicators showed consistent 90-day improvement rates and increasing stability over time. the validity of results is supported by levels of change along predicted lines among different patient cohorts.

Clinical Implications

It is possible and beneficial to use routine outcome measures to demonstrate clinical effectiveness at service level. the future of managing mental health outcomes will be in electronic health records systems.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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2 Sugarman, P. Governance, strategy and innovation in mental health. Psychiatr Bull 2007; 31: 283–5.
3 Sugarman, PA, Watkins, J. Balancing the scorecard: key performance indicators in a complex healthcare setting. Clinician Manag 2004; 12: 129–32.
4 Coop, CF. Balancing the balanced scorecard for a New Zealand mental health service. Aust Health Rev 2006; 30: 174–80.
5 Slade, M, McCrone, P, Kuipers, E, Leese, M, Cahill, S, Parabiaghi, A, et al. Use of standardised outcome measures in adult mental health services. Randomised controlled trial. Br J Psychiatry 2006; 189: 330–6.
6 Cohen, A, Eastman, N. Needs assessment for mentally disordered offenders: measurement of ‘ability to benefit’ and outcome. Br J Psychiatry 2000; 177: 493–8.
7 National Centre for Outcomes Development. Health Outcome Indicators: Severe Mental Illness. Report of a working group to the Department of Health. NCOD, 1999 (http://nchod.uhce.ox.ac.uk/mentalillness.pdf).
8 Thomson, R, Taber, S, Lally, J, Kazandjian, V. UK Quality Indicator Project (UK QIP) and the UK independent health care sector: a new development. Int J Qual Health Care 2004; 16 (suppl 1): i516.
9 Dausey, DJ, Rosenheck, RA, Lehman, AF. Preadmission care as a new mental health performance indicator. Psychiatr Serv 2002; 53: 1451–5.
10 Gilbody, SM, House, AO, Sheldon, TA. Outcomes research in mental health. Systematic review. Br J Psychiatry 2002; 181: 816.
11 Phelan, M, Slade, M, Thornicroft, G, Dunn, G, Holloway, F, Wykes, T, et al. The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness. Br J Psychiatry 1995; 167: 589–95.
12 Wing, JK, Beevor, AS, Curtis, RH, Park, SB, Hadden, S, Burns, A. Health of the Nation Outcome Scales (HoNOS). Research and development. Br J Psychiatry 1998; 172: 11–8.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Managing outcome performance in mental health using HoNOS: experience at St Andrew's Healthcare

  • Philip Sugarman (a1), Lorraine Walker (a1) and Geoff Dickens (a2)
Submit a response

eLetters

HoNOS-ty: Does HoNOS provide a good enough measure of outcome?

Benjamin J Sieniewicz, F2 Doctor
17 August 2009

Sugarman and colleagues highlight an important aspect of mental health care in their paper which analyses the use of HoNOS in assessing change amongst psychiatric patients. While they demonstrate that it is possible to measure outcomes using a suitable instrument, their data also reveals the limited utility of such a “blunt instrument” and they provide an honest account of its shortcomings, recommending that it not be used alone. Indeed, the tiny degrees of change indicated in their results havelittle meaning for real-life clinical practice1.

Historically, measuring clinical outcomes in psychiatry was discardedas anathema2 despite the availability of a variety of simple, quick and meaningful scales in many major conditions; the Beck Depression Inventory (BDI) 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 (PbR) and the public availability of information about health providers that is now being published online.

A further demand, shaped by the Next Stage Review and various NICE 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 depression3 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 PANSS, 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 stability4.

The use of a dynamic markers such as remission scores to measure progress is actively encouraged in the WHO Mental Health Gap Action Programme (mhGAP) 5. 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.

References1 Sugarman P, Walker L, Dickens G. Managing outcome performance in mental health using HoNOS: experience at St Andrew’s Healthcare. Psychiatr Bull 2009; 33: 285-88.2 Jacques J. Payment by results and mental health services. Psychiatr Bull2008; 32: 361-63 3 Frank E, Prien RF, Jarret RB, Keller MB, Kupfer DJ, Lavori PW, Rush AJ, Weissman MM. Conceptualisation and rationale for consensus definitions ofterms in major depressive disorder: remission, recovery, relapse, and recurrence. Arch Gen Psychiatry 1991; 50(5): 407-08.4 Yeomans D, Taylor M, Currie A, Whale R, Ford K, Fear C, Hynes J, Sullivan G, Moore B, Burns T. How long have you been well? Remission as an outcome in schizophrenia. Adv Psychiatr Treat 2009; in press.5 World Health Organisation. mhGAP: Mental Health Gap Action Programme: scaling up care for mental, neurological and substance use disorders. WHO Press, 2008.
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