HoNOSty: does HoNOS provide a good enough measure of outcome?

Sugarman et al highlight an important aspect of mental healthcare in their paper which analyses the use of Health of the Nation Outcome Scales (HoNOS) in assessing change among psychiatric patients.[1][1] Although they demonstrate that it is possible to measure outcomes using a suitable instrument,


Is this not discrimination?
During one of the recent ward rounds, we decided to discharge a patient who had a diagnosis of schizoaffective disorder. He had been on the ward for about 2 months as a voluntary patient and he was treated with antipsychotic medication. We advised him that he should continue the medication on a daily basis after the discharge in order to prevent future relapse. He said that he had to pay for prescriptions and therefore expressed his difficulty in taking the antipsychotic medication on a longterm basis.
Research by Rethink (unpublished;personal communication, 2009) shows that 26% of service users currently pay for prescriptions (56% of those who have been in paid employment over the past 12 months); 38% of people with severe mental illnesses like schizophrenia have to choose between paying household bills and prescription charges (www.prescriptionpromise.org). This group of patients will now have to pay even more due to the recent increase in prescription charges, which many already cannot afford. This grossly unjust situation can result in people not getting their medicines and as a result having a relapse of their mental illness.
Patients with chronic conditions such as hypothyroidism and diabetes mellitus are receiving free medication irrespective of their job or financial background (www. nhsbsa.nhs.uk/1126.aspx). Prescription charges have also been abolished recently for people with cancer, and the Parkinson's Disease Society has now urged the government to end prescription charges in England for people with Parkinson's disease. Why not those with enduring mental health difficulties? Although a number of patients with chronic mental health problems do get free medication owing to their poor financial status, there are patients who may have some money in the bank or other income. It is not fair to presume that all psychiatric patients do not have any money and all of them are not capable of generating an income or even not entitled to inherit wealth.
The ethos for providing free medication in chronic conditions such as hypothyroidism should be valid and applicable to those with long-term mental health difficulties.
The College, along with the voluntary sector, should actively campaign to put pressure on the government to abolish prescription charges for people with longterm mental illness. HoNOSty: does HoNOS provide a good enough measure of outcome? Sugarman et al highlight an important aspect of mental healthcare in their paper which analyses the use of Health of the Nation Outcome Scales (HoNOS) in assessing change among psychiatric patients. 1 Although they demonstrate that it is possible to measure outcomes using a suitable instrument, their data also reveal the limited utility of such a 'blunt instrument' and they provide an honest account of its shortcomings, recommending that it should not be used alone. Indeed, the tiny degrees of change indicated in their results have little meaning for real-life clinical practice.
Historically, measuring clinical outcomes in psychiatry was discarded as anathema 2 despite the availability of a variety of simple, quick and meaningful scales in many major conditions: the Beck Depression Inventory 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 and the public availability of information about health providers that is now being published online.
A further demand, shaped by the Next Stage Review 3 and various National Institute for Health and Clinical Excellence 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 depression 4 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 Positive and Negative Syndrome Scale, 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 stability. 5 The use of dynamic markers such as remission scores to measure progress is actively encouraged in the World Health Organization's Mental Health Gap Action Programme. 6 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. Involvement of a young service user in the appointment of a doctor The importance of involving service users in all aspects of their care has been Columns Correspondence AUTHOR'S PROOF