Informatics 2000sep3

Journal of Informatics in Primary Care 2000 (September):8-9


Measuring health and social functioning in primary care:  adapting the Health of the Nation Outcome Scales (HoNOS) for the primary care setting

Damian Mitchell RGN, RMN, BA (Hons), MA1

Andrew G Meal, BMedSci (Hons), BM BS, MPhil2

1     Lecturer, School of Nursing, Lincoln County Hospital, Greetwell Road, Lincoln LN2 5QY.  (email

2     Lecturer, School of Nursing Postgraduate Division, B Floor, Queen’s Medical Centre, Nottingham NG7 2UH. (email


Mental health problems contribute significantly to the workload in primary health care (PHC), involving, to some extent, all members of the primary health care team (PHCT).  However, there is wide variation in the type and quality of mental health data recording, rendering it difficult to assess both the impact of mental health problems and the outcomes of interventions at primary care level.  The problem has three main aspects:

·           mental health data may be recorded in a problem-based and/or diagnosis-based manner

·           shifting boundaries of care exist between PHC professionals

·           terminology and diagnosis of mental health problems may change over time.

At the heart of the wide variation in mental health recording lies the issue of taking a diagnosis- or problem-based approach.  Diagnosis-based recording of mental health problems is derived from the specialist secondary psychiatric services, but the mental health problems seen in PHC might be more appropriately considered using a problem-based approach.  Often such problems are psychosocial rather than definitively ‘psychotic/neurotic’, but even for a condition that can be diagnosed with clarity, an individual’s level of social functioning may be of more immediate concern for the PHCT than the diagnosis.

General Practice computer databases are an obvious medium for recording mental health problems in PHC, but data might only be recorded on practice computer systems if the patient was seen by a general medical practitioner.  The recent shifting of care boundaries between PHC professionals may mean that a patient with a mental health problem does not consult a general medical practitioner.  For example, Community Psychiatric Nurses (CPNs) are working increasingly within PHC settings1 and other members of the PHCT are also experiencing the knock-on effects of increased community based mental health problems. Beck2 suggests that there is an increasing role for the community midwife in the assessment of mental health problems experienced by women in the community.

A further issue concerns the coding of clinical data on computer systems.  The Read code schemes used by a majority of GP computer systems may not be appropriate for the type of mental health problems encountered in PHC because they are primarily diagnosis-based3.

A problem-based approach

The potential benefits of using a measure of health and social functioning in PHC are numerous, but most importantly it would provide a framework for developing a comprehensive information system for the recording of psychosocial problems in PHC.  This in turn would:

i)     Integrate mental health data recording in PHC with existing projects, for example Mental Health National Service Framework, Minimum Mental Health Data Set Project, Primary Care Information Services (PRIMIS)4

ii)    Allow examination of the interface between PHC and the Specialist Psychiatric Services

iii)    Help to compare primary service data with national indicators for likely levels of psychiatric morbidity, to assist with public health planning

iv)   Improve communication between professional groups

v)    Make mental health data accessible for public health research

vi)   Assist the new Primary Care Groups (PCGs) in the development of a strategy for improving the mental health of local people

vii)   Provide a baseline for measuring improvement in the effectiveness of PHC services.

Is HoNOS a way forward?

The Health of the Nation Outcome Scales (HoNOS) were developed in response to the first mental health target in the White Paper The Health of the Nation5, “to improve significantly the health and social functioning of mentally ill people”.  HoNOS was designed to quantify this target and to allow measurement of progress6.  Following extensive testing, HoNOS was shown to have the following characteristics:

·           Short, simple, acceptable and useful to clinicians

·           Provides an overview of clinical and social problems

·           Sensitive to improvement or deterioration or lack of change in a given period

·           Known reliability and validity

·           Known relationship to more established scales

·           Simple indicator for local and national use of health outcome

HoNOS was designed specifically for use within the specialist secondary mental health services and could not, as it stands, be used to record health and social functioning in PHC.  However, the potential value of adapting HoNOS for the PHC sector has been recognised by the original developers;  they suggest6 that:

“If a comparable primary care HoNOS were devised, tested and widely used, the age old problem of relating data collected from secondary health and social agencies to a relevant population base would be much simplified.”

Adapting HoNOS for use in PHC would allow Health Authorities and PCGs to use such problem-based data to both measure outcomes and determine the extent to which services are geared to meeting the identified problems within the community.  The potential long-term value would be to provide a framework for developing a comprehensive information system for recording mental health problems, which is both acceptable to practitioners and provides reliable data for local and national public health planning.  It would also prepare the way for PHC data to be incorporated into the new Mental Health Minimum Data Set, which is planned for the Specialist Psychiatric Services.

In spite of these advantages there is a danger that HoNOS may become another redundant clinical tool unless it could be integrated into existing GP computer databases.  A great advantage of HoNOS is that the assessment gives rise to a numerical score, and codes for each stage of the assessment are incorporated into Version 3 of the Read codes, but earlier versions of the Read codes do not contain HoNOS codes. 


We suggest that adapting HoNOS for PHC may provide PHC professionals with a valuable tool for assessing mental health from a problem-based perspective.  It offers the potential for unifying the data recorded by all members of the PHCT who deal with mental health problems.  It would not replace, but augment diagnosis-based systems.  If a modified HoNOS were to be adopted in PHC, versions of the Read codes prior to Version 3 would need to incorporate codes for the HoNOS scores.


1       Gournay K, Brooking J.  The community psychiatric nurse in primary care:  an economic analysis.  Journal of Advanced Nursing 1995;  22(4):769–778

2       Beck CT.  Maternal depression and child behaviour problems:  a meta-analysis. Journal of Advanced Nursing 1999;  29(3):623–629

3       CHDGP Guidelines Version 3.  Appendix 5:  Mental Health Recording.  NHS Executive 1999


5       Department of Health.  The Health of the Nation.  Department of Health, London, 1992

6       Wing JK, Beevor AS, Curtis Park SB, Hadden S, Burns A.  Health of the Nation Outcome Scales (HoNOS). Research and development.  Br J Psychiatry 1998;  172:11–18


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