1286184623MHCT Training Day 1 v5 0807 2010 MJ

HoNOS and the Mental Health
Clustering Tool (MHCT)

Train the Trainers
How to allocate patients to Care Clusters for payment by
results in mental health and/or record routine clinical
outcome measures with Health of the Nation Outcome
Scales (HoNOS)
1
Royal College of Psychiatrists 2010
Day one - agenda
Introductions
Objectives
HoNOS (Glossary, rules and principles for rating)
MHCT (Additional items, rules and principles for rating)
Rating practice
Data Quality
Outcomes measurement
Introduction to clustering
2
Aims and Objectives

Describe the background to the development of HoNOS and the
MHCT
Explore its place in Todays NHS
Explain the rules and principles of rating the HoNOS/MHCT
Provide experience in HoNOS rating
Understand how to use the MHCT and how to allocate your
patients to Care Clusters
Identify how HoNOS/MHCT can benefit clinical practice
Identify the limitations of HoNOS
Explore how the quality of HoNOS/MHCT data can be ensured on
an on-going basis
Gain practical experience of using the HoNOS/MHCT and
complete inter-rater reliability exercises using clinical vignettes
in group exercises
Explain how HoNOS data can be used as a measure of outcome
across a mental health service and how MHCT will be used by
commissioners
Provide guidance on the development of local implementation
and training strategies
Background to the
Development of HoNOS
The Health of the Nation white paper identified mental
illness as one of the five key areas in its strategy.
It had three targets:
To improve significantly the health and social functioning of
mentally ill people
To reduce the overall suicide rate by at least 15% by the
year 2000 (from 11.0 per 100,000 population in 1990 to no
more than 9.4)
To reduce the suicide rate of severely mentally ill people by
at least 33% by the year 2000 (from the life-time estimate
of 15% in 1990 to no more than 10%)
4
HoNOS - international
Its use is mandated across mental health services in

Australia and New Zealand as a routine outcome measure.
It has been translated into many languages including
Danish, Dutch, Finnish, French, German, Italian, Korean,
Norwegian, Spanish and Thai.
It is also used routinely in Canada, Denmark, Holland,
Germany, Italy, Norway and Spain.
5
HoNOS is..
A set of 12 items with 5-point scales which are completed in
a few minutes by mental health professionals after routine
assessment, CPA reviews etc
The scales:
Are designed for use in any setting in secondary mental
health care services
Are based on a rating of the worst symptoms/problems
within a specified time period
Provide a numerical record of the clinical assessment
Are ratings of mental health outcome, not health care
outcomes
6
Background to the
development of the MHCT
The Department of Health:
Are driving the development of a national currency/tariff for
Payment by Results for Mental Health. This will enable
commissioners to understand the needs of people who use mental
health services and set tariffs for reimbursing Trusts for the work
that they do.
2010-11 trial phase; shadow currencies
2011-12 expectation that currencies will be used in some
form; establishing local prices
This clinical data set has been developed in partnership with the
Royal College of Psychiatrists. It builds on work done by the Care
Pathways and Packages Project in developing an assessment tool
that allows allocation of clients to Care Clusters. It has the
advantage that it retains intact HoNOS, an internationally
recognised outcome measure (collection of which is mandatory),
thus avoiding the need for two separate data collections.
7
The MHCT is..

The HONOS with the addition of a further 6 scales measuring
beliefs in non psychotic patients, risk, vulnerability and
engagement
PART 1 contains 13 scales to record problems experienced during
the 2 week period prior to your assessment (the current rating
period)
PART 2 contains another five scales (A-E) that consider problems
from a historical perspective. These will be problems that occur
in episodic or unpredictable ways. While they may not have been
experienced by the individual during the 2 week current rating
period, clinical judgement would suggest there is still a cause for
concern that cannot be disregarded (i.e. no evidence to suggest
that the person has changed since the last occurrence either as a
result of time, therapy, medication or environment etc.) In these
circumstances any event that remains relevant to the cluster
allocation (and hence the interventions offered) should be
included
The MHCT will allow you to allocate to one of 21 Care Clusters
What does MHCT Provide?

A single rating is completion of the 12 ITEMS
A single rating provides:
A profile of the individual patient and measure of severity of
mental health problems. This provides the evidence to
allocate to a cluster.
Two HoNOS ratings provide:
Measure of health outcomes when two or more ratings are
compared
Three or more HoNOS ratings provide:
A means of examining trends over time; for individuals or
groups when three or more ratings are compared
HoNOS ratings cannot be compared if any of the items are
scored at 9
9
Are HoNOS scales robust?
Problem profile and severity for people with non affective

psychosis at acute admission in Australia and SE London
Southwark (n = 524)
OCC
LIV C
A DL
RE LS
DE P
HA L
DIS
COG
S UB S
DS H
BEH
4
3
2
1
0
OTH
F20-29 - mean scores at admission
Australia (n = > 34,000)

10
Summary of the Clinical Benefits of

HoNOS and the MHCT
Benefits of Routine Clinical Outcome
Measurement
Benefits of Clustering for PbR in Mental

Health
Patient classification system to describe and

Benchmarking and evaluating services. A driver
benchmark services.Transparent process for
1 for service improvement. Providing a common
reporting population need to commissioners
'language' to discuss and compare services
of services
A standard record of progress across 12
2 common types of problem and a quick checklist Workforce modelling and planning
for MH professionals
A method of matching patient needs to
Clearer understanding of who does what and
3
practitioner skills, casemix and caseload
for whom
4 Tools for clinical audit and reseach
Tool for demand and capacity modelling to

meet population need
5 Gap analysis to inform service development
Tool to support service redesign
A standard record of progress for all clients in

the service
Provides practice based evidence of the clinical

effectiveness of services
Promoting reflective practice in clinical teams.
Comparison of outcome against clinical
8
interventions for different groups of service
users
7
Currencies from which to develop local PbR

tariffs
Framework for outcomes and quality
measures
Convergence of clinical provision to guidance
and best practice through pathways and
packages
11
HoNOS other versions

HoNOS was designed for use in general adult mental
health services.
There are separate HoNOS versions for mental health
specialities:
old age (HoNOS65+),
child and adolescent (HoNOSCA)
There are also versions for
forensic services (HoNOS-Secure),
learning disability services (HoNOS LD) and
acquired brain injury (HoNOS-ABI)
MHCT is currently being rolled out in working age adult
services and the use of other HoNOS variants is currently
being considered.
12
Using HoNOS
HoNOS is not a clinical assessment but a clinical assessment
is a pre-requisite for rating HoNOS
A rating of HoNOS is a rating of the patients current
problems in terms of impact on the patient of the problem
Not included in making a rating is:
The diagnosis
The cause of the problem
The intervention
The risk to others or the effect on others of the problem
13
MHCT/HoNOS Cautions
MHCT was not constructed to measure mental health

problems in the general population or in general practice
HoNOS cannot be used to compare wards, districts,
treatment regimes etc. Unless context/background
information is also collected (e.g. MDS) and like is
compared with like
A brief one-off training course is not sufficient to guarantee
comparability between individual raters or between groups
of raters. Practice is required to maintain reliability and
efficiency
14
MHCT Structure
18 ITEMS, each with 5-point severity scales (0-4)
0
1
2
3
4
- no problem
= minor problem requiring no action (sub-clinical)
= mild problems but definitely present (mild)
= problem of moderate severity (moderate)
= severe to very severe problem (severe/very severe)
The glossary provides further information on each ITEM and

examples of each point in the SEVERITY SCALE
When no information is available to score an ITEM, the figure 9
is used to indicate not known. The 9 is not added to the 0-4
scores. Further information should be collected again and a 0-4
score given without a full set of scores the rating cannot be
used to measure outcome or cluster a client.
15
Scoring MHCT
Since HoNOS contains 12 items which can be scored from 0 to 4
on the SEVERITY SCALE, the range of total scores is 0 to 48
HoNOS items can be grouped into sections:
behavioural (1 to 3),
impairment (4 & 5),
symptomatic (6 to 8) and
social problems (9 to 12).
Sub-scores can be identified for each section, but each section has
different ranges.
MHCT is broken down into
Current items (Scales 1-13)
Historical items (Scales A B C D E)
Sub scores and totals cannot be used if there are ratings of 9
16
Scoring MHCT
The following guidance is offered to separate the rating
period for current and historical problems.
The rating period for the first 13 current scales is the 2
week period prior to your clinical assessment.
The rating period for the five historic scales (A-E) is any
point in time prior to the current rating period.
By adhering to this protocol you will ensure that double
counting of the same event / problem is avoided.
17
Points of Assessment
The MHCT will soon be available on your IT system and you should be
able to Cluster your patient and / or record an outcome measure using
exactly the same fields. This will ensure that clinical staff do not have
to make duplicate entries on the system.
Scale 1 does not contribute to cluster determination but is required to
measure health outcome and should always be rated at every point of
assessment.
In practice the required points of assessment are much the same for
both Care Clustering and for routine clinical outcome measurement.
These are at the point of Referral, at any formal Review, at any time of
Crisis and at Transfer from a team or from the service i.e. at any point
where a significant change in need occurs. Clustering is not required at
discharge from Trust services since no care package will be provided,
but clinical outcome measurement is required at discharge.
Only the first 12 original HoNOS scales are used to measure health
outcome and these scales can be used at any other time clinical staff
deem appropriate to monitor the impact of specific clinical
18
interventions.
The MHCT
THE MHCT SCORESHEET
SCALE
1
2
3
4
5
6
7
8
PART 1 (CURRENT SCALES)

SCALE DESCRIPTION
Overactive, aggressive, disruptive or agitated behaviour
Non accidental self injury
Problem drinking or drug taking
Cognitive problems
Physical illness or disability problems
Problems with hallucinations & delusions
Problems with depressed mood
Other mental & behavioural problems
Vignette 1 Vignette 2 Vignette 3 Vignette 4

SCORE
SCORE
SCORE
SCORE
Please specify which problem - A, B, C, D, E, F, G, H, I, J,

NB if you choose 'J' (other problem) then please specify the problem
9
10
11
12
Problems with relationships

Problems with activities of daily living
Problems with living conditions
Problems with occupation and activities
TOTAL HoNOS SCORE FOR OUTCOME MEASUREMENT
13
Strong unreasonable beliefs in non psychotic disorders ONLY

PART 2 (HISTORIC SCALES)
SCALE
SCALE DESCRIPTION
A
Agitated behaviour / expansive mood (historical)
B
Repeat self harm (historical)
C
Safeguarding children and vulnerable dependent adults (historical)
D
Engagement (historical)
E
Vulnerability (historical)
The MHCT contains HoNOS and these scales are Copyright The Royal College of Psychiatrists
The HoNOS is the first 12 scales. Their total score is used to measure health
outcome. The MHCT is all 18 Scales (1-13 then scales A-E). The score profile
19
generated at assessment is used to allocate to a Care Cluster.
MHCT General Guidelines

There is no absolutely correct rating
Rating is the clinical judgement of the rater
Serial ratings should be made by the same rater wherever
possible and where this is not possible the use of multidisciplinary
team ratings should be encouraged
Each mental health/social problem is rated only once
Rate each scale in order from 1 to 13 (Part 1) followed by scales A
to E (Part 2)
Do not include information rated in an earlier scale except for
scale 10 which is an overall rating
Rate the most severe problem that occurred during the period
both current and historical
20
MHCT is not..
A structured clinical assessment tool or interview guide

An assessment of future risk
A measure of health care outcomes or clinical effectiveness
(e.g. interventions)
A substitute for more specific standardised assessment
tools/rating scales
But the MHCT is used to summarise your full clinical
assessment
21
MHCT Features
Are short, simple, acceptable and useful to mental health
professionals
Provide an overview of clinical and social problems
Have a variety of uses for mental health professionals,
administrators and researchers
Are sensitive to improvement, deterioration or lack of
change
HoNOS has a known relationship to more established scales
such as BPRS, role functioning scales
HoNOS is a simple indicator for local and national use of
health outcome if like is compared with like using context
information (e.g. MDS)
22
Part 1
Current Problems
Rate each scale considering the most severe
example that occurred during the 2 weeks
preceding your assessment
23
Health of the Nation Outcome Scales (HoNOS) Royal College of Psychiatrists 1996
Rate 9 if Not Known
1. Overactive, aggressive,
disruptive or agitated behaviour
Include such behaviour due to any cause (e.g. drugs, alcohol,
dementia, psychosis, depression, etc.).
Do not include bizarre behaviour rated at Scale 6.
0 No problem of this kind during the period rated.
1 Irritability, quarrels, restlessness etc. not requiring action.
2 Includes aggressive gestures, pushing or pestering others;
threats or verbal aggression; lesser damage to property
(e.g. broken cup, window); marked overactivity or agitation.
3 Physically aggressive to others or animals (short of rating 4);
threatening manner; more serious overactivity or destruction of
property.
4 At least one serious physical attack on others or on animals;
destructive of property (e.g. fire-setting); serious intimidation or
obscene behaviour.
24
Rate 9 if Not known
2. Non-accidental self-injury
Do not include accidental self-injury (due e.g. to dementia or
severe learning disability); the cognitive problem is rated at Scale
4 and the injury at Scale 5.
Do not include illness or injury as a direct consequence of
drug/alcohol use rated at Scale 3 (e.g. cirrhosis of the liver or
injury resulting from drink driving are rated at Scale 5).
1 Fleeting thoughts about ending it all but little risk during the
period rated; no self-harm.
2 Mild risk during the period rated; includes non-hazardous selfharm (e.g. wrist-scratching).
3 Moderate to serious risk of deliberate self-harm during the period
rated; includes preparatory acts (e.g. collecting tablets).
4 Serious suicidal attempt and/or serious deliberate self-injury
during the period rated.
25
Rate 9 if Not Known
3. Problem-drinking or drug-taking
Do not include aggressive/destructive behaviour due to alcohol or
drug use, rated at Scale 1.
Do not include physical illness or disability due to alcohol or drug
use, rated at Scale 5.
1 Some over-indulgence but within social norm.
2 Loss of control of drinking or drug-taking, but not seriously
addicted.
3 Marked craving or dependence on alcohol or drugs with frequent
loss of control; risk taking under the influence.
4 Incapacitated by alcohol/drug problem.
26
Rate 9 if Not Known
4. Cognitive problems
Include problems of memory, orientation and understanding
associated with any disorder: learning disability, dementia,
schizophrenia, etc.
Do not include temporary problems (e.g. hangovers) resulting
from drug/alcohol use, rated at Scale 3.
1 Minor problems with memory or understanding (e.g. forgets
names occasionally).
2 Mild but definite problems (e.g. has lost the way in a familiar
place or failed to recognise a familiar person); sometimes mixed
up about simple decisions.
3 Marked disorientation in time, place or person; bewildered by
everyday events; speech is sometimes incoherent; mental
slowing.
4 Severe disorientation (e.g. unable to recognise relatives); at risk
of accidents; speech incomprehensible; clouding or stupor.
27
Rate 9 if Not Known
5. Physical illness or disability

problems
Include illness or disability from any cause that limits or prevents
movement, or impairs sight or hearing, or otherwise interferes
with personal functioning.
Include side-effects from medication; effects of drug/alcohol use;
physical disabilities resulting from accidents or self-harm
associated with cognitive problems, drink-driving, etc.
Do not include mental or behavioural problems rated at Scale 4.
0 No physical health problem during the period rated.
1 Minor health problems during the period (e.g. cold, non-serious
fall, etc.).
2 Physical health problem imposes mild restriction on mobility and
activity.
3 Moderate degree of restriction on activity due to physical health
problem.
4 Severe or complete incapacity due to physical health problem.
28
Rate 9 if Not Known
6. Problems associated with

hallucinations and delusions
Include hallucinations and delusions irrespective of diagnosis.
Include odd and bizarre behaviour associated with hallucinations
or delusions.
Do not include aggressive, destructive or overactive behaviours
attributed to hallucinations or delusions, rated at Scale 1.
0 No evidence of hallucinations or delusions during the period rated.
1 Somewhat odd or eccentric beliefs not in keeping with cultural
norms.
2 Delusions or hallucinations (e.g. voices, visions) are present, but
there is little distress to patient or manifestation in bizarre
behaviour, i.e. clinically present but mild.
3 Marked preoccupation with delusions or hallucinations, causing
much distress and/or manifested in obviously bizarre behaviour,
i.e. moderately severe clinical problem.
4 Mental state and behaviour is seriously and adversely affected by
delusions or hallucinations, with severe impact on patient.
29
Rate 9 if Not Known
7. Problems with depressed mood

Do not include overactivity or agitation, rated at Scale 1.
Do not include suicidal ideation or attempts, rated at Scale 2.
Do not include delusions or hallucinations, rated at Scale 6.
0 No problem associated with depressed mood during the period
rated.
1 Gloomy; or minor changes in mood.
2 Mild but definite depression and distress (e.g. feelings of guilt;
loss of self-esteem).
3 Depression with inappropriate self-blame; preoccupied with
feelings of guilt.
4 Severe or very severe depression, with guilt or self-accusation.
30
Rate 9 if Not Known
8. Other mental and

behavioural problems
Rate only the most severe clinical problem not considered at items
6 and 7 as follows.
Specify the type of problem by the entering the appropriate letter:
A phobic; B anxiety; C obsessive-compulsive; D mental
strain/tension; E dissociative; F somatoform; G eating; H sleep; I
sexual; J other, specify.
0 No evidence of any of these problems during period rated.
1 Minor problems only.
2 A problem is clinically present at a mild level (e.g. patient has a
degree of control).
3 Occasional severe attack or distress, with loss of control (e.g. has
to avoid anxiety provoking situations altogether, call in a
neighbour to help, etc.) i.e. moderately severe level of problem.
4 Severe problem dominates most activities.
31
Rate 9 if Not Known
9. Problems with relationships

Rate the patients most severe problem associated with active or
passive withdrawal from social relationships, and/or nonsupportive, destructive or self-damaging relationships.
0 No significant problem during the period.
1 Minor non-clinical problems.
2 Definite problem in making or sustaining supportive relationships:
patient complains and/or problems are evident to others.
3 Persisting major problem due to active or passive withdrawal from
social relationships and/or to relationships that provide little or no
comfort or support.
4 Severe and distressing social isolation due to inability to
communicate socially and/or withdrawal from social relationships.
32
Rate 9 if Not Known
10. Problems with activities of

daily living
Rate the overall level of functioning in activities of daily living
(ADL) (e.g. problems with basic activities of self-care such as
eating, washing, dressing, toilet; also complex skills such as
budgeting, organising where to live, occupation and recreation,
mobility and use of transport, shopping, self-development, etc.).
Include any lack of motivation for using self-help opportunities,
since this contributes to a lower overall level of functioning.
Do not include lack of opportunities for exercising intact abilities
and skills, rated at Scales 11-12.
33
Rate 9 if Not Known
10. Problems with activities of

daily living cont.
0 No problem during period rated; good ability to function in
all areas.
1 Minor problems only (e.g. untidy, disorganised)
2 Self-care adequate, but major lack of performance of one
or more complex skills (see above).
3 Major problem in one or more areas of self-care (eating,
washing, dressing, toilet) as well as major inability to
perform several complex skills.
4 Severe disability or incapacity in all or nearly all areas of
self-care and complex skills.
34
Rate 9 if Not Known
11. Problems with living conditions

Rate the overall severity of problems with the quality of living
conditions and daily domestic routine.
Are the basic necessities met (heat, light, hygiene)? If so, is there
help to cope with disabilities and a choice of opportunities to use
skills and develop new ones?
Do not rate the level of functional disability itself, rated at Scale
10.
NB: Rate patients usual situation. If in acute ward, rate

activities during period before admission. If plan of care
for client to remain in current environment for next 6
months or more rate, current placement not home
setting. If information not available, rate 9.
35
Rate 9 if Not Known
11. Problems with living conditions

cont.
0 Accommodation and living conditions are acceptable; helpful in
keeping any disability rated at Scale 10 to the lowest level
possible, and supportive of self-help.
1 Accommodation is reasonably acceptable although there are minor
or transient problems (e.g. not ideal location, not preferred
option, doesnt like the food, etc.).
2 Significant problem with one or more aspects of the
accommodation and/or regime (e.g. restricted choice; staff or
household have little understanding of how to limit disability or
how to help use or develop new or intact skills).
3 Distressing multiple problems with accommodation (e.g. some
basic necessities absent); housing environment has minimal or no
facilities to improve patients independence.
4 Accommodation is unacceptable (e.g. lack of basic necessities,
patient is at risk of eviction, or roofless, or living conditions are
otherwise intolerable) making patients problems worse.
36
Rate 9 if Not Known
12. Problems with occupation and

activities
Rate the overall level of problems with quality of day-time
environment. Is there help to cope with disabilities, and
opportunities for maintaining or improving occupational and
recreational skills and activities? Consider factors such as stigma,
lack of qualified staff, access to supportive facilities e.g. staffing
and equipment of day centres, workshops, social clubs, etc.
Do not rate the level of functional disability itself, rated at Scale
10.
NB: Rate patients usual situation. If in acute ward, rate

activities during period before admission. If plan of
care for client to remain in current environment for
next 6 months or more rate, current placement not
home setting. If information not available, rate 9.
37
Rate 9 if Not Known
12. Problems with occupation and

activities cont.
0 Patients day-time environment is acceptable: helpful in keeping
any disability rated at Scale 10 to the lowest level possible, and
supportive of self-help.
1 Minor or temporary problems (e.g. late giro cheques): reasonable
facilities available but not always at desired times, etc.
2 Limited choice of activities; lack of reasonable tolerance (e.g.
unfairly refused entry to public library or baths, etc.);
handicapped by lack of a permanent address; insufficient carer or
professional support; helpful day setting available but for very
limited hours.
3 Marked deficiency in skilled services available to help minimise
level of existing disability; no opportunities to use intact skills or
add new ones; unskilled care difficult to access.
4 Lack of any opportunity for daytime activities makes patients
problems worse.
38
Practice vignette 20 minutes

Arrange yourselves in groups.
Decide severity on these first 12 scales ONLY using the glossary in your
Mental Health Clustering Booklet (pages 7-9) and record your severity
rating for each scale on the score sheet provided.
Negotiate an agreed score between participants in your group.
One member of each group to be identified to speak for the group
explaining the rationale for the scores you have agreed.
39
Scale 13
Rate 9 if Not Known

(Current)
Strong unreasonable beliefs

occurring in non-psychotic
disorders only.
Rate any apparent strong unreasonable beliefs (found in some
people with disorders such as Obsessive Compulsive Disorder,
Anorexia Nervosa, personality disorder, morbid jealousy etc.)
Do not include Delusions rated at scale 6.
Do not include Severity of disorders listed above where strong
unreasonable beliefs are not present rated at Scale 8.
Do not include Beliefs / behaviours consistent with a persons
culture.
40
Rate 9 if Not Known
Scale 13
(Current)
Strong unreasonable beliefs

occurring in non-psychotic
disorders only.
0 No Strong unreasonable beliefs evident.
1 Holds illogical or unreasonable belief(s) but has insight into their lack of logic or
reasonableness and can challenge them most of the time and they have only a
minor impact on the individuals life.
2 Holds illogical or unreasonable belief(s) but individual has insight into their lack
of logic or reasonableness. Belief(s) can be successfully challenged by
individual on occasions. Does not have a significant negative impact on the
persons life.
3 Holds strong illogical and unreasonable belief(s) but has some insight into the
relationship between the beliefs and the disorder. Belief(s) can be shaken by
rational argument. Tries to resist belief but with little effect. Has a significant
negative impact on persons life. The disorder makes treatment more difficult
than usual.
4 Holds strong illogical or unreasonable belief(s) with little or no insight in the
relationship between the belief and the disorder. Belief(s) cannot be shaken
by rational argument. Does not attempt to resist belief(s). Has a significant
negative impact on the persons life or other peoples lives and the disorder is
very resistant to treatment.
N.B. Additional rating scales (e.g. for cultural diversity, mental
capacity, participation and carers support) may be included at this
41
point in subsequent versions of this data set.
Part 2
Historical Ratings
Rate each scale considering the most
severe example that occurred prior to
the current rating period
42
Guidance on Historical Ratings

For scales A to E, rate problems that occur in an episodic or
unpredictable way. Whilst there may not be any direct
observation or report of a manifestation during the last two
weeks the evidence and clinical judgement would suggest that
there is still a cause for concern that cannot be disregarded (i.e.
no evidence to suggest that the person has changed since the
last occurrence either as a result of time, therapy, medication or
environment etc.)
In these circumstances, any event that remains relevant to the
current plan of care or risk management plan should be
included.
Therefore the rules for historic items differ from the first 13
items considered in the current rating period - Severity on these
items only considers past behaviour / events to the extent that
they remain relevant to current care planning and in
circumstances where the patient has not changed since the last
occurrence.
43
Rate 9 if Not Known
A. Agitated behaviour/
expansive mood (historical)
Rate agitation and overactive behaviour causing
disruption to social role functioning. Behaviour causing
concern or harm to others. Elevated mood that is out of
proportion to circumstances.
Include such behaviour due to any cause (e.g. drugs,
alcohol, dementia, psychosis, depression etc)
Excessive irritability, restlessness, intimidation, obscene
behaviour and aggression to people animals or property.
Do not include odd or bizarre behaviour to be rated at
Scale 6.
44
Rate 9 if Not Known
A. Agitated behaviour/
expansive mood (historical)
0 No needs in this area.
1 Presents as irritable, argumentative with some agitation. Some
signs of elevated mood or agitation not causing disruption to
functioning.
2 Makes verbal / gestural threats. Pushes / pesters but no evidence
of intent to cause serious harm. Causes minor damage to
property (e.g. glass or crockery). Is obviously over-active or
agitated.
3 Agitation or threatening manner causing fear in others. Physical
aggression to people or animals. Property destruction. Serious
levels of elevated mood, agitation, restlessness causing significant
disruption to functioning.
4 Serious physical harm caused to persons / animals. Major
destruction of property. Seriously intimidating others or
exhibiting highly obscene behaviour. Elevated mood, agitation,
restlessness causing complete disruption.
45
Rate 9 if Not Known
B. Repeat self-harm
(historical)
Rate repeat acts of self harm aimed at managing people, stressful

situations, emotions or to produce mutilation for any reason.
Include self cutting, biting, striking, burning, breaking bones or
taking poisonous substances etc.
Do not include accidental self-injury (due e.g. to learning disability
or cognitive impairment); the cognitive problem is rated at Scale 4
and the injury at Scale 5.
Do not include harm as a direct consequence of drug / alcohol use
(e.g. liver damage) to be rated at Scale 3. Injury sustained whilst
intoxicated to be rated at Scale 5.
Do not include harm with intention of killing self rated at Scale 2.
46
Rate 9 if Not Known
B. Repeat self-harm
(historical)
0 No problem of this kind.

1 Superficial scratching or non-hazardous doses of drugs.
2 Superficial cutting, biting, bruising etc or small ingestions of
hazardous substances unlikely to lead to significant harm
even if hospital treatment not sought.
3 Repeat self-injury requiring hospital treatment. Possible
dangers if hospital treatment not sought. However, unlikely
to leave lasting severe damage even if behaviour continues
providing hospital treatment sought.
4 Repeat serious self-injury requiring hospital treatment and
likely to leave lasting severe damage if behaviour continues
(i.e., severe scarring, crippling or damage to internal organ)
and possibly to death.
47
Rate 9 if Not Known
C. Safeguarding Children &

Vulnerable Dependent
Adults (historical)
Rate the potential or actual impact of the patients mental
illness, or behaviour, on the safety and well being of
vulnerable and dependent persons, including children,
vulnerable adults and dependent elders.
Include any patient who lives in a household with children
under the age of 18 years.
Include any patient who has substantial access and contact
with children or other vulnerable persons.
Do not include risk to wider population covered at scale A.
Do not include challenge to relations covered in scale 9.
48
Rate 9 if Not Known
C. Safeguarding Children &

Vulnerable Dependent
Adults (historical)
0 No obvious impact of the individuals illness or behaviour on the
safety or well being of vulnerable persons.
1 Mild concerns about the impact of the individuals illness or behaviour
on the safety or well-being of vulnerable persons.
2 Illness or behaviour has an impact on the safety or well being of
vulnerable persons. The individual is aware of the potential impact
but is supported and is able to make adequate arrangements.
3 Illness or behaviour has an impact on the safety or well being of
vulnerable persons but does not meet the criteria to score 4. There
may be delusions, suicide risk or self-harm. However, the individual
has insight, can take action to significantly reduce the impact of their
behaviour on the children and is adequately supported.
4 Without action the illness or behaviour is likely to have direct or
indirect significant impact on the safety or well-being of vulnerable
persons. Problems such as delusions, severe suicide risk or problems
of impulse control may be present. There may be lack of insight, an
inability or unwillingness to take precautions to protect vulnerable
persons and/or lack of adequate support and protection for vulnerable
persons.
49
Rate 9 if Not Known
D. Engagement
(historical)
Rate the individuals motivation and understanding of their

problems, acceptance of their care/treatment and ability to
relate to care staff.
Include the ability, willingness or motivation to engage in
their care/ treatment appropriately, agreeing personal goals,
attending appointments. Dependency issues.
Do not include Cognitive issues as in scale 4, severity of
illness or failure to comply due to practical reasons.
50
Rate 9 if Not Known
D. Engagement
(historical)
0 Has ability to engage / disengage appropriately with services. Has

good understanding of problems and care plan.
1 Some reluctance to engage or slight risk of dependency. Has
understanding of own problems.
2 Occasional difficulties in engagement i.e. missed appointments or
contacting services between appointments inappropriately. Some
understanding of own problems.
3 Contacts services inappropriately. Has little understanding of own
problems. Unreliable attendance at appointments.
Or attendance depends on prompting or support.
4 Contacts multiple agencies i.e. GP, A & E etc, constantly. Little or no
understanding of own problems. Fails to comply with planned care.
Rarely attends appointments. Refuses service input.
Or Attendance and compliance dependent on intensive prompting and
support.
51
Rate 9 if Not Known
E. Vulnerability
(historical)
Rate failure of an individual to protect themselves from risk

of harm to their health and safety or well-being.
Include physical, sexual, emotional and financial
exploitation or harm/ harassment
Do not include problems of engagement (rated at scale D).
52
Rate 9 if Not Known
E. Vulnerability
(historical)
0 No vulnerability evident.
1 No significant impact on persons health, safety or well-being.
2 Concern about the individuals ability to protect their health,
safety or well-being requiring support or removal of existing
support would increase concern.
3 Clear evidence of significant vulnerability affecting the individuals
ability to protect their health and safety or well-being that
requires support (but not as severe as a score of 4).Or removal
of existing support would increase risk.
4 Severe vulnerability total breakdown in individual's ability to
protect themselves resulting in major risk to the individual's
health, safety or well-being.
53
Complete Practice Vignette

Arrange yourselves in groups again.
Decide severity on these last 6 scales ONLY using the
glossary in your Mental Health Clustering Booklet (pages 911) and record your severity rating for each scale on the
scoresheet provided.
Negotiate an agreed score between participants in your group.
One member of the group to be identified to speak for the
group explaining the rationale for the scores you have agreed.
54
Data Quality
If we are to use HoNOS or MHCT data to benchmark and
evaluate services to drive service improvement, we need
some assurance about the data quality.
A brief one-off training course is not sufficient to guarantee
comparability between individual raters or between groups
of raters. Practice is required to maintain reliability and
efficiency.
Serial ratings should be made by the same rater wherever
possible or within MDT discussions and local protocols that
guide practice and encourage this should be agreed.
Ratings that include 9 cannot be used to measure
outcomes or allocate to clusters.
55
Benchmarking individual HoNOS

scores
http://wdst.mhnocc.org/
Reports available for:
HoNOS, HoNOSCA and HoNOS65+
Collection occasion status and episode of care change
scores
For total, subscale or individual item scores
Reports can be stratified by:
Gender [all, male, female]
Service setting [inpatient, residential, ambulatory]
Age [10 year bands]
Collection occasion [admission, discharge, review]
Diagnosis
56
57
Using aggregated HoNOS data

For similar groups of clients within similar services
Measuring trends over time
Evaluating service redesign/new interventions and ways of
working
Benchmarking using casemix/severity score profiles for
services
Benchmarking the outcomes of services
An internationally recognised, standard record for clinical
research
58
Using aggregated HoNOS data
Examples of the use of aggregated HoNOS scores will

be provided on the day by your trainer a copy of the
slide set covering the aggregated uses is set out in this
training booklet.
The Royal College of Psychiatrists would like to thank

Kevin Smith and Prof Alastair MacDonald for their
permissions to use the materials generated by their
work in this section.
59

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HoNOS and the Mental Health

Clustering Tool (MHCT)

Day one - agenda

Aims and Objectives

Its use is mandated across mental health services in

The MHCT is..

What does MHCT Provide?

Are HoNOS scales robust?

Problem profile and severity for people with non affective

F20-29 - mean scores at admission

Australia (n = > 34,000)

Royal College of Psychiatrists 2010

Summary of the Clinical Benefits of

Benefits of Clustering for PbR in Mental

Patient classification system to describe and

Tool for demand and capacity modelling to

5 Gap analysis to inform service development

Tool to support service redesign

A standard record of progress for all clients in

Provides practice based evidence of the clinical

Currencies from which to develop local PbR

Royal College of Psychiatrists 2010

HoNOS other versions

MHCT was not constructed to measure mental health

The glossary provides further information on each ITEM and

PART 1 (CURRENT SCALES)

Vignette 1 Vignette 2 Vignette 3 Vignette 4

Please specify which problem - A, B, C, D, E, F, G, H, I, J,

Problems with relationships

Strong unreasonable beliefs in non psychotic disorders ONLY

MHCT General Guidelines

A structured clinical assessment tool or interview guide

Rate 9 if Not Known

Rate 9 if Not known

Rate 9 if Not Known

Rate 9 if Not Known

Rate 9 if Not Known

5. Physical illness or disability

Rate 9 if Not Known

6. Problems associated with

Rate 9 if Not Known

7. Problems with depressed mood

Rate 9 if Not Known

8. Other mental and

Rate 9 if Not Known

9. Problems with relationships

Rate 9 if Not Known

10. Problems with activities of

Rate 9 if Not Known

10. Problems with activities of

Rate 9 if Not Known

11. Problems with living conditions

NB: Rate patients usual situation. If in acute ward, rate

Rate 9 if Not Known

11. Problems with living conditions

Rate 9 if Not Known

12. Problems with occupation and

NB: Rate patients usual situation. If in acute ward, rate

Rate 9 if Not Known

12. Problems with occupation and

Practice vignette 20 minutes

Rate 9 if Not Known

Strong unreasonable beliefs