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HoNOS – their utility for payment by results in mental health

Barry L Speak (Department of Psychology Management, Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK)
Paula Hay (Department of Finance, Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK)
Steven J Muncer (School of Health and Social Care, Teesside University, Middlesbrough, UK)

International Journal of Health Care Quality Assurance

ISSN: 0952-6862

Article publication date: 9 March 2015




The purpose of this paper is to present findings from two studies exploring the Health of the Nation Outcome Scale’s (HoNOS) utility within a new payment by results (PbR) system for mental health services in England.


In the first study principal axis factoring extraction was used to explore a sample of 23,641 HoNOS ratings. In a second study confirmatory factor analysis was used to evaluate four subscale structures on a new sample of 34,716 HoNOS ratings.


No HoNOS factor structure evaluated in this study demonstrated adequate fit statistics across several clinical presentations. A new four-factor model was the only structure to achieve fit statistics across all clinical populations, but can only be championed on a “best fit” basis as opposed to “good fit” at the present time.

Research limitations/implications

Data used in the current studies relate to six NHS mental health service providers. Replication using a national sample is recommended. Exploration of different HoNOS factor structures for different mental health clusters within the PbR system in England is also recommended. However, it is also possible that removing redundant or adding new items may result in a more stable HoNOS generic factor structure.


This is the first HoNOS evaluation as a generic outcome measure for use within a PbR system and provides important insights into its mental health utility and limitations. The findings have significant implications for those developing the national PbR quality and outcomes framework for England’s mental health services. However, there are also implications for all nations in which HoNOS is used to report mental health outcomes.



The authors would like to acknowledge and thank Mr Bob Craig, Clinical Lead for PbR in Tees, Esk and Wear Valleys NHS Foundation Trust, for his advice and expertise on PbR and mental health clustering.


Speak, B.L., Hay, P. and Muncer, S.J. (2015), "HoNOS – their utility for payment by results in mental health", International Journal of Health Care Quality Assurance, Vol. 28 No. 2, pp. 115-128.



Emerald Group Publishing Limited

Copyright © 2015, Emerald Group Publishing Limited

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