Letter to the editor: Resettlement and the Health of the Nation Outcome Scales (HoNOS) in the elderly

The mental health policy in England over recent years has been to care for people with mental illness as close to home as is compatible with health and safety (NHS Executive, 1996). The bene®ts of resettlement into the community in long-stay elderly patients have been described by Trieman et al. (1996), who noted that the detoriation in cognition was less than in those who remained in hospital. The Health of the Nation Outcome Scales (HoNOS) were developed following the need for an instrument to quantify and measure progress towards a Health of the Nation target set up by the Department of Health (Wing et al., 1998). The scales form a 12-item instrument covering behavioural, clinical and social problems with item scores ranging from 0 to 4 covering `no problem' to `severe'. In a study of a cohort of elderly longstay psychiatric patients resettled into a purpose-built modern residential/nursing home, we set out to monitor them over an 18-month period using the Health of the Nation Outcome Scales. A group of elderly patients who remained in hospital over the same period were similarly assessed for comparison with the resettled group. Ratings using HoNOS were carried out for the 2-week period in July 1996 prior to transfer into the community from longstay inpatient care. At the same time, two long-stay wards in a psychiatric hospital in the northern outskirts of London were selected to carry out NoHOS ratings over the same period. The HoNOS ratings over the period prior to resettlement were carried out by the same investigator for both groups. Eighteen months after resettlement, a second investigator rated both groups again using HoNOS. The investigators received training in using HoNOS and the HoNOS glossary for guidance in rating. Our results were analysed using descriptive statistics and HoNOS ratings compared using the chi-squared test and paired t-test with level of signi®cance set at p5 0.05. There were 20 resettled patients, consisting of 12 (60%) males and eight (40%) females with a mean age of 79 (SD 7.9) years, compared to 23 longstay inpatients made up of 11 (47.8%) males and 12 (52.2%) females with a mean age of 78 (SD 7.9) years. Schizophrenia was the most common diagnosis in the resettled group, being present in 16 (80%) patients, while in the longstay inpatient group there were nine (39.1%) patients with dementia and an equal number with schizophrenia. HoNOS ratings indicated an improvement in physical illness and disability problems in the resettled group on follow-up 18 months later (Table 1). In more than half the resettled patients, the predominant problems prior to resettlement were in cognition, physical illnesses and activities of daily living compared to after resettlement, when in more than half of the patients there were problems in relationships and activities of daily living. In the longstay group, in more than half of the patients HoNOS identi®ed problems in cognition, physical illnesses and activities of daily living at the onset of the study, compared to 18 months later, when in over half the patients the predominant problems were in cognition, physical illnesses, relationships and activities of daily living, with a signi®cant worsening in relationship problems occurring. The mean total HoNOS score for the longstay patients was signi®cantly higher on follow-up, while in the resettled patients there was a trend towards a lower score. This study gave us the opportunity to observe two groups of elderly psychiatric patients in dierent settings using HoNOS. Resettlement in the elderly can result in increased mortality, especially where the disruption of the patient group and nursing sta is maximum (Robertson et al., 1993). To overcome this problem in our