Health Of The Nation Outcome Scales Research Articles

The meagre outcomes of HoNOS.

To ask the Leginski question of an outcome measurement process. Articles elicited by a literature search of 'HoNOS' are analysed for evidence of its value or cost effectiveness to consumers, clinicians or administrators. None of the 260 studies elicited by the search attempted to assess the cost of the use of Health of the Nation Outcome Scale (HoNOS). One study investigated the effect of routine outcome measurement, finding that it failed to result in the provision of evidence-based care. One study reported positive outcomes. The ability of HoNOS to improve the health and social functioning of mentally ill people has not been demonstrated. The widespread use of HoNOS as a routine outcome measure is not justified by the evidence.

Reliable and clinically significant change based on the Health of the Nation Outcome Scales

To evaluate treatment outcomes of individual patients based on clinician-rated instruments, the assessment of reliable and clinically significant change (RCSC) is essential. In heterogeneous samples, RCSC underestimates treatment outcome. Therefore, the Reliable Change Index (RCI) was adjusted by a stratification into subsamples. This method was tested on the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) ratings (n = 12,547) at admission and discharge of youths (age 6-18 years) treated in ten psychiatric institutions. Based on the test-retest reliability of a subsample (n = 397), the RCI was calculated for three severity groups ("very severe," "moderately severe," and "subclinical/mild"). Individuals who accomplished reliable change during treatment and moved to a subclinical score were classified as recovered. Using the traditional RCSC calculation, the large majority (75.1%) of the sample would be considered as unchanged, 2.9% as deteriorated, 18.9% as improved, and 3.1% as recovered. Using RCI cutoff points based on the severity ratings at admission results in a more representative distribution of outcome groups, where 54.6% of the sample was stable, 7.5% worsened, 21.6% improved, and 16.3% recovered. This methodological framework for calculating RCSC for heterogeneous populations is applicable for all HoNOS instruments, making it very useful for mental health professionals.

A profile of adolescents admitted to a private inpatient unit and mental health outcomes.

To characterise adolescents admitted to a voluntary adolescent inpatient unit and investigate treatment outcomes. A retrospective cohort design was employed. Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) pre- and post-admission scores were collected, measuring global functioning. Demographic variables such as age, gender, primary diagnosis, comorbidity and length of stay (LOS) were analysed. Data were collected from May 2017 to April 2018. All adolescents admitted to the inpatient unit were included. The majority of adolescents (n = 72; HoNOSCA data available on n = 57) were 16 years of age (26%), female (82%) and with a primary diagnosis of a mood disorder (57%). Most adolescents improved at the time of discharge. Self-injury and emotional symptoms had greater reductions according to clinician and adolescent-self-ratings (p < 0.01). Mean change (improvement) in HoNOSCA total score was 7.3 (SD 7.5) based on clinician ratings and 7.2 (SD 9.5) for adolescent-self-ratings. The mean LOS was 28 days (SD 15.8). The inpatient unit proved effective at meeting the needs of young people in terms of symptom stabilisation. Further research is needed to describe adolescent inpatient models of care, the operations and philosophies to better examine how these relate to treatment outcomes.

Use of self-report outcome measures in an acute inpatient CAMHS setting.

Outcome measures are increasingly being used to index change in service users' presentation. However, within Child and Adolescent Mental Health Services (CAMHS), these raise questions around what should be measured, who should be asked to rate outcome and what constitutes progress. This study sought to audit the value of two self-report measures within the inpatient adolescent setting. An admission sample of 67 young people completed the Revised Child Anxiety and Depression Scale (RCADS) and Young Person's Clinical Outcomes in Routine Evaluation (YP CORE), with clinicians completing the Children's Global Assessment Scale (CGAS) and Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). A follow-up dataset consisted of 20 young people who completed the measures on two occasions, with clinician ratings completed on admission and discharge. The RCADS and YP CORE measures showed discriminant and convergent reliability and appeared to index change in the current inpatient sample of adolescents. Self-report of symptoms and general functioning were closely related. There was little relationship between self-report and clinician ratings, emphasising the importance of collating self-report in addition to clinician ratings.

Measuring outcomes on a Medical Psychiatric Unit: HoNOS,, CANSAS and costs

ObjectiveTo study the course of the functional status and healthcare needs of patients on a Medical Psychiatric Unit (MPU). MethodsIn a single-centre observational prospective design the Health of the Nation Outcome Scales (HoNOS) and Camberwell Assessment of Needs Short Appraisal Schedule (CANSAS) instruments were administered at admission and discharge. Functional status and healthcare needs were assessed utilizing the HoNOS and CANSAS respectively. The total costs of healthcare claims related to the admission were calculated based on claims data. ResultsIn total 50 patients were included with a mean improvement of 4.6 on the HoNOS and an effect size of 0.6.The total number of unmet needs fell from 208 to 115. The median costs per decreased HoNOS point were €2.842 and €6.880 per unmet need. DiscussionMany patients improved, but due to a large standard deviation at baseline and a low Cronbach's alpha, only 4 patients showed a reliable improvement on functional status. That substantial remission was achieved was shown by the decrease in unmet needs of 93 (44.7%) for the whole group. These observations support the implementation of MPUs, although more research is warranted to ensure cost-effectiveness.

Evaluating the cost and clinical effectiveness of long-acting, injectable aripiprazole and paliperidone palmitate once a month in a real-world setting.

BackgroundAntipsychotics are an effective treatment option for patients with schizophrenia and several long-acting injectables (LAIs), including risperidone, olanzapine, paliperidone, and aripiprazole are available in the UK. Treatment adherence is an issue in severe mental illness and LAIs have been hypothesized to offer clinical advantages over their oral equivalents. However, meta-analyses of randomized clinical trials and mirror-image studies have yielded equivocal results and have focused on economic rather than clinical outcomes.ObjectiveThis study evaluated routinely collected data to ascertain cost-effectiveness and clinical outcomes of two LAIs, aripiprazole and paliperidone palmitate once a month. Clinical effectiveness was assessed using the Health of the Nation Outcome Scale (HoNOS) scores.Materials and methodsA 1-year mirror image observational study of patients cared for by North Staffordshire Combined Healthcare Trust who received either the LAIs aripiprazole or paliperidone once a month from 2011 until the end of the study in 2016. The primary outcome was the effectiveness of the LAIs using a mirror-image design with HoNOS scores and bed use as the main outcomes.ResultsA total of 30 patients received aripiprazole and 84 received paliperidone once a month during the study period. A significant reduction in bed use was accompanied by clinical improvements, as measured by the HoNOS for both study drugs (aripiprazole: 13.4 before vs 8.7 after [P=0.001]; paliperidone: 15.8 before vs 12.9 after [P=0.02]). Analysis of several metabolic markers showed mean values within the normal range but the mean prolactin level in patients treated with paliperidone once a month was elevated.ConclusionThe LAIs aripiprazole and paliperidone once a month are associated with clinical improvement and reduced bed use. Routine data gathering using, for example, HoNOS will offer the opportunity to provide additional insights into the clinical and cost benefits associated with LAIs and other interventions in the treatment of schizophrenia.

Outcome measurement in mental health services: insights from symptom networks

BackgroundIn mental health, outcomes are currently measured by changes of individual scores. However, such an analysis on individual scores does not take into account the interaction between symptoms, which could yield crucial information while investigating outcomes. Network analysis techniques can be used to routinely study these systems of interacting symptoms. The present study aimed at comparing outcomes using individual scores vs. symptom networks, after a 1 year intervention at a local community mental health centre.MethodsWe used the Health of the Nation Outcomes Scales, which defines a set of 12 scales investigating mental health and social functioning. We first assessed how individual scores varied from baseline to end point and which items were associated to treatment response. Second, using network analysis techniques, we measured the overall connectivity of the networks and determined the most important symptoms.ResultsThe individual scores analysis revealed a significant improvement amongst most scales. No specific factors were related to treatment response at end point. At end point, network analysis revealed a very densely connected network while agitation and substance use were the most connected symptoms.ConclusionsIndividual scores and symptom network analysis resulted in very different outcomes, with network analysis toning down positive results gained from individual scores analysis. The strong connectivity of patients’ network at end point may reflect their increased complexity. Allocating more resources to interventions tailored to symptoms that are the most connected would decrease network connectivity and improve patients’ prognosis. When investigating outcomes, network analysis could give insights complementary to standard analysis on individual scores.

A model for predicting missing items on the Health of the Nation Outcome Scale (HoNOS)

HoNOS is one of the most widely used clinician rated outcome measures in mental health services. A commonly encountered problem is that one or more of the 12 individual HoNOS items is left uncompleted (missing data rates of up to 25% have been reported), which affects the degree to which organisations can rely on the accuracy of historical HoNOS data. In this brief paper we outline a simple statistical method of predicting missing item scores for HoNOS, both in general adult and 65+ populations. The method accounts for the average pattern of responding being non-uniform across items: i.e., some HoNOS items consistently elicit higher scores than others. By calculating individual item weights based on a very large sample of fully completed HoNOS assessments, we were able to accurately predict the value of missing items in a new sample. We contrast the accuracy of this approach with two other simple statistical procedures, and show that the weighted means model returns a much lower error rate. Although this is not the only method of predicting missing items, it carries the advantages of being: (i) free of charge, (ii) easily applicable to large datasets using a spreadsheet and (iii) unreliant on the availability of previous assessment data for the same patients. We hope this method will be of use to other organisations that are processing large volumes of HoNOS data.

Outcome-based providing and commissioning: pathways and standards.

Aims and methodImplementation of evidence-based psychosocial interventions in accordance with National Institute of Health and Care Excellence guidelines and quality standards has been incomplete. This project involved allocation of adults under mental health services to six guideline categories, completion of a clinician- and patient-rated outcome measure, and individual assessment against clinical standards. RESULTS: In the first 3 months of the project, 5048 patients were allocated to a pathway and 3734 (73%) were assessed against at least one of the relevant standards. All were assessed using the Health of the Nation Outcome Scales (91-93% of scales completed) and 1866 (36%) completed the patient-rated outcome measure, DIALOG.Clinical implicationsClinicians will allocate patients to pathways, complete outcome measures and assess against standards, providing data to guide practice, service design and costing of mental health systems with supporting technology to assist data entry and presentation. This has the potential to provide much improved and readily accessible information about individual outcomes and standards for people with mental health problems and those working with them. It could also provide a method for payment for services which directly support good clinical practice.Declaration of interestNone.

Predictors of disengagement from cognitive behavioural therapy for psychosis in a National Health Service setting: A retrospective evaluation

To evaluate whether demographic and clinical variables are related to disengagement rates in cognitive behavioural therapy (CBT) for psychosis in a clinical setting. The medical records and symptom severity data (from Health of the Nation Outcome Scales) were analysed retrospectively for 103 referrals for CBT for psychosis in a National Health Service secondary care and Early Intervention in Psychosis team. Overall, 42.7% (n=44) disengaged from CBT. There was no impact of gender or ethnicity, and no impact of clinical variables such as risk history and comorbid diagnosis. However, risk of disengagement was significantly higher for those who were younger, F=6.89, partial η2 =.064, p=<.05; those with greater total HoNOS scores, F=4.22, partial η2 =.04, p<.05; more severe symptoms on the HoNOS items of overactive, aggressive, disruptive, or agitated behaviour, χ2 =6.13, p<.01; problem drinking or drug taking, χ2 =7.65, p<.05; depressed mood, χ2 =7.0, p<.01; and problems with occupation and activities: χ2 =3.68, p<.05. There was a non-significant trend for shorter waiting times to be associated with greater levels of disengagement. These results indicate that it may not be psychosis per se that disrupts engagement in CBT, but linked behavioural and emotional factors. A more assertive approach to these factors - overactive, aggressive, disruptive, or agitated behaviour, problem drinking or drug taking, depressed mood, and problems with occupation and activities, particularly in younger people - may be valuable prior to or early on in therapy as a means of increasing engagement in CBT for psychosis. Risk of disengagement from CBT for psychosis increases with overactive, aggressive, disruptive, or agitated behaviour (54.9% vs. 30.8%), problem drinking and drug taking (61.1% vs. 32.8%), depressed mood (56% vs. 30.2%), and problems with occupation and activities (53.3% vs. 34.5%), with a trend for younger age. An assertive and motivational approach to engagement and a focus on addressing low mood and problematic behaviours, prior to or early in therapy, may be warranted, particularly for younger people. This evaluation is limited by small sample size and being retrospective. These results speak to the question of whether psychosis itself renders people inappropriate for CBT for psychosis, or whether problems arise due to behavioural and emotional factors that might be addressed to increase access to CBT for psychosis.

Implementation of outcome measurement (HoNOS) in an outpatient psychiatric clinic in Sligo/Leitrim mental health service.

Routine clinical outcome monitoring (RCOM) is the standardised gathering of measures of clinical outcomes in everyday practice. HoNOS (Health of the Nation Outcome Scales) is a tool used in RCOM. To examine (a) agreement between HoNOS and Global Assessment of Functioning (GAF), (b) HoNOS changes over time/attendance and (c) clinical parameters affecting HoNOS scores. Data from outpatient clinics were collected at each contact over 2years until June 2016 including: gender, age, diagnosis (ICD-10) and HoNOS scores. In a subsample, the GAF also were completed by community psychiatric nurses blind to HoNOS scores. A number of 470 outpatients have undergone 1125 HoNOS assessments during the study period. Mean age of the attendants was 43.12; SD 14.6. Male = 220 (46.8%). Longitudinal analysis demonstrated that lower HoNOS scores are independently significantly associated to number of assessments and diagnosis in ICD-10 categories of F20-F29 (Schizophrenia, schizotypal and delusional disorders) F30-F39 (mood disorders) F40-F48 (neurotic, stress-related and somatoform disorders) and F50-F59 (behavioural disorders associated with physiological disturbances). Gender and age were not significantly associated with decline of HoNOS scores. Neither were other diagnostic categories. Agreement between HoNOS and GAF was excellent (N = 261, rho = - 0.919, p < 0.001). This study shows that HoNOS is a feasible instrument which can be potentially used in ROCM in mental health services in Ireland and supports further the need for implementation of routine measurements in Mental Health Services. It adds longitudinal data which is lacking in similar previous studies.

Home treatment for acute mental healthcare: randomised controlled trial.

Home treatment has been proposed as an alternative to acute in-patient care for mentally ill patients. However, there is only moderate evidence in support of home treatment. To test whether and to what degree home treatment services would enable a reduction (substitution) of hospital use. A total of 707 consecutively admitted adult patients with a broad spectrum of mental disorders (ICD-10: F2-F6, F8-F9, Z) experiencing crises that necessitated immediate admission to hospital, were randomly allocated to either a service model including a home treatment alternative to hospital care (experimental group) or a conventional service model that lacked a home treatment alternative to in-patient care (control group) (trial registration at ClinicalTrials.gov: NCT02322437). The mean number of hospital days per patient within 24 months after the index crisis necessitating hospital admission (primary outcome) was reduced by 30.4% (mean 41.3 v. 59.3, P<0.001) when a home treatment team was available (intention-to-treat analysis). Regarding secondary outcomes, average overall treatment duration (hospital days + home treatment days) per patient (mean 50.4 v. 59.3, P = 0.969) and mean number of hospital admissions per patient (mean 1.86 v. 1.93, P = 0.885) did not differ statistically significantly between the experimental and control groups within 24 months after the index crisis. There were no significant between-group differences regarding clinical and social outcomes (Health of the Nation Outcome Scales: mean 9.9 v. 9.7, P = 0.652) or patient satisfaction with care (Perception of Care questionnaire: mean 0.78 v. 0.80, P = 0.242). Home treatment services can reduce hospital use among severely ill patients in acute crises and seem to result in comparable clinical/social outcomes and patient satisfaction as standard in-patient care.

Protocol for a prospective, longitudinal mixed-methods case study: supporting a Model of Care for Healthier Adolescents (The MoCHA study)

IntroductionImproving mental healthcare for adolescents is a global policy priority. Despite demands for community-based services, many adolescents require more intensive interventions, such as an inpatient admission. This is typically at...

Severe Mental Illness in Community Mental Health Care in Spain: Prevalence and Related Factors.

The aims of this study were to determine the prevalence of severe mental illness (SMI) in patients in contact with mental health services and to determine the factors associated with SMI. A total of 260 patients who met diagnostic criteria for SMI were assessed using the Global Assessment of Functioning (GAF) scale and Health of the Nation Outcome Scales. The overall prevalence of SMI was 6.08 per thousand. According to the three different cutoff points with GAF, the prevalence of SMI ranged from 5.38 per thousand under the weak criterion (GAF < 70) to 1.01 per thousand under the strict criterion (GAF < 50). In the regression model, the dependent variable (presence of SMI) was defined using a GAF < 60, and the variables independently associated with the dependent variable were years of disease duration since diagnose, mental health service use, alcohol or other substance abuse, and depressive anxiety and other psychological symptoms.

Service evaluation of the need for care and clinical risk management procedures using the Health of the Nation Outcome Scale (HoNOS) secure

Purpose The purpose of this paper is to explore whether the current forensic mental health inpatient population within a medium secure unit is more or less complex (i.e. clinical and risk presentations) than former years using the Health of the Nation Outcome Scale (HoNOS) secure. Additionally, the use of the HoNOS secure as a service-wide measure is discussed in terms of its usefulness. Clinical implications and recommendations are offered for the continued use of the HoNOS secure in services more widely. Design/methodology/approach A retrospective case review of completed HoNOS secure assessments for 130 patients over three time intervals 2012, 2015 and 2018 was used. A multivariate analysis was performed on the data using SPSS version 25. Findings The findings revealed that contrary to clinical opinion, inpatients’ clinical and risk presentations had not changed significantly overtime. Research limitations/implications The study shows the benefits of using the HoNOS secure at a service-wide level to explore and understand similarities and differences in inpatient admissions over time. It also highlights the usefulness of the HoNOS secure for considering different ward characteristics and the needs of patients residing in these environments. Originality/value Although much research exists surrounding the individual use of the HoNOS secure in relation to outcomes, there is limited research focusing on use of the HoNOS secure at the service level. The paper therefore provides evidence of the utility and value of the HoNOS secure as a service-level outcome measure.

Do patients get better? A review of outcomes from a crisis house and home treatment team partnership

Aims and methodThe Tower Hamlets Crisis House (voluntary sector), in partnership with the local home treatment team, offers a brief residential alternative to psychiatric hospital admission. Here, we review clinician-reported (Health of the Nation Outcome Scales; HoNOS) and patient-reported (DIALOG) outcome scores collected from successive admissions between June 2015 and December 2016, to assess the effectiveness of the service model. We identified 153 successive admissions, and of these, 85 (55.6%) and 91 (59.5%) patients completed both admission and discharge DIALOG and HoNOS questionnaires, respectively. We analysed ten out of twelve HoNOS domains and eight patient-reported outcome measure DIALOG domains. RESULTS: We found a statistically significant improvement in nine out of ten domains of HoNOS and three out of eight domains of DIALOG.Clinical implicationsA partnership between a home treatment team and crisis house can result in positive outcomes for patients, as determined by both clinicians and patients.Declaration of interestNone.

Early intervention service for first episode psychosis in Modena, Northern Italy: The first hundred cases.

To report on the development of an early intervention service in Modena, Italy, with information relevant to the first 4 years of implementation. The 2-year service was offered to people aged 18-35 with psychotic manifestations, within 2 years from psychosis onset/or naïve to antipsychotics, by teams placed within community mental health Centres, according to a "specialist within generalist" model. Treatment included pharmacological consultation, psychoeducation and social inclusion programs. Health of the Nation Outcome Scale was administered at baseline and every 6 months. One hundred cases accepted the treatment from 1 March 2013 to 31 December 2016. Of these, 71% were male with a median age of 23. Ninety percent were diagnosed with non-affective psychosis, yielding an estimated treated incidence of 19.1/105 . General practitioners (GPs)represented the most frequent referrers to the program (38%), followed by referrals from acute general and psychiatric hospital units (22%) and self-referrals (14%). Meaningful clinical improvement was observed, 6 months after enrolment. An early intervention service for psychosis was successfully implemented within existing community outpatient services. GPs represented the main referrals, providing some validation of the "specialist within generalist" model of care. A promising clinical improvement and trend of reduction in duration of untreated psychosis was found, supporting the variety of early detection efforts in the community. The high median age and lack of information about pathways to care underline possible barriers to access for younger patients. These findings will inform refinement of treatments and service models for the Region.

Oriented mentalization-based treatment for borderline personality disorder patients: preliminary results at Camposampiero Mental Health Center.

This contribution presents two brief reports about preliminary results of 18 months of oriented Mentalization-Based Treatment (MBT), with Borderline Personality Disorder patients, recruited at the Camposampiero Mental Health Center. Following in large part Bateman and Fonagy guidelines for MBT in institutional settings, this paper presents preliminary results in two brief reports related to two cohorts of patient underwent to the oriented MBT in Camposampiero Mental Health Center (MHC). In the first study, we analyzed a group of 9 patients: an anamnestic schedule was administered; then, symptoms (SCL-90-R), psychodiagnostic scale and global health functioning (Health of the Nation Outcome Scale, Structured Clinical Interview for DSM-IV Axis II Disorder [SCID-II], Global Assessment of Functioning, [GAF]), data on service impact and service costs (Cassel Community Adjustment Questionnaire, Patient Evaluation Schedule and folder data) were provided at the beginning (T0), at the end of the treatment (T2) and 1 year after the end of the MBT project. The second study showed a micro-analytical change on a second patient cohort (n=6) at T0, 3, 6 and 9 months (T1) were presented considering specifically mentalization (Comparative Psychotherapy Process Scale, Modes of Mentalization Scale, Mentalization Imbalances Scale) and patienttherapist session evaluation trends (Session Evaluation Questionnaire) and patient reflective functioning at T0 and T2 (Reflective Functioning Questionnaire). Aims and hypotheses of the two studies pointed out how the oriented MBT bring to an improvement of the overall functioning of the patients, a reduction of the symptoms, a decrease of the diagnostic criteria for the Borderline Personality Disorder (BPD) and the other Axis II disorders, a reduction of the workload hours for the MHC staff and of the costs of the assistance. The analyses of both the studies were carried out using non-parametric statistics (Friedman test, Spearman correlation, Chi-square). Preliminary results confirmed the improvement in the overall functioning of patients (GAF), the reduction in BPD-related symptoms and in diagnostic criteria for BPD (SCID-II), the improvement of patients’ mentalization skills, and a significant reduction in workload for health staff. Standing the limits and the preliminary results, the two brief reports demonstrate the feasibility of an oriented MBT within an Italian Public Service and the effectiveness of this treatment pathway for patients with BPD, leaving some open questions to stimulate a fruitful clinical discussion.

Key performance indicators and administrative data in an early psychosis service.

This study aimed to introduce a set of administrative key performance indicators (KPIs) for Early Psychosis Services. The study design was longitudinal with data retrieved from a 4-year period between January 2009 and December 2013 included in the study. Descriptive statistics and t tests were used to evaluate the KPIs. Results in the 1 year before early psychosis (EP) intervention and 1-year postintervention were calculated for most items, and entry and exit scores were calculated for involuntary treatment orders (ITOs) and Health of the Nation Outcome Scale (HoNOS) scores. There was a 54% reduction in mental health emergency department presentations representing a cost saving of $62 524.00 (AUD). There was also an improvement in the number and duration of mental health admissions with a financial saving of $1 653 534.00 (AUD). Patients improved on all HoNOS scores from entry to exit from the services. ITOs were reduced by approximately 29% on discharge from the service. Administrative data can provide useful KPIs to measure the effectiveness of EP teams and allow benchmarking with similar services.

Continuity of care and clinical outcomes in the community for people with severe mental illness.

High continuity of care is prized by users of mental health services and lauded in health policy. It is especially important in long-term conditions like schizophrenia. However, it is not routinely measured, and therefore not often evaluated when service reorganisations take place. In addition, the impact of continuity of care on clinical outcomes is unclear.AimsWe set out to examine continuity of care in people with schizophrenia, and to relate this to demographic variables and clinical outcomes. Pseudoanonymised community data from 5552 individuals with schizophrenia presenting over 11 years were examined for changes in continuity of care using the numbers of community teams caring for them and the Modified Modified Continuity Index (MMCI). These and demographic variables were related to clinical outcomes measured with the Health of the Nation Outcome Scales (HoNOS). Data were analysed using generalised estimating equations and multivariate marginal models. There was a significant decline in MMCI and significant worsening of HoNOS total scores over 11 years. Higher (worse) HoNOS scores were significantly and independently related to older age, later years and both lower MMCI and more teams caring for the individual in each year. Most HoNOS scales contributed to the higher total scores. There is evidence of declining continuity of care in this 11-year study of people with schizophrenia, and of an independent effect of this on worse clinical outcomes. We suggest that this is related to reorganisation of services.Declaration of interestNone.