Jacobs & Moran, ^{Reference Jacobs and Moran1} in their article enthusiastically supportive of the use of Health of the Nation Outcome Scales (HoNOS) as a routine outcome measure, recommend ‘mild coercion’ by trust managers to improve completion rates. They acknowledge the bluntness of the instrument and its inappropriateness in some specialist services but fail to consider that it may be totally inapplicable in some psychiatric specialties, one of which is liaison psychiatry.

The authors state the truism that for HoNOS to be considered an outcome measure, there need to be paired ratings. Liaison psychiatry services see patients mainly in emergency departments (A&E) and in-patient medical units. The A&E assessments are mainly one-off assessments where paired assessments are inapplicable. The average stay for acute care in the UK is about 6 days; ² thus there are few patients on medical wards where paired ratings with a space of at least 2 weeks between them are possible.

Another problem in using HoNOS as an outcome measure, even in the few cases where it may be possible, is the nature of consultation-liaison work. The consultations are often directed at the referring medical team, examples including clarifying a complex capacity situation or advising on change in psychopharmacology in patients with organ impairment. Even when the consultation is patient-focused the interventions are not necessarily aimed at bringing about symptomatic change in a short period of time. Thus, HoNOS would at best fail to capture relevant outcomes and at worst seriously misrepresent the effectiveness of liaison psychiatry teams.

This is not to say that outcome measures are not important in liaison psychiatry but they need to be smarter. Operational definitions for consultation outcomes that focus on the effectiveness of individual consultations should be agreed - such an approach has been recently studied by a Brazilian group. ^{Reference de Albuquerque Citero, de Araujo Andreoli, Nogueira-Martins and Andreoli3} Quality of liaison psychiatry services should be judged by looking at consultation outcomes and performance standards such as those recently published by the Psychiatric Liaison Accreditation Network. ^{Reference Palmer, Dupin, Hinchcliffe and McGeorge4}