Care pathways originated in the North East, Yorkshire and Humber regions and I understand why the current 21 clusters have been developed. There is a need to measure what psychiatric services do and develop objective ways of assessing outcome rather than process. ¹ The problem is that this newly imposed system does not achieve these objectives. Its main measure of outcome, the Health of the Nation Outcome Scales (HoNOS), was developed in the 1990s at a time when the focus was on psychotic illnesses. At the time there were concerns about the instrument's sensitivity to change and ability to measure outcome. ^{Reference Trauer, Callaly, Hantz, Little, Shields and Smith2,Reference Bebbington, Brugha, Hill, Marsden and Window3} In 2010, the focus has broadened to include statistically more significant health challenges such as stress disorders, substance misuse, somatoform disorders, personality disorder, anxiety and depression. HoNOS remains a helpful tool in rehabilitation services and forensic settings, but its applicability to general and community psychiatry is limited. Using it on a day-to-day basis, as I have been instructed to, it smacks of a system that is out of date and that simply does not address the heart of the matter.

For example, if somebody has psychotic experiences as a result of drinking alcohol, the computerised system will allocate that individual to a psychotic pathway even though it is clear that alcohol had a causal role. There is only one care pathway for substance misuse despite the variations in substances, legality and levels of addiction and yet there are eight pathways for psychosis. There is no appropriate care pathway for eating disorders, nor is there any specific enquiry at any point about whether a person is losing weight.

It does not surprise me that anecdotal findings suggest that many people referred to general psychiatry are categorised into the common and mild pathways, 1 and 2. This is a problem with the unbalanced nature of the assessment tool rather than the referral process. It alarms me when I hear commissioners and senior mental health trust managers suggesting that psychiatric services should not see such patients. This may lead the local communities that we serve to perceive us as increasingly irrelevant.

Care pathways are a bureaucratic procedure. It is labour intensive and competes with other documentation processes for time spent in direct face-to-face contact with patients. In my view, the process has the ability to mislead clinicians, managers and the general public. It also has the power to offend some service users by labelling their distressing conditions as, for example, ‘common mental health problems (low severity)’. As a professional body, I think we should ask the question, is this a good enough measure to underpin payment by results?