Introduction

Concerns have been raised on social media about the High Intensity Network (HIN) and Serenity Integrated Mentoring (SIM)^1,2,. We aim to highlight some of the concerns raised, for example the limited evaluation linked to the expansion of the project, and the way psychological principles are being used clinically. We have also sought information from the programme lead, Paul Jennings to provide some context. Finally we will make some recommendations for an independent review and signpost people to further information.

Main Content

Background

A group of mental health service users, and allies have registered concerns with NHS England and launched a petition to try to halt the expansion of ‘Serenity Integrated Mentoring’ (SIM) and to call for an independent review³. A number of professional organisations have published statements in response, adding to calls for such a review^4,5,6. SIM has been developing as a crisis care innovation since 2013. In 2016, SIM was adopted by for expansion as an NHS Innovation Accelerator project. In April 2018, the Academic Health Science Networks (AHSN) selected SIM as for national adoption^7. There are now 23 Mental Health Trusts and 18 Police Forces using the SIM model of care. There is a network of SIM teams within the ‘High Intensity Network’ (HIN). This is described as a national ‘community of practice’ which hosts webinars where teams share learning, this includes anonymised clinical information⁸.

SIM brings together key urgent care agencies involved in responding to ‘High-Intensity Users’ (HIUs) of crisis services^9,10. Paul Jennings noted referrals for potential inclusion in the programme include service users where the frequency, levels of distress and risk are sufficiently significant that a multi-agency response is required and usual efforts to engage with service users have not been effective. He stated ‘the aim is to bring services together with the service user to help address the difficulties more effectively, in a lawful, necessary and proportionate way’.

Paul Jennings said there are monthly multiagency meetings which include Mental Health, ambulance, A&E staff, the police, and the AMPH team; ‘there is a focus on capacity regarding decision-making, and clinical decision-making around whether this approach would help lower the risk of harm, there is also consideration of public risk’.  He stated ‘decisions are ‘team based’‘. He noted the SIM team is led principally by a mental health professional (who leads clinically and oversees the clinical safety of any decisions and crisis plans) and a police officer (who leads on behaviour, community safety, and risk/harm reduction). He noted the aim is that together, the mental health clinician, police officer and service user co-create a personalised ‘crisis response plan’ that is more helpful and accurate for crisis responders and emergency services, and which the GP has access to. Paul Jennings said ‘sustained efforts are made to build trust and a collaborative plan for managing crises: this is not time limited, or linked to individuals disengaging or being discharged from mental health services.’ He identified improvements in crisis care for service users through potentially more clinically led, consistent decision making, more co-production with service users around what helps in crisis, and a reduction in distress leading to behaviour which is harmful to the individual or others.

Concerns

1. Crisis Support Plans can lead to service users being denied treatment in crisis.

We are concerned that ‘crisis response plans’ are based on misapplied ideas about psychological principles particularly behavioural interventions. This centres on the idea that providing intervention from emergency services can ‘reinforce’ self-harm and help-seeking from such services. We are concerned this may lead to people who are at high risk of self-harm or suicide and in acute mental distress being denied potentially life-saving treatment following risk-related behaviour, for example from ambulance services, A&E, mental health crisis services, community mental health teams and the police.

Paul Jennings responded: ‘SIM teams do not deny care or treatment in any way. SIM works with service users when they are not in crisis to better prepare for moments where they are. Some of this support work does involve conversations about how services can be used differently and how safety can be found more appropriately, with less risk of suicide, death by misadventure or harm/impact on public safety.’

2. Service users don’t have a choice of being identified as a ‘HUI’ and part of SIM

We raised concern that in services which have adopted the model service users are not given a choice about their identification or treatment as a ‘HIU’.

Paul Jennings responded: ‘SIM should be considered in the same way that other multi-agency risk prevention methods are run. If any individual is frequently presenting in ways that can present with very high risks of harm or impact to themselves or others, then there is a statutory duty from public protection teams to step in and help. A multi-agency panel makes a rigorous assessment of capacity, risk, the intervention skills required and the risk to the public. If an individual meets the criteria on this assessment (1 in 3 do not) then no, the individual does not get to choose because statutory duties to intervene take primacy, until the risk/harm/impact subsides. It is a step up – manage – step down model. That said, once on SIM, every individual is treated with respect and compassion. SIM is an intervention built on relationship, mentoring, empowerment and encouragement.’

3. For crisis response plans to be helpful, there needs to be genuine collaboration with service users, SIM can’t do this if people feel coerced to engage

ACP-UK believe that for all service users, genuine collaboration in development of a ‘crisis support plan’ is important. The process of engagement may take time to work towards, and is enabled by compassionate support at the point of crisis, and working alongside the person when they feel able, to understand and work with the issues leading to distress. Co-developed crisis support plans can help people access the support they need in crisis, based on a person-centred understanding of their experience, coping skills and what they find helpful.

Paul Jennings agreed: “Ten years ago I was a high intensity service user. My voice wasn’t heard. I didn’t have a plan. I was considered ‘broken’, ‘bad’ or both. SIM is based on the ‘nothing about me without me principle’ wherever possible. Service users are relentlessly encouraged to coproduce. Only where they consistently refuse and where high risks to themselves or the public remain, might we write a plan on their behalf. It is no different from any other form of safeguarding. We are the experts in our own lives and safety”

Paul Jennings noted how sometimes people with complex difficulties who are ‘HUIs’ are discharged from mental health services due to ‘lack of engagement’ leaving them feeling more isolated, and that SIM aims to provide more coordinated support for this group of people.

4. The SIM model is focused on the coercive powers of the police

We share the concern that the SIM model is focused on the coercive powers of the police through ‘High Intensity Officers’ in SIM teams being involved in care reviews to enforce “behavioural responsibility” and “behavioural management”, which may include taking legal action. We are concerned along with others about the impact this has on service users’ ability to trust in the services supporting them in acute distress, and to receive compassionate, trauma-informed support when distress. We are also concerned about the focus on people with a diagnosis of Emotionally Unstable Personality Disorder (EUPD), which may further stigmatise this group of people and reinforce negative attitudes towards their care and treatment, particularly when in crisis and distress. Significant effort has been made to move away from this, for example in the ‘Personality Disorder’ Consensus Statement¹¹.  ACP-UK believe it is important that psychological principles are used appropriately, and that Clinical Psychologists and others adequately trained and supervised in the appropriate, compassionate application of psychological theory and practice are involved in the crisis care pathway.

Paul Jennings responded ‘This paints a very inaccurate picture of the SIM police officers we select specifically for the role. They primarily do not operate through coercion. That does not mean to say that they do not have to have some difficult conversations about responsibility, civic duty, anti-social behaviour and the risks of being arrested but their primary agenda is to build relationship and negotiate ways of coping that don’t come anywhere near the criminal justice system. There is still a long way to go – we need to get better at harmonising what we do for people with the different forms of trauma, diagnosis and communication needs but this is exactly why we set the HIN up – we knew we needed to be better – I knew service users deserved more. We are not diagnosis driven, SIM was designed first and foremost to find every opportunity to ensure mental health patients are not criminalised.’

5. Some interventions, such as reducing access to emergency care services and treatment may re-traumatise individuals and increase risk

There seems to be recognition of the level of trauma in the experience of service users identified as ‘HIUs’. ACP-UK believe it is important to recognise that interventions, such as reducing access to emergency care services and treatment may re-traumatise individuals, for example leading people to engage in higher frequency self-harm, or more risky behaviour when they feel their distress is not heard by services and that support is not available for them. While ‘positive risk taking’ can in the long-term lead to better outcomes for people, there needs to be a clear rationale around this, developed with the individual and shared between services involved in providing support, alongside clarity around the support accessible to the person in crisis. People who have experienced trauma and who experience overwhelming emotion linked to self-harm need support to develop ways to understand their feelings, and skills to help them manage strong emotions, and crisis support so they can stay safe. This can be a difficult process which takes time, and trust in the individuals supporting care and the organisational system. Coordinating care across the system can be helpful to improve the consistency of support offered in crisis, but again the safety planning around this needs to be trauma-informed, compassionate and developed in collaboration with the person.

Paul Jennings agreed with these principles of practice. He noted however that ‘one service user had co-developed a ‘crisis support plan’ which stated they would not receive medical treatment if they presented at A&E following overdose. This plan was acted upon, with the aim of decreasing the risk-taking behaviour in the longer term.’

ACP-UK believe it is important that crisis care is always accessible for people. Trauma informed care seeks to work with the person to help them access crisis services prior to engaging in risk-related behaviour so they can be supported to manage the crisis in safe ways. There is an inherent power imbalance as a ‘HUI’ who has no choice but to be within the SIM system. It is also important to reassess capacity in relation to an individual accessing treatment at the time of any risk-related behaviour. When highly distressed, people can act impulsively as a consequence of the ‘fight or flight’ system being triggered; it is very difficult for anyone to consider and weigh up logically the short- and long-term consequences of different courses of action until they are in a calm state of mind. Any of us may need others to act in our ‘best interests’ if we are in a state of acute mental distress and health care should not be denied to anyone in crisis.

6. Concern has been raised regarding the HIN ‘Data Portal’, which ‘allows teams to gather, analyse and report quantitative and qualitative performance outcomes, demand and cost data for each individual they are supporting’

Paul Jennings explained ‘HIN holds no patient identifiable data, ‘only anonymised data’, for example on an individual’s police response, ambulance deployment, and use of PLT teams which is shared across the network.’ He noted ‘this is to help teams develop a clearer understanding of how service users struggling with intensive distress can move across emergency and healthcare services’.

7. Concern the SIM model is being extended without adequate evaluation

ACP-UK share the concern that the evidence base that led to the roll out of the model, appears to have been on limited data which focused on the reduction of contacts with services and the consequent financial savings to those services. This is linked to an understandable concern that the model is about cost reductions rather than the quality of service provided and clinical outcomes for this vulnerable group of people. We believe that mental health interventions should primarily be evaluated on their clinical outcomes and qualitative information from those who have experienced the service.

Paul Jennings responded ‘I recognise the initial evaluation included very small numbers of people, the need to evaluate the model more thoroughly, and to include a range of clinical outcomes and qualitative feedback.’ He noted ‘I was hopeful that the NHSE Innovation Accelerator programme would enable further evaluation, but unfortunately this hasn’t been the case. I would welcome links with organisations that can help to support more extensive and comprehensive evaluation.‘

Summary

We recognise that the SIM model was developed with the intent of providing more coordinated services for people who frequently use a range of emergency services, when they are experiencing acute distress and are in crisis. This group of people may find that emergency services such as A&E staff, Mental Health crisis services and the police respond in inconsistent ways, or ways they do not find helpful. Greater coordination of support can be helpful, for example through the coproduction of a ‘crisis response plan’.  However health care exists in a social and cultural context. It is important to recognise that some communities have not been treated equally or served well by Mental Health or Police Services. To name some groups – black, brown and minoritised people, disabled people and neurodiverse people. For some people, including those who frequently access crisis services, trust in health and policing has been damaged or broken. Developing trusting relationships between communities, individuals, health and emergency services needs to be actively developed and takes time, and an appropriate, trauma informed approach.

We share a number of significant concerns about the SIM model, in particular how psychological principles are being applied. It is vital that crisis care is trauma informed, and that all staff providing crisis care are adequately trained and supervised in relation to trauma informed practice. All people have a right to access appropriate, compassionate care when they are in crisis. A national evaluation of the programme across the organisations involved, supported by an independent body, using a range of outcomes is essential for its safe continuation. Evaluation needs to be undertaken in partnership with experts by experience, to ensure that psychological principles are being used appropriately, and to ensure that compassionate, trauma-informed intervention is always provided for this group of people in crisis.

We recommend a coordinated, national, independent review of the SIM model with a focus on:

• The range of psychological models and evidence-based interventions that have informed the SIM model, the appropriateness of these models and the governance around their safe and effective application
• Evaluating the extent to which understanding of risk-related behaviour and crisis-response planning is collaborative with the individual in and how challenges to engagement are managed
• The extent of focus on supporting the development of skills to manage emotion and risk in crisis, to seek support before risk related behaviour, and on the individual’s hopes for positive change
• How the service model has been evaluated and in particular how the clinical outcomes and qualitative feedback from service users have been measured and acted upon
• The governance around the training and regular supervision provided. Whether this is supported by Clinical Psychologists or other appropriately trained Practitioner Psychologists for staff providing crisis services to ensure safe, compassionate, effective practice
• The consistency of application of the model across organisations and comparison of outcomes with different models of crisis care
• It is essential that experts by experience who have experienced SIM are involved in the review process. Experts by experience who have experienced other models of crisis care should also be involved in the review process.
• Practitioner Psychologists with expertise in a range of therapeutic psychological approaches and trauma informed crisis care should be involved in the review

References

1. www.stopsim.co.uk, and @StopSIMMH on twitter also hashtags: #HighIntensityNetwork #StopSIM
2. Aves, Wren. (2021) Review of the High Intensity Network and Serenity Integrated Mentoring: https://www.psychiatryisdrivingmemad.co.uk/post/behaviourism-bpd-and-the-high-intensity-network?fbclid=IwAR3JqCzQI7uvV-cNVXPXJIdsUxVyXwdH7ES2d8MmI4iAoxaQEVzFvtwLUKg
3. Petition: https://www.change.org/p/nhs-england-stopsim-halt-the-rollout-and-delivery-of-sim-and-conduct-an-independent-review
4. BASW responds to concerns about the High Intensity Network’s ‘Serenity Integrated Mentoring’ https://www.basw.co.uk/media/news/2021/may/basw-responds-concerns-about-high-intensity-network%E2%80%99s-%E2%80%98serenity-integrated [Accessed 12.05.21]
5. Royal College Statement on the STOPSIM Campaign (11^th May 2021) https://www.rcot.co.uk/news/royal-college-statement-stopsim-campaign [Accessed 12.05.21]
6. BPS statement regarding the High Intensity Network’s Serenity Integrated Mentoring | BPS [Accessed 12.05.21]
7. SIM London End of Year Report (2020) Available at: https://healthinnovationnetwork.com/wp-content/uploads/2020/12/SIM-London-End-of-Year-Report-2020.pdf [Accessed 10.05.21]
8. High Intensity Network https://highintensitynetwork.org
9. SIM and High Intensity Network Business Case [Internet], p. 7. Available from https://highintensitynetwork.org/img/resources/SIM_and_High_Intensity_Netwok_-_Business_Case_(Commissioner)_v4.docx [accessed 4^th May 2021].
10. Paul Jennings. What is SIM and the High Intensity Network? [Internet]. 2019 Mar 26; Daresbury Park Hotel. Slide 30 of 65. Available from: https://www.slideshare.net/InnovationNWC/paul-jennings-high-intensity-network-sim [accessed 4^th May 2021].
11. ‘Personality Disorder’ Consensus Statement : https://www.mind.org.uk/media-a/4408/consensus-statement-final.pdf