When Skinny Hobbit shared an iNews article with me the other day about the mistreatment of high-service-needs people with mental illness, I had no idea just how deep of a rabbit hole the whole thing would be. The story of Serenity Integrated Mentoring, the NHS (the UK’s National Health Service), and the way the whole thing has blown up up is fascinating on multiple levels. What’s particularly interesting is that it shows just how powerful a mental health patient group can be.
The iNews story was published on June 15 quoting a whistleblower psychiatrist, but before we get to that, let’s get some background and look at what Serenity Integrated Mentoring (SIM) actually is and how it got started. Grab yourself a cup of tea, because this’ll be a long one.
What Serenity Integrated Mentoring (SIM) is
Serenity Integrated Mentoring’s reason for existence is to save money by reducing emergency service usage, including police, ambulance, and A&E (Accident & Emergency, same as ER) by High Intensity Users of those same services. Patients get assigned to SIM based on their service usage level.
Patients who are assigned to SIM are given a police “mentor” who meets with them once or twice weekly; these are police officers who are given NHS contracts. SIM officers complete a three-day intensive training along with their NHS care coordinator colleagues. The “High Intensity Officers” are supposed to establish boundaries and consequences, while care coordinators are supposed to deal with the clinical side of things.
Once patients are assigned to SIM, they get flagged in all of the relevant systems so that if they come into contact with emergency services, they get handled in a certain way as dictated by SIM.
SIM was developed by a former police sergeant, Paul Jennings, and the rollout and training is delivered by his private company, the High Intensity Network. Jennings was given an NHS Innovation Accelerator fellowship to get SIM up and running on the Isle of Wight in 2013. Since then, SIM has been widely adopted, and is currently used in 23 of 52 NHS Trusts.
On April 21, 2021, a coalition of anonymous mental health service users and allies calling themselves StopSIM released a consensus statement calling on the NHS to halt the rollout of SIM and conduct an independent evaluation of SIM. They unearthed a massive amount of information, much of it from materials on the SIM website, and it’s all carefully referenced.
Interestingly, shortly before this, a Twitter thread dated April 11 reveals that the High Intensity Network claimed on their website that they worked with The Mental Elf, a large UK-based website providing evidence-based mental health information. The Mental Elf Twitter account responded that this was not the case.
Go directly to jail. Do not pass go, do not collect $200
Getting back to StopSIM, according to SIM documentation they accessed, most of the patients have a borderline personality disorder diagnosis and a history of sexual abuse. SIM documents repeatedly describe High Intensity Officers’ role as “coercive” to reduce patients’ use of emergency services. One such coercive measure is a Community Behaviour Order, which can result in up to 5 years in prison for engaging in prohibited behaviours, such as calling 999 (same as North American 911). Having a heart attack? Been stabbed, or perhaps shot? Put that phone down or else you’re going to prison.
Services like A&E’s are instructed not to provide service to SIM patients, including potentially life-saving services. StopSIM quotes the High Intensity Network’s Business Case for Commissioning SIM across NHS Trusts in England, which describes the effect of SIM on health professionals:
“Specifically, they can give doctors and nurses the confidence NOT to treat or respond in ways in which they would have felt compelled to before, such as:
- Not requesting scans/x-rays/MRIs/blood tests
- Not keeping the individual in the ED for observation
- Not pursuing the individual if they decide to discharge themselves
- Not requesting the police to find the individual or conduct a welfare check at home”
The Business Case further states that SIM “provides frontline responders with the confidence to trust response plans which advise them not to intervene.” As for the risk of “accidental death,” the document reassures providers that they won’t be held responsible, because SIM would have provided supports that were “lawful, proportionate and least restrictive.”
What’s the justification for this? According to SIM documentation, “attention-seeking” behaviours place an “unnecessary financial burden” on the NHS, and “high-risk behaviour” is “positively reinforced” if, heaven forbid, someone were to actually be given help. B.F. Skinner, who came up the idea of operant conditioning and the role of reinforcement, must be turning in his grave.
The Health Innovation Network, who are somehow part of the excessively complicated NHS bureaucratic hodgepodge, published an evaluation report on SIM in London from the period of April 2018 to May 2020. It describes SIM as an “innovative mental health workforce transformation model that brings together the police and community mental health services, in order to better support ‘high intensity users’ of Section 136 of the Mental Health Act (MHA) and public services.” I don’t think the word “support” means what they think it means.
The evaluation metrics, all tied to dollars and cents (or pounds and pence, I suppose), were:
- Police deployments
- Police calls
- Ambulance resources despatched
- Ambulance calls received
- A&E attendances
- S136 detentions (detentions by police under Section 136 of the Mental Health Act)
- Mental health bed days
The report indicated that on average, there was improvement in all seven metrics and an average monthly reduction in costs of 42% per patient. Based on the entire time across the evaluation period that SIM operated in London, they estimated a total cost savings of £1.45 million.
What’s totally lacking from these indicators is even a single marker of patient mental health outcomes or patients’ subjective experience. It’s like the program evaluation version of dead person goals; if a dead person could do better than a living person possibly could, your goals aren’t very good, or your evaluation metrics are complete bollocks. A dead person would come out ahead on all seven of those metrics.
Emails that have accessed through Freedom of Information requests show that police had raised concerns the irregularities regarding the High Intensity Network’s evaluation of SIM’s initial implementation on the Isle of Wight.
Award and Recognition for SIM
People were clearly impressed by Serenity Integrated Mentoring and its money-saving results. An NHS Innovation Agency article, which isn’t dated, piles on the love: “Based on its success to date, in 2016 SIM was adopted by the NHS Innovation Accelerator programme, and in 2018 it was selected for national scaling and spread across the AHSN Network. AHSNs across the country will partner with mental health trusts and police services to roll out the SIM model.”
SIM was awarded the 2016 HRH The Prince of Wales Award for Integrated Approaches to Care at the Nursing Times Awards. An article about this on the Wessex Academic Health Science Network (AHSN) includes quotes from a couple of NHS higher ups crowing about how wonderful SIM is.
The Wessex AHSN posted a statement on June 16, 2021, attempting to distance themselves from SIM, saying “The AHSN was not involved in the creation or running of the project.” They also say “From late 2017 onwards, NHS Right Care commissioned the national roll-out of SIM through to November 2018; and NHS England then commissioned the AHSNs from April 2018 through to March 2020, when that national commission came to end.” Who is NHS Right Care? That’s a good question. Their website is rather vague, but it’s something to do with systems change.
In 2017, SIM received a HSJ Value in Healthcare Award for Clinical Support Services. HSJ, a health leadership publication, wrote that “The judges were blown away by the real impact on people’s lives, families and communities.” Oh there was an impact, alright.
SIM was also the HSJ award winner for Mental Health and Highly Commended for Workforce Efficiency. HSJ mentioned (and I couldn’t tell if this was their wording or the High Intensity Network’s) that officers “used a combination of clinical expertise, compassion and appropriate boundaries to help the individuals.” That’s messed up, because police officers don’t have clinical expertise, nor should anyone be claiming that they do.
Reactions to StopSIM
Whoever is behind the StopSIM coalition really knows their shit, and they also know how to get shit done. They organized a petition that gained lots of support, but more importantly, they’ve also gotten a whole lot of people in power in several different places taking them very seriously.
The Association of Clinical Psychologists UK issued a statement in May 2021 in relation to the concerns raised by StopSIM. They called for an independent review, and in particular expressed concerns about the psychological validity of SIM’s argument that “providing intervention from emergency services can ‘reinforce’ self-harm and help-seeking from such services.”
The Centre for Mental Health has also published a statement about SIM, saying that “We are also deeply concerned about the way such approaches could further heighten the stigma around people with complex needs, or re-traumatise them, instead of giving people the compassionate support they need and deserve.”
The NHS responds
On May 11, 2021, Tim Kendall, National Clinical Director for Mental Health at NHS England and NHS Improvement, posted on Twitter a copy of a letter he’d sent to all medical directors of NHS Mental Health Trusts. In it, he highlighted several issues, including:
- a lack of patient reported outcomes in evaluations of SIM
- SIM not conforming to national guidelines around treating people who self-harm
- involving police in case management for people with complex mental health needs
- the legal basis for police access to patient medical records
- “the human rights and inequalities implications of the approach”
According to Kendall’s letter, the NHS “does not mandate the ‘SIM’ model and at this time is not formally endorsing or promoting its spread.” He asked medical directors to ensure that SIM implementations follow best practice guidelines for personality disorders and self-harm and confidentiality/information-sharing policies.
Claire Murdoch, the leader of the Central and North West London NHS Foundation Trust, posted a letter the same day that said essentially the same thing.
So, the NHS didn’t develop SIM, nor did they mandate it, but they funded it, promoted it, and let it spread like a nasty fungus? The buck’s got to stop somewhere.
It all falls down
The Royal College of Psychiatrists released a statement on June 14. They thanked StopSIM, and said “There will be some difficult learning here; any review must examine why professional frameworks did not identify or act on these concerns.” Um, yeah…
They added: “Where people remained unwell and continued to self-harm, attempt suicide or report suicidality, in some cases they were prosecuted and imprisoned or community protection notices were applied which required them to stop self-harming or calling for help, with imprisonment as a potential sanction if they breached the notice.”
Finally, that brings me to the article Skinny Hobbit sent me, which was published on June 15 by iNews. They interviewed a psychiatrist whistleblower who said they were forced to discharge a patient in crisis from the emergency department because of SIM. The psychiatrist said that patients were coming to the A&E in distress, such as this patient who had attempted suicide, and they were getting the boot because SIM said that’s what had to be done.
When iNews tried to email the High Intensity Network, there was an automated response indicating that they are permanently closed. Their website has also been shut down.
Taking on the NHS and winning?
For StopSIM to have had this big an impact is truly remarkable. While the chances of anyone at the NHS actually owning this mess are probably slim, I wouldn’t be surprised if the euphemistically named Serenity Integrated Mentoring were to hastily be disappeared.
It doesn’t surprise me that the NHS implemented something to try to cut down on ER frequent fliers, but this is an ass-backwards way of going about it. People access emergency resources because they can’t get their needs met in the community. If you make sure there are community services that have the capacity to meet that level of need, and you actively support people in getting connected to those services, they no longer need to use the ER as often. But to tell people to just STFU or you’ll haul their ass off to jail just means that, eventually, one of those suicidal gestures/attempts will likely go a little further than intended, A&E will tell them to fuck off, and you’ve got yourself a very literal dead person performance metric.
As for the NHS, they seem like an octopus with a gazillion different legs that may or may not realize they all belong to the same octopus. It really shouldn’t be so confusing for someone non-British like me trying to look up who the heck all these different people and agencies are. The more complex the system, the less likely it is that anyone will take responsibility for anything. I’m very impressed, though, with StopSIM’s ability to get through to a few key people.
What are your thoughts on this whole mess? Are you surprised by StopSIM’s success?
You can find more on mental illness stigma on the Stop the Stigma page.