THE message that it is “time to talk” if you are feeling mentally unwell is broadcast through multiple mental health campaigns. And yet there is a scheme spreading throughout the NHS that means that certain people can be prevented from accessing help in a crisis. 

Former police officer Paul Jennings is described as the “innovator” behind the scheme, which he gave the unlikely name Serenity Integrated Mentoring (SIM) and which is now managed through the High Intensity Network (HIN) he set up. 

The approach bears a striking resemblance to an early embodiment of the government’s Troubled Family Scheme where the most “challenging” families, who require support from multiple agencies, are identified with the aim of modifying their behaviour through a mixture of coercion and support – “Family intervention workers make it clear that they have to either take this intensive help or face some tough consequences.” (2012 Annual Report of the Troubled Families Programme).

The innovative aspect of SIM is switching the approach from families to individuals – NHS patients who repeatedly ask for help from crisis services and who are often diagnosed with a personality disorder. The language used is robust, as some of the resource materials for the scheme show: “The project team will be dealing with service users with often high risk, malicious and litigious behaviours.”

With the mixture of NHS support and police involvement service users are “encouraged” to change their behaviour, through a care and crisis plan prepared by clinical and police members of the SIM team. 

Each plan outlines expected behaviours, including the police actions if a service-user follows proscribed actions such as, in some cases, contacting the emergency services. Parts of the plan can include the threat of and imposition of legal recourses such as Community Protection Notices (CPN) and Community Behaviour Orders (CBO) — legal measures that were introduced primarily to deal with anti-social behaviour but are now being used for mental health patients. 

London-based consultant liaison psychiatrist, Dr Alex Thomson, said: “Over the last decade there has been growing concern about an apparent general increase in both police response to mental health emergencies, and the use of criminal sanctions such as anti-social behaviour orders, community protection notices, criminal behaviour orders, or even prosecution, as an intervention for suicidality.”

The plan is then shared with all the services the patient may encounter, which may advise them to withhold certain services for the patient. This consistency of message is something stressed throughout the guidance from the SIM/HIN programme and can effectively block the avenues a service-user can go down when they are in need of help. 

Sharing such sensitive clinical data has been justified by the idea that people are only included in the scheme in an emergency, and that sharing is therefore in their best interests. 

To quote the SIM/HIN description of the people under consideration: “They are constantly an emergency case, just fluctuating at different levels of intensity, causing varying levels of impact. Our strong argument therefore is that all agencies involved in the network can share personal data and clinical data about these service users at any time, both in a preventative capacity when they are not using emergency services and in a reactive capacity when they are.”

The usual approach is that clinical information about individuals should very rarely be shared outside the health services, and data-sharing without consent should only happen in exceptional circumstances where urgent action is needed. In SIM the idea of what is an emergency is being stretched to justify routine sharing of clinical information on all patients managed by the team.

Service-users are told that sharing information can happen with their consent or without it. but even when they agree, the nature of consent in this situation is highly problematic because the prospect of coercion remains an active option for those who continue what the team consider undesirable behaviour and yet show “refusal to engage with mentors.”

Benefits claimed for SIM are that it brings savings for the NHS, including by reducing the number of patients taken by the police to be assessed in a so-called place of safety under section 136 of the Mental Health Act. But the original study from the Isle of Wight, on which the scheme is based, reported on only four patients of the original eight who were seen by the team, with no comparison group. A second study that included seven people in London was unable to show a benefit from the service. There is no significant independent research indicating that the approach benefits mental health service users, nor research into possible harms — which may occur when service users are barred from seeking help in a crisis.  

Jan was placed under this scheme, without her consent, by her mental health worker. By the time she was told about it the group of professionals had already met and discussed her case. No matter where Jan turns for help, she is now met with the same response, as data has been shared between all the services including Accident and Emergency, her GP, 999 and 111 phone lines and even some of her friends and family members. 

Professor of Social Psychiatry at Bangor University Rob Poole said there was a trend to regard frequent users of emergency mental health services as a problem rather than as people with problems. “This is used to justify the use of coercion, withholding of services and overriding of rights.” He added: “In my opinion, it is unacceptable to marginalise people as ‘the wrong kind of patient’. We have the wrong kind of services.”  

In a well-functioning organisation, complaints are valued as a way to help the service perform to a higher standard. Documents from the High Intensity Network suggest a different view: “Making complaints against staff can often be a way in which service users (at times of stress) attempt to avoid consequences or responsibility. They can also be used in an attempt to distance themselves from the staff who are supervising them so that they do not have to continue with the programme.”

Ali was concerned about how her care plan, compiled by the police officer, gave her no options if she felt in crisis. She thought complaining to the SIM team would be counterproductive so turned to the Patient Advice and Liaison Service (PALS). They seemed genuinely shocked at her treatment. Not long after that a conclusion was reached; her complaint, now termed an “allegation,” was found to be “malicious” in nature.

Due to the experiences of Ali, Jan and many others dragged into this scheme, an alliance of service users and others concerned about SIM has been set up. The ‘Stop SIM’ coalition has said: “Our concerns about SIM relate to the evidence, legality (including GDPR, Human Rights and Safeguarding), aims, governance and ethics.”

National mental health organisations have been vocal too, including Mind, Rethink and The Centre of Mental Health – which has said that any new approach needs to be tested “robustly and independently” before it is spread widely. 

Professional bodies have also distanced themselves from the scheme. The National Director for Mental Health is writing to every mental health trust asking them to review their involvement in the scheme from a patient care and legal perspective. The letter says: “I would like to clarify that NHS England and NHS Improvement (NHSE/I) does not mandate the ‘SIM’ model and at this time, it is not formally endorsing or promoting its spread.”

The blurring of the line between care and coercion in the SIM scheme fits with the growing use of criminal sanctions in mental healthcare, and as such, has the potential to undermine all the hard work of anti-stigma campaigns. Thomson has called for “an urgent need to review practice in this area and develop guidance for professionals across the UK.”

Allan House is Professor of Liaison Psychiatry at the Faculty of Medicine and Health at the University of Leeds;  Ruth F Hunt is an author, freelance journalist and service user.

To sign the petition go to bit.ly/34uMj3N. For more information visit Stopsim.co.uk or find them on Twitter here: @StopSIMMH.