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  • The High Intensity Network (HIN) approach and SIM model for mental health care and 'high intensity users' – what are your views?

    • UK
    • Processes and systems
    • Pre-existing
    • Public domain
    • No
    • High Intensity Network https://highintensitynetwork.org/
    • 21/04/21
    • Everyone

    Summary

    The Serenity Integrated Mentoring (SIM) model is described 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."

    The SIM model is part of a 'High Intensity Network' (HIN) approach, which is now live in all south London boroughs.

    In this hub post, Steve Turner highlights the benefits and risks of this approach and seek your views on it.

    Content

    Background

    In 2018, SIM was selected for national scaling and spread across the Academic Health Science Networks (AHSNs). The High Intensity Network (HIN) has been working with the three south London Secondary Mental Health Trusts: The South London and Maudsley NHS Foundation Trust, Oxleas NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, and the Metropolitan Police, London Ambulance Service, A&E, CCG commissioners, and the innovator and Network Director of the High Intensity Network.

    The model can be summarised as: 

    1. A more integrated, informed, calm approach in the way we respond to individuals that have unique needs during a crisis and
    2. A better form of multi-skilled, personalised support after the crisis event is over.

    So in July 2013 we invented the Serenity Integrated Mentoring (SIM) model of care. This is how it works:

    1. SIM brings together all the key urgent care agencies involved in responding to high-intensity crisis service users around the table, once a month.
    2. This multi-agency panel selects each individual based on demand/risk data and professional referrals.
    3. They use a national 5-point assessment process to ensure that the right clients are chosen and in a way where we can ensure a delicate balance between their rights as an individual but our need to safeguard. Selected individuals are then allocated to a SIM intervention team.
    4. The SIM team is led principally by a mental health professional (who leads clinically) and a police officer (who leads on behaviour, community safety, risk and impact).
    5. The team supports each patient, to better understand their crises and to identify healthier and safer ways to cope. In the most intensive, harmful or impactive cases, the team also does everything it can to prevent the need for criminal justice intervention.
    6. Together, the mental health clinician, the police officer and the service user together create a safer crisis plan that 999 responders can find and use 24 hours day.
    7. The crisis plan is then disseminated across the emergency services.
    8. The SIM team reinforces these plans by training, briefing and advising front line responders in how to use the plans and how to make confident, consistent, higher quality decisions.

    What are the benefits and risks of this approach?

    Benefits:

    It is claimed that this is a more integrated, calm and informed approach to responding to individuals in crisis and the HIN provides "better multi-skilled, personalised support after a crisis event was over".

    The HIN website states:

    "Across the UK, emergency and healthcare services respond every minute to people in mental health crisis and calls of this nature are increasing each year. But did you know that as much as 70% of this demand is caused by a small number of ‘high-intensity users’ who struggle with complex trauma and behavioural disorders? These disorders often expose the patient to higher levels of risk and harm and can simultaneously cause intensive demand on police, ambulance, A&E departments, and mental health crisis teams."

    Risks:

    This approach has been subject to strong criticism from some users of mental health services, mental health clinicians and mental health support organisations. Concerns have been raised about whether the HIN/SIM approach is safe, effective or appropriate.

    I believe we need an open and inclusive discussion about High Intensity Networks, with users of mental services leading the debate.

    As a former mental health nurse in an Assertive Outreach team I'm keen to learn:

    • How users of services were involved in the initial development of the model?
    • What are the similarities and differences between High Intensity Networks and an Assertive Outreach model?
    • How this approach compares with approaches in other countries?
    • How users of services are involved in evaluating and adapting the model?
    • What the specific benefits are for users of services and are there any risks to this approach? Does this lead to a long term improvements for users of services?

    I hope people will feel able to contribute openly to this discussion, so we can learn together.

    #HighIntensityNetwork #mentalhealth

    The High Intensity Network (HIN) approach and SIM model for mental health care and 'high intensity users' – what are your views? https://highintensitynetwork.org/
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    Here's the reason I posted this. As a former #mentalhealth #nurse in an Assertive Outreach team I share these concerns from users of services. 

    Related post:

     

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    I've now signed the #StopSIM Petition: https://www.change.org/p/nhs-england-stopsim-halt-the-rollout-and-delivery-of-sim-and-conduct-an-independent-review

    As a mental health clinician, and former mental health Assertive Outreach Team member  I was appalled to read about the way mental health 'High Intensity Networks' are being implemented. Without any meaningful involvement from patients / users of services and with an apparent lack of regard to data protection laws.

    People in crisis need help based on their individual needs, not to be put on a 'programme', I believe this represents a potential abuse of vulnerable people. Imagine if this approach was taken in physical health care. Yes, the services need to work together, with the person involved at the centre. 

    'No decision about me without me' applies to us all. 

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    I have engaged in several discussions on twitter and facebook with supporters of StopSIM and with the person who appears to be the spokesperson (LD) for the StopSIM Coalition (which is anonymous). While there is some valid criticism of the lack of genuine co-production with service users in the development of the programme, and lack of independent evaluation of the programme (which I think cannot be blamed on HIN), the most alarming criticisms such as "withholding potentially life-saving treatment" and the "coercive" nature of the programme appear to be blatant misrepresentations. The very tagliine of StopSIM ("Mental illness is not  a crime") is itself a blatant misrepresentation, chosen to stir up opposition to SIM, because mental illness is not stated to be a crime anywhere in the SIM/HIN source documents. (I suggest that the real issues is whether having a mental illness absolves a person completely from responsibility for their own actions - which raises the question of what kind of 'legal equality' can exist between those with and those without a mental disability under the UNCRPD.) Although many service users are raising concerns about SIM, they are basing their concerns on their own negative experience of contact with the police outside of any SIM programme, or on newspaper reports of people being convicted for their anti-social behaviour presumably resulting from mental illness. It is such bad experiences and convictions which the SIM programme aims to reduce (among other goals) by co-producing crisis response plans with the service user (as outlined in your blog) and by training police officers to respond more knowledgeably to those in mental health crises. I have not yet encountered anyone who is or was mentored in a SIM or related programme. One AMHP told me about a service user she knows well who is on a local SIM programme and is very satisfied with her experience of it. The spokesperson LD refuses to confirm whether the Coalition has made any contact with current or former mentees of the programme - refuses even to provide a number of mentees who have given evidence to the Coalition - on the excuse that the disclosure of this number will somehow jeopardise the privacy or safety of those who might (or might not) have complained to the Coalition. Ruth Hunt in her article in the Morning Star claims to have had contact with 2 verified mentees ('Jan' and 'Ali') but in view of LD's refusal to confirm contact with any mentees, I am somewhat sceptical about this. The majority of professional organisations echo the concerns raised by StopSIM although they have not expressed any concerns over the years until StopSIM gained popularity. They are often 'appalled' by the 'insensitive' terminology used by HIN/SIM (such as "attention-seeking") and by candid comments apparently from SIM mentors (such as "I dislike her less now") and by the behavioural model behind the programme (has behaviourism been totally discredited?). ... So my view is that the programme appears to be a positive step forward and is not "unsafe" as claimed. Undoubtedly independent evaluation is overdue (as the founders acknowledge and called for back in 2015) and far more attention could be given to feedback from actual mentees of the programme (rather than to 'concerns' raised by those with no experience of the programme). I was impressed by an early comment for a non-SIM service user  

    "... treatments that are demonstrably working & well liked by SUs should not be earmarked for closure using lack of research evidence as justification. When we all tell you its saving & changing our lives, don't employ an 'independent' firm to tell us we're wrong."
     
     

    ."  

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    Thanks Barry, you raise some important points. It made me think. Like you, I have not yet encountered anyone (outside of social media) who is or was mentored on a Serenity Integrated Mentoring [SIM] or related programme. 

    I agree about the importance of not stopping moving forward on something because it hasn’t been fully evaluated, and the need to try any approach (behavioural or otherwise) if it works for people.

    The High Intensity Network [HIN] approach needs an independent and patient / service user  led evaluation, so we don't miss the opportunity to make the most of what works and learn from what doesn’t.

    When I hear talk of areas where ‘potentially life-saving treatment has been withheld’, I am very concerned. This is something which needs looking at as part of any evaluation.

    Overall, I am concerned about how I believe High Intensity Networks operate.

     Here is a personal reflection on my main concerns:

    1.    Person led approaches to care.

    Is the HIN / SIM approach focused on the patient or on services? Is involvement time limited?

    My worry is that people , especially those who are vulnerable,  under pressure and feeling disempowered will derive less benefit from a formulaic approach to their care, than from an individual, tailored  long-term approach.

    There’s a power imbalance that need to be addressed so that people can begin to trust the services and open up on what happened to them, and how this has affected them.

    2.    Services working together in a network.

    Do the services work together as a single team or as a more loosely connected network?

    I believe in joint working and a linked approach to care, however some people I have worked with benefited from the fact that different services took different approaches. For example, I’ve worked with people who told me they  trusted the Police more than the Mental Health Team. This was to their advantage and helped them, when in a crisis.

    In my experience, patients / users of services frequently tell me that the most important things for them were to be believed, to be able to trust individual members of services and build a relationship that helps them manage their own care.

    3.    Data sharing.

    If a  care plan (or suchlike) is shared between services, how is the person encouraged to own their own plan and how much of their information is shared?

    I believe it is vitally important only to share information as agreed by the patient /user of services and nothing else. The exceptions being if there are safety of safeguarding issues that need to be shared, as part of a professional duty to the patient and the public.

    The idea that the patient has control of what information about them is shared is vital to build trust. (This, of course, is also enshrined in data protection law). I have seen people make amazing progress after being confident to disclose past trauma to someone in the services that they trust, knowing it will be handled carefully and shared only as agreed.

     

    I base these concerns on my personal experience as an Assertive Outreach Nurse, working with some of the most vulnerable and isolated people in society. In this job I saw people make major steps forward in their lives. Sometimes over and above what anyone expected.

    When I asked people, ‘what helped most?’ the most frequent comments were that they were ‘believed’ (sometimes for the first time), and that they found people to work with who they trusted.

    When dealing with emotive areas and people in distress there are, in my view, as many approaches to care as there are people. These approaches must be transparent and recognise everyone’s rights and responsibilities. The HIN / SIM approach feels like it is primarily designed to benefit the services rather than the patients /users of services.

    I am happy to be corrected on this and to learn more.

    We need an open and honest discussion on this led by patients / users of services and supported by professionals. Let’s share everything and learn together.

     

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    Yes we do need open and honest discussion about what SIM/HIN actually does, rather than a heavily publicised attack consisting mostly of 'concerns' about what it 'might' be doing, some of which border on being malicious and libellous. The hostility of the attack against HIN - with many professional organisations also now distancing themselves from it and expressing new-found 'concerns' which never bothered them before - has resulted in the HIN directors avoiding engagement and taking their website offline. Hostility and deliberate misrepresentation does not provide an environment in which there can be 'open and honest discussion'.  

    It is one thing to investigate formal complaints by those who have experienced SIM or its variants first hand, and another to address 'concerns' expressed by people with no experience of SIM who (like you) are alarmed by the allegations they are reading. The former requires a formal, independent investigation and possibly suspension of all SIM-related activities pending official approval (which is what StopSIM appears to be asking for - the clue is in the name), while the latter could be satisfied by a press conference. The latter can be service-user led, but the former needs to be led by people who are unbiased by any personal or popular views, have the confidence of the public and the authority to compel the answers and information requested, who know their way around the system, know what they are looking for and what is reasonable practice within the NHS or the Police Service.  

    In answer to your concerns :

    1. SIM arose out of concern about impact on services rather than concern about the welfare of individual service users. It was not devised as a form of therapy but as a strategy to reduce the detrimental impact which some service users are having on emergency services. It is not a replacement for the Assertive Outreach Nurse. Like 'street triage' the prime objective is to improve the effective use of resources rather than to improve the choice. satisfaction and ultimate well-being of service users. As such I don't think it needs to be 'patient-led' nor 'patient-focussed' - although I expect it can benefit from feedback provided by current or potential users of its own service. 

    Nevertheless to my understanding SIM does aim to benefit both services and service users by taking a pro-active approach towards potentially criminal behaviour. It aims to influence the service user (yes using some measure of 'coercion' by warning about potential consequences of continued anti-social behaviour) to form better habits of self management, and engage with the appropriate chronic services on offer, rather than seek help from acute services which cannot provide what the SU needs. (There is a question here of whether they have been offered suitable chronic services.) The police and criminal justice systems have a duty to protect society against individuals (whether or not their behaviour can be excused by mental illness), rather than to do what is best for the individual offender.   

    2. It seems to me that the nature of the incidents - potentially criminal but possibly excusable by mental illness - means that both mental health and police services must necessarily be involved, The involvement of the police in mental health is inherent in the Mental Health Act 1983, eg by virtue of s 136.

    If someone is causing a public disturbance by threatening to jump from a motorway or railway bridge, or is repeatedly calling for an ambulance when one is not needed, or has reported their spouse for domestic abuse when none has taken place, or is being threatening and abusive at an A&E department, then it is the police who are qualified to respond to such situations. They are obliged to investigate, to warn about potential consequences if the offence is repeated, direct the person to appropriate support or advice, and as a last resort to consider prosecution (if the circumstances would normally warrant it) regardless of the person having a diagnosis of mental illness. It is not for them to judge that mental illness is an adequate defence, that is for the CPS or the courts to decide in all the circumstances.

    On the other hand SIM does give the service user the option of co-creating a crisis response plan tailored to their own needs. Doesn't that meet your requirement of being 'patient-focussed' with the service user choosing how they would like to be treated?

    3. It also seems to me that the serious nature of the above incidents usually does justify data sharing, without consent, arising from a duty to protect not only the service user but also the public, the people who provide services, and the service-resources.

    Data is routinely shared with the police and other services in Adult and Child Protection Case Conferences, which are somewhat similar. These take place merely because of 'concerns' whether or not the Vulnerable Adult or Child wants 'protection'. As the 'suspected abuser' in an APCC, I was shocked at how readily information which I had provided in confidence (along with rumours and 'concerns') was shared behind my back and subsequently discussed at Conferences from which I and my mother (the presumed victim) were excluded. To the extent that I felt completely isolated and victimised myself, and powerless to 'stop' a chain of events which resulted in my elderly mother's death 3 years later, after being later locked up in hospital for 2 years.

    So if you want to complain about data sharing without consent, and harmful services which operate on the basis of what they think is best for you rather than how you would like your own life to turn out, then I suggest that you really ought to compare what happens across Health & Social Care Partnerships, and in the Forensic Mental Health and Criminal Justice Systems, and not focus exclusively on small fry like SIM. As though that is the only source of evil in society. 

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    Thanks. I find you comments helpful, informative and also (on data sharing) familiar and disturbing. 

    I agree SIM is small fry and, from what you say, potentially valuable.

    Rather than taking information off-line I think the HIN / SIM Leaders should be openly discussing and defending it. Otherwise it feels like service leaders only listen to the patients / users of services who shout loudest, rather than those who are most in need (many of whom may feel unable to speak up).

    The bigger issues which may be mixed up in SIM criticism's (something I have been guilty of) are:

    • The decline & disbandment of Assertive Outreach Services.
    • The decline of Drug Services, including the over-emphasis on abstinence as opposed to harm reduction.
    • Inappropriate data sharing, which includes sharing inaccurate information (and 'labels') that adversely affects people's care. 
    •  Mental Health Service deficiencies that contribute to deterioration in people's mental state. For example, people being transferred back to the care of their GP because they are 'too complex'.
    • Incarceration of people with autism and learning disabilities in inappropriate settings.

    I hope more people will feel able to comment on this.

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    Yes it would be more helpful if HIN directors were willing to engage in discussion. However from my own experience on twitter and facebook I can understand their decision not to do so. 

    When people are attacking you via social media as StopSIM is attacking HIN/SIM then defending yourself is not wise. The more you defend yourself, the more belligerent your critics become. If you don't want to apologise unreservedly, then it is best for all if you just keep quiet and disengage. In my own unwise encounters I continued defending myself, resulting in abuse, accusations that I was really Paul Jennings(!), and being blocked so that others in the thread could continue bad-mouthing me behind my back.

    Paul Jennings answered questions from the Association of Clinical Psychologists (ACP-UK) which nevertheless retained "significant concerns" about issues which were not thoroughly explored in the interview. I asked ACP whether any of its concerns pre-dated contact with it from StopSIM - to date it has not replied. If a professional organisation like ACP cannot acknowledge that Sgt Jennings' answers have adequately countered most of its concerns, and that those concerns did not exist prior to contact from the popular SU-led campaign StopSIM, then it is not surprising that he is reluctant to engage more widely. 

    https://acpuk.org.uk/rapid-response-concerns-about-the-high-intensity-network-hin-and-serenity-integrated-mentoring-sim-2/

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    An interesting development:

    Quote

    Royal College of Psychiatrists  calls for urgent and transparent investigation into the NHS Innovation Accelerator and the Academic Health Science Network  following the High Intensity Network [HIN] suspension

    https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2021/06/14/rcpsych-calls-for-urgent-and-transparent-investigation-into-nhs-innovation-accelerator-and-ahsn-following-hin-suspension

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    More allegations. Still no investigation. The title is misleading, making it appear that HIN has been shut down by powers above. But there is no evidence of it having been found guilty of anything. The text suggests that it is voluntarily shutting down, probably because of the hostility not only from StopSIM but also from professional organisations like RCP. The statement gives the impression that any review or investigation is a foregone conclusion, and that RCP members played a key role in unearthing this public scandal. Hypocrisy and opportunism. 

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    Thank you for this post Steve.

    To me SIM and HINs raise a couple of important points.

    1) Many (but not all) people under the carer of HINs will have been given a diagnosis of personality disorder. I would be interested to know how many of these people previously had access to care recommended by NICE.  NICE make two recommendations, and in healthcare we tend to only say the first and forget to say the second. 1) "People tend not to benefit from inpatient admission" 2) "People do benefit from copious amounts of community based psychological therapy". I know that in many areas access to this care is restricted. Often a referral will be made to community based psychological therapies (so, not IAPT, but a much more intense programme) and the referral is rejected because the patient is "too unwell". Clearly, without access to evidence based support the chances of recovery decrease. When we look at this patient group we see a lot of use of S2, S3, S136, the forensic sections, the community treatment orders. We see a lot of use of acute MH hospitals, PICUs, secure units, eating disorder inpatient units. We see a lot of use of community treatment teams - community MH, crisis teams, ED teams. We see a lot of use of emergency departments, and acute physical health hospitals and burns units. We see people have these huge, complicated, packages of care that are mostly reactive to crisis and do not do much to help people get back control over their life. In my opinion this clearly sucks for those patients. We should focus on the collapse of provision of high intensity community based psychological therapy. We should also focus on the collapse of "system wide" working. 

    2) In Gloucestershire we used to have a thing called "MARMAP" (multi agency risk management and assessment panel (I think it was something like that). Because it was a local authority thing it got a different name in every LA region). This was run by the local adult social services department. It was a big multi agency meeting to discuss how best to provide care. There were problems with it, it was far from perfect. But it had some good points. It recognised the need for excellent care coordination and getting all HCPs to stick to the plan, and to only make changes in agreement with the patient and each other. Often, an HCP will feel frustration at lack of "progress" and will just change the care plan. This can lead to chaos. And blame for that chaos is never placed upon the clinician changing the plan, it's always placed upon the patient for "splitting" the team. LA funding has been decimated. This means they had to stop providing things like this. So, when you have a patient with a system-wide package of care there does need to be excellent care coordination and I don't think we have that.

    3) When we talk to staff about this group of people we find that staff feel they do not have the skills and competence to provide support; they do not have the time to provide support; they feel confused by the lack of psychological therapy; they feel unsupported by their organisation. If you know the right questions to ask you can sometimes find shocking examples of stigma and discrimination, a real lack of compassion.

    Into this vacuum (lack of community based psychological therapy, lack of excellent system wide care coordination, lack of competence within an organisation) we get SIM. To me this is why SIM got rolled out so quickly, with such little scrutiny. Systems need something to happen. Orgs need something to happen. Staff are glad there's now a more specialised service. And patients? Well, often they're pleased to be getting anything at all, even if it's not good.

    I think we probably need to be careful to be clear whether we're talking about SIM or HINs, because it's possible for a HIN to be a good intervention even if there are problems with SIM. I think we also need to be clear about whether the withdrawal of service is a result of SIM/HIN or because of something else in that local system. Some people who've been prosecute for breaching CBOs were not, I think, under the care of a HIN.

    When you scrutinise any model of care you can probably find something concerning. That's the point about "always improving". The surprising thing about SIM and some HINs is that you don't have to look far to find problems.

    SIM frequently talks about interventions "done to" and not "done with" service users. Here's part of an answer from one of their FAQs "If you have been approached by your local mental health provider to talk about being supported by a high intensity team, then it is highly likely that a multi-agency panel called a High Intensity User Group (or similarly named risk panel) will have already met to discuss your care and safety. This panel consists of key decision makers from the NHS, the police, the ambulance service and local A&E; departments. The panel could also include: Social Care, Drug & Alcohol Services and specialist 3rd Sector/Charity providers. " -- this is pretty far from "nothing about me without me". It's not coproduction of care. It's not personalised.

    There appears to be a very low threshold in some regions before people are put on a HIN pathway. The original IOW documents talk about 8 patients per 140,000 population. But then we see far more people placed on a HIN pathway.

    In some places the HINs are about providing a clear and easy to understand plan: "When you feel like this, you should do these things in this order", and about making sure care providers respond appropriately. But in other places the HINs do appear to be about withdrawing support.

    Police describe their presence as coercive. This should be really concerning in the context of MCA and MHA. (See slide 3 here: https://emahsn.org.uk/images/End_of_project_status_report_SIM_implementation_April_2020.pdf

    The slide that talks about benefits to police forces mentions "reduction in the use of police cells for people in distress (and therefore the reduction of deaths in custody)". To me this isn't talking about a reduction in death. It's talking about where that death happens. That's chilling, isn't it?

    I saw an anonymised care plan for someone in a HIN. A lot of the care plan was spent detailing how this person was at risk for death by misadventure, but not suicide. I felt that 1)  dead is dead and we want to prevent death 2) defensive working to provide evidence to a coroner is a sub-optimal way to work and 3) it's a misunderstanding of coroners conclusions.

    The language used around severe emotional distress is genuinely awful. "Within my mental health service, I have two groups of service users with Personality Disorder. The first group makes clinical progress. The second is simply uncontrollable". https://www.iow.gov.uk/azservices/documents/2880-04-PJ-PB-SIM-MENTORING.pdf  (And, again, this slide pack mentions "accidental suicide" which is incoherent.)

    And then there are the problems with data. There's a slide somewhere (and I struggle to find it now) where they compare use of emergency service pre- and post- HIN. But they're comparing the full year before HIN, and only 4 months on SIM. And for one of the people they say "Look, use of S136 / PICU / Ambo call / Ambo triage / Ambo attendance dropped to zero, A&E / police / missing person all dropped". They mention, but don't highlight, the fact that for the four months this data covers this person was in hospital. There are *loads* of examples like this.

    So, I get that everyone is really busy. I get that for meetings there are too many papers; the papers are too long; the papers are too dense. But it means that scrutiny is now based on "they're probably trying to do the right thing, and we'll fix any problems later".  We urgently need better regulation and scrutiny and oversight. There were so many people involved in this that could have read the slide deck and said "you need to fix the language" and "you need to fix the data" and "you really can't say it if it's not true". And maybe they did say these things, but because it all happened behind closed doors, away from patients, the already low levels of trust have been destroyed.

    Finally, I speak to a lot of people in this kind of situation and while I hear talk about the need for clarity and for strong care coordination I've never heard people say "we need more police involvement". They overwhelmingly ask why community based psychological therapy isn't available.

     

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    Also, there's some other things that have an effect here.

    We know that merely giving people the diagnosis of personality disorder will cause them harm. Under ICD10 you cannot give a dx of personality disorder to someone under the age of 18. But we see CAMHS using phrases like "emerging personality disorder", and we see CAMHS and adult services using phrases like "traits of PD". These pseudo-diagnoses cause some of the harm without bringing much of the benefits that a dx can have. They can also causes diagnostic over-shadowing. Access to autism diagnostic services is dire in many places, and so there are autistic women who don't get an autism dx, but do get a pseudo-dx of "traits of PD", and are then denied access to suitable autism support because 1) that doesn't exist and 2) they've been put on a HIN pathway.

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    Thank you Dan, and everyone who has contributed to this discussion. So much to reflect on.

    Three things stands out for me right now,

    1. The lack of suitable community based (long-term) therapies.
    2. Diagnostic overshadowing.
    3. The way in which national bodies have responded to being challenged by patients. Which seems at times unhelpful, insular and defensive.

    I work with people with multi-morbidity. Time and time gain we see diagnostic overshadowing and inappropriate 'labeling'; a desperate unmet need for appropriate non drugs based community therapy or treatments, set against a  background of provider organisations that don't hear what their patients are telling them.

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    On 17/06/2021 at 13:27, DanBC said:

    ...

    A. SIM frequently talks about interventions "done to" and not "done with" service users. Here's part of an answer from one of their FAQs "If you have been approached by your local mental health provider to talk about being supported by a high intensity team, then it is highly likely that a multi-agency panel called a High Intensity User Group (or similarly named risk panel) will have already met to discuss your care and safety. This panel consists of key decision makers from the NHS, the police, the ambulance service and local A&E; departments. The panel could also include: Social Care, Drug & Alcohol Services and specialist 3rd Sector/Charity providers. " -- this is pretty far from "nothing about me without me". It's not coproduction of care. It's not personalised.

    ...

    B. Police describe their presence as coercive. This should be really concerning in the context of MCA and MHA. (See slide 3 here: https://emahsn.org.uk/images/End_of_project_status_report_SIM_implementation_April_2020.pdf

    C. The slide that talks about benefits to police forces mentions "reduction in the use of police cells for people in distress (and therefore the reduction of deaths in custody)". To me this isn't talking about a reduction in death. It's talking about where that death happens. That's chilling, isn't it?

    D. The language used around severe emotional distress is genuinely awful. "Within my mental health service, I have two groups of service users with Personality Disorder. The first group makes clinical progress. The second is simply uncontrollable". https://www.iow.gov.uk/azservices/documents/2880-04-PJ-PB-SIM-MENTORING.pdf  (And, again, this slide pack mentions "accidental suicide" which is incoherent.)

    E. And then there are the problems with data. ... They mention, but don't highlight, the fact that for the four months this data covers this person was in hospital. There are *loads* of examples like this.

    F. ... We urgently need better regulation and scrutiny and oversight. There were so many people involved in this that could have read the slide deck and said "you need to fix the language" and "you need to fix the data" and "you really can't say it if it's not true". ...

    G. ... I've never heard people say "we need more police involvement". 

     

    I have no experience of HIN/SIM other than what I've read, which is the ideal version rather than what is implemented. I am a former carer with no professional training.

    My comments on the above :

    A, Such a multi-agency panel does not look out of place to me. As I understand, the MAP is not creating your HIN care plan then retrospectively inviting you to "co-produce" it. It is merely deciding who, from among those who have been nominated, to offer the HIN/SIM service to  - ie do you meet the threshold criteria? could you benefit from it? They don't need to interview all candidates, only those short-listed, so to speak. The 'individualised crisis response plan' is then produced with you if you agree, or without you if you refuse - because it is better to have an imperfect crisis response plan than none at all. 

    B. The essential nature of policing IS coercion. As I wrote above, the police have a duty to uphold the law - to encourage people to obey the law, especially to warn those who are on a course of action which will result in them breaking the law. Therefore it is entirely appropriate (and refreshingly honest) for them to describe their function as "coercive,"

    In a SIM programme the police are not offering to provide mental health care or 'treatment' (which is what StopSIM claims that SIM is doing), they are offering to show you how to make better decisions so that you can avoid committing a crime and being prosecuted. (If a financial adviser gave a mentally ill person advice about managing their finances better, would they be providing mental health care or treatment?) 

    C. I don't see where you are getting the quote from. It doesn't appear on these slides.

    No I don't find this statement chilling. Nor is it necessary to interpret it as you have done, as being concerned solely about the place of death. You are imposing your own meaning onto words which do not justify it. It a fact that people suffering mental distress react badly to being arrested and locked up in a police cell, and may commit suicide as a result. It is entirely appropriate to want to minimise such deaths by reducing the numbers of people taken to a police cell, which is achieved by reducing the behaviours which lead to the arrest.

    D. You appear to be attributing this quote to HIN/SIM. However the slide attributes it to an unidentified mental health manager during an informal discussion at a conference. It is not stated whether this person has any connection with HIN/SIM. Just because someone quotes what someone else said does not mean that they endorse the statement or the language used. (The response is clearly being used as a selling point to other managers.)

    The anomaly of the phrase 'accidental suicide' is already noted on the slide by placing it in quotation marks. The writer is aware this is an oxymoron.

    E. Yes it would be good to see the document you are paraphrasing here. Or that for any of the "loads" of example you mention. It does seem anomalous that a programme that makes a significant claim about its effectiveness would immediately after it make another statement which disproves the claim. Either the writer was utterly stupid, or the note has been misunderstood in some way. 

    F. If the only problem with HIN/SIM is the language or the use of data, then I don't understand why there is an urgent need for scrutiny and regulation. Such "concerns" justify a Public Inquiry according to StopSIM. Are these "concerns" actually causing mental or physical or financial harm to anyone? Or is it all a "storm in a teacup"? 

    Incidentally, StopSIM does not balk at saying things which are not true. EG claiming that SIM promotes the withholding of potentially life-saving care, and criminalises people for experiencing mental distress. 

    G. Having previously praised "excellent care co-ordination" in MARMAP, which included Gloucestershire Police, it now seems inconsistent that you criticise police involvement through SIM.

    The tragic deaths of Olaseni Lewis in London and Sheku Bayoh in Scotland, and the more recent case of the 17 year old learning-disabled girl who was hit 30 times with a baton then tasered, all suggest that the police need a better understanding of and a better response to mental crises, rather than to be sidelined as you appear to be suggesting.

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    Great discussion and important points from all perspectives.

    Information and perspectives which we all need to reflect on.

    I hope StopSIM campaigners, the Police & emergency services, NHS trust leaders, NHS England, academics & AHSN leaders are looking at this, and will feel able to contribute. 

    One  thing that I see as important is discussing what's behind the comments that 'SIM promotes the withholding of potentially life-saving care'.

    I don't know what's exactly behind this (are there examples?) However I do believe that England's current approach to mental heath care and its delivery  frequently denies people access to potentially life saving care in the long term. I say this openly as a mental health clinician. 

    We have a system that too often is set up around short-term (fixed time) initiatives, very poor access to psychological & other therapies for people with complex issues, no drop in facilities for people in crisis, very little sharing of medical records with patients, poor interdisciplinary & trans-disciplinary working, and frequently medicines prescribed by clinicians who don't follow the competency framework or monitor their effect with the patient.  I see this every week in my practice. Including subjective, demeaning and totally inaccurate comments in people notes, and reports of awful practices such as transferring people back to the care of their GP because they are 'too complex'. 

    Don't get me wrong... Sometimes coercion is the only safe approach if the risks are high and, for example, someone lacks capacity. 

    We all need to talk openly and sometimes those who hold all the cards (the service leaders) are just too interested in reputation and 'awards' to engage in open & inclusive discussions..

     

     

     

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    Edited by Steve Turner

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    Yes I would agree with MOST of that Steve. What I don't agree with is the importance of the claim that "SIM promotes the withholding of potentially life-saving treatment."

    As proof of this claim StopSIM and its supporters point to a single passage which plainly says that the co-produced crisis response plan (CRP) gives ED staff the confidence to refuse to do blood tests, x-rays etc at the demand of the HIU which the ED staff suspect are not needed. This confidence comes from the fact that the behaviour observed has been predicted in the CRP and the HIU has pre-authorised the ED staff to withhold such tests if the circumstances match. 

    What StopSIM supporters do is to ring fence a specific block of this text, which they interpret in isolation (ie out of context) as SIM either ordering or authorising the ED staff to refuse to treat someone who clearly requires it and may 'potentially' die without it. However, the sentences immediately adjacent (which are deliberately excluded from the highlight) make it abundantly clear that this is NOT the case. The treatment is NOT needed to save life, and the patient was co-producer of the authorisation (ie the CRP).

    The interpretation given by StopSIM supporters, that ED staff are looking for the slightest excuse to refuse to give life-saving treatment to someone who clearly needs it, just because that person is mentally ill and vexatious and the injury might have been deliberately self-inflicted, is manifestly preposterous. (I have heard of malicious ED staff refusing to stitch a self-inflicted cut - WITHOUT any authorisation from a SIM team! - but nothing anywhere near life-threatening.) They would lay themselves open to prosecution for criminal negligence if they did what StopSIM is suggesting. Even if the authorisation came from the CE of the NHS, this would provide no defence in court because the immediate circumstances, and the patient's right to life (ECHR Article 2), would emphatically over-ride it. 

    Otherwise, I agree with everything you say about the failings of our beloved NHS - for which SIM cannot be blamed.

    I don't think SIM is perfect, either as intended or as implemented. But I do think it was well-intentioned, and it has been unjustly maligned by people who had an ax to grind and others who jumped on the bandwagon to avoid being unpopular and/or to divert attention away from their own harmful practices (eg Royal College of Psychiatrists). 

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