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A recent blog I wrote (see link below) brings together key information for clinicians, and especially for prescribers, from a variety of sources, including patients, relatives and carers. The aim is to help to prevent patients with autism and learning disabilities being harmed by inappropriate medicines. I began this in 2018 following the death of Oliver McGowan, which I cover in teaching for (non-medical) prescribing students and in my clinical education work. It links to the NHS Learning Disability Mortality (LeDeR) Review Programme. Key points: Most of the prescribing in this area is ‘off label’ (#jargonbuster – that’s medicines prescribed for something that isn’t listed as an ‘indication’ for that medicine ). This prescribing can include multiple anti-psychotic medicines, often medicines in the same class. There is a limited evidence base for this type of prescribing. Psychotropic medicines in people with learning disabilities who show symptoms of distress are not always prescribed by a specialist in this area. Diagnostic overshadowing may lead to inappropriate prescribing. This is the attribution of a person’s symptoms to their mental condition, when such symptoms actually suggest a comorbid condition. Further resources: The Oliver McGowan Mandatory Training in Learning Disability and Autism – “Oliver’s Story” Presentation: Stopping over-medication in people with learning disabilities – 'Reasonable adjustment' Learning Disabilities Mortality Review annual reports University of Bristol: Learning Disabilities Mortality Review

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: A more integrated, informed, calm approach in the way we respond to individuals that have unique needs during a crisis and A better form of multi-skilled, personalised support after the crisis event is over. So in July 2013 the Serenity Integrated Mentoring (SIM) model of care was proposed. This is how it works: SIM brings together all the key urgent care agencies involved in responding to high-intensity crisis service users around the table, once a month. This multi-agency panel selects each individual based on demand/risk data and professional referrals. 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. 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). 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. 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. The crisis plan is then disseminated across the emergency services. 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

'Dr Lucy Johnstone, one of the lead authors of the Power Threat Meaning Framework, said: "The Power Threat Meaning Framework can be used as a way of helping people to create more hopeful narratives or stories about their lives and the difficulties they have faced or are still facing, instead of seeing themselves as blameworthy, weak, deficient or ‘mentally ill’. It highlights and clarifies the links between wider social factors such as poverty, discrimination and inequality, along with traumas such as abuse and violence, and the resulting emotional distress or troubled behaviour, whether it is confusion, fear, despair or troubled or troubling behaviour. It also shows why those of us who do not have an obvious history of trauma or adversity can still struggle to find a sense of self-worth, meaning and identity.“ In traditional mental health practice, threat responses are sometimes called ‘symptoms’. The Framework instead looks at how we make sense of these experiences and how messages from wider society can increase our feelings of shame, self-blame, isolation, fear and guilt. The approach of the Framework is summarised in four questions that can apply to individuals, families or social groups: What has happened to you? (How is power operating in your life?) How did it affect you? (What kind of threats does this pose?) What sense did you make of it? (What is the meaning of these situations and experiences to you?) What did you have to do to survive? (What kinds of threat response are you using?) Two further questions help us think about what skills and resources people might have and how they might pull all these ideas and responses together into a personal narrative or story: What are your strengths? (What access to Power resources do you have?) What is your story? (How does all this fit together?)' Further reading The British Psychological Society: 'Power, Threat, Meaning Framework' The British Psychological Society: The Power Threat Meaning Framework: (2 page) Summary Boyle M. Johnstone L. A straight talking introduction to the Power threat meaning framework: A alternative to psychiatric Diagnosis. PCCS Books 2020.