Why NHS England’s failure to publish our co-produced policy is a betrayal of service users

By members of the StopSIM Coalition

As members of the StopSIM coalition, we’ve campaigned for two years against Serenity Integrated Mentoring (SIM), a model which placed police officers within community mental health teams. The StopSIM campaign, which has been run by mad and disabled activists from our bedrooms, gained national attention, and in 2021 we agreed to work with NHS England on the issue. 

We’ve spent the last 15 months collaborating to produce what would have been the first national NHS policy to be jointly written with mad/disabled activists. However, the publication of the policy was much delayed due to the institution’s PR concerns and legal challenges from other actors involved in promoting SIM. As a result, over a month ago we set a deadline of Friday 10 March. On that day, instead of finally publishing the policy, NHS England published a watered down letter from mental health director Tim Kendall which we feel is a betrayal of service users.

How SIM happened

SIM was created by an ex-police officer, Stg Paul Jennings, and run through his company the High Intensity Network. The scheme was first piloted on the Isle of Wight in 2012, pitched as a cost-saving intervention targeting so-called “high intensity users” of mental health and emergency services. The aim was to reduce patient contact with emergency services primarily through the use of behavioural contracts and multi-agency information sharing. 

SIM was based on crude behaviourist assumptions about shaping behaviour through reward and punishment. It described the police officers it placed within community mental health teams as “coercive” figures to enforce boundaries and consequences, who could impose, or threaten to impose, legal sanctions in response to “excessive” contact (the definition of excessive varied between SIM teams. In some areas this was as little as two s136 detentions within 12 months). The intervention also promoted coordinated withholding of care across agencies through “care plans” and/or behaviour contracts, in some cases written without the individual’s involvement or consent. Unsurprisingly, there was a notable lack of service user involvement in the development of this model.

Service users and mental health activists had been raising red flags about SIM since 2018. Wide-ranging concerns included the potential for significant harm and loss of life resulting from withholding of life-saving treatment from vulnerable individuals; discrimination contravening the Equality Act and the Human Rights Act, especially against Black and racially minoritised patients, people with mental health disabilities, autistic people and people with learning disabilities; and data-sharing practices which appeared counter to GDPR legislation. This included granting police officers access to patients’ sensitive medical records on alleged “vital interest” grounds, claiming that the individuals placed under SIM were “constantly an emergency case”.

There was also a glaring lack of evidence for SIM. A freedom of information request to Hampshire constabulary revealed that “completely inaccurate data” from the SIM pilot had been used to sell SIM across the country. Despite this, SIM received an NHS Innovation Accelerator fellowship in 2016, which provided NHS money and support in the development and spread of the model. In 2018 it was selected by the Academic Health Science Network (AHSN) for national adoption and spread, even though email exchanges indicate that by November that same year Hampshire constabulary had shared concerns about flawed data with Wessex AHSN. By 2021, SIM (or a version of SIM under a different name) was operating in 26 mental health trusts in England, with rapid further expansion being pursued. 

SIM unravels, but the problem remains

As a result of the StopSIM coalition’s national campaign —which involved tens of thousands of collective hours and a huge amount of physical and emotional labour—the unimpeded spread of SIM was halted. In June 2021, the High Intensity Network closed down its website and subsequently announced it would be shutting down with immediate effect. This happened after Tim Kendall told mental health trusts across England to review their use of SIM and associated practices, in May 2021.

In December 2021, we were invited —and agreed —to form a working partnership with NHS England to produce a joint public response based on an analysis of these reviews. The trusts’ individual reviews did not go as far as the independent inquiry we had called for and varied hugely in quality, depth and outcomes. This meant it was not always straightforward to identify exactly what models or practices were occurring in each trust. Additionally, we believe the way the reviews were conducted meant that, in places, they excluded the views of some people who had negative experiences.

However, analysis of the reviews suggested that while six trusts had discontinued using SIM or SIM-like models altogether, fourteen others were still using key features of the SIM model, and an additional five were continuing the approach with no significant changes beyond a name-change or rebrand. In some trusts, the scheme even appeared to be expanding, for example through changes to localised criteria such as reducing the age bracket for inclusion. Meanwhile, a small number of trusts provided very little information or claimed that they never used SIM, yet service users in these areas reported that they were experiencing SIM-like practices, even under a different name. 

Resisting the criminalisation of distress

Through our work with NHS England, we wanted to address not just the SIM model but all the different iterations and elements of it. We wanted all discriminatory, coercive and punitive approaches within mental health teams —which are widespread —to be stopped. While the policy we wrote with NHS England was inevitably a compromise, we worked hard to produce a document that would have functioned as a practical guide for both healthcare workers and service users to identify, address, and prevent the harmful practices associated with or resembling SIM.

The letter Tim Kendall published on 10th March 2023 mandates changes that our policy identified as necessary. It states that the police must not be actively or routinely involved in non-emergency community mental health services, and mental health services must not use the threat of prosecution as a way of seeking to control someone’s behaviour. It also states that coercive and punitive approaches, withholding care and behavioural contracts for patients must end. Finally, it states that discriminatory practices towards patients who self-harm or attempt suicide, such as telling patients they have capacity to take their own life, must end. However, the letter falls far short of the detailed policy we jointly authored, crucially omitting an apology to service users who have been harmed by SIM and commitments to make changes within NHS England to prevent mistakes that led to the endorsement of SIM from being repeated.

While a number of Trusts have discontinued their SIM model since our campaign began, SIM has not ended. A number of trusts continue to use the model (or something similar under a different name) and the practices outlined above. NHS England’s failure to publish the policy in full undermines the chances of stamping out these practices once and for all and denies service users access to a policy that could protect them. Furthermore, NHS England’s failure to acknowledge the harm their endorsement of SIM has caused, and its disregard for lived experience labour, shows that their professed commitments to accountability and ‘co-production’ are little more than lip service. The institution’s behaviour provides an insight into the wider culture within the healthcare sector which enabled SIM to emerge in the first place. 

The approaches that SIM used, and indeed the prejudices and unfounded assumptions it was based upon, existed long before it did. SIM merely gave them a new kind of legitimacy. The model thrived within a wider context of increasingly securitised and unaccountable healthcare environments. NHE England’s betrayal of service users underscores how much work still needs to be done. We continue to call on NHS England to publish the full policy. Our contributions to Medact’s ongoing project are another way we will keep working on this issue. Our resistance to the criminalisation of distress is far from over.