Concerns About The Evidence Base Relating To The High Intensity Network (HIN) And Serenity Integrated Mentoring (SIM)

Serenity Integrated Mentoring (SIM) and interventions associated with the High Intensity Network (HIN) are being rolled out at pace and scale across NHS England. As we outlined in our preliminary coalition consensus statement[1], dated 21/04/21, SIM’s key intervention components include a co-ordinated withholding of potentially lifesaving treatment by multiple agencies [2] (A&E, mental health, ambulance and police services), and using SIM’s own words, the “coercive”[3] approach of a police officer as an interventionist.

To our knowledge, no robust, high quality research has been conducted, which would justify such a rapid implementation of this novel, complex and high-risk intervention. There is also a wider absence of evidence that attests to the safety, efficacy and acceptability of interventions that involve withholding potentially lifesaving assessment and treatment across multiple agencies, which also utilise police officers as interventionists[4].

Complex clinical and high-risk interventions typically undergo a rigorous and lengthy development and evaluation process, as outlined by the Medical Research Council’s Guidelines for the Development and Evaluation of Complex Interventions[5]. This process results in multiple peer-reviewed publications, enabling a wide scrutiny of the evidence base, which is notably absent in relation to SIM and its associated interventions. SIM has not been compared to treatment as usual, or NICE recommended non-coercive and lower risk interventions for self-harm[6], or for Borderline Personality Disorder (BPD)[7], a condition which the majority of SIM recipients are reported to have[8].

As far as we are aware, the following information relating to SIM’s evaluation is available in the public domain:

  • Pilot Intervention Case Study, published in the Journal of Criminological Research, Policy and Practice[9] (June 2017): Described as a pragmatic evaluation of a quality improvement intervention. Data generated July 2013 – December 2014; Service users: n = 4; Outcomes: reports a reduction in emergency service contacts, S136 detentions and rudimentary cost saving calculations. Narrative reports by authors in relation to service user outcomes assert that clinical improvements were observed but it is unclear what those improvements might be. No patient outcome measures used, no interviews with service users.
  • SIM Project Pilot Report[10] (no date): Described as a project pilot report. Data generated July 2013 – February 2015; Service Users: n = 6 (n = 4 appear to be the same service users reported in the Pilot Intervention Case Study, Matheson and Jennings (2017)); Outcomes: reports a reduction in S136, rudimentary cost saving calculations, 4 narrative case studies and an ‘interview’ between a service user and Vicki Haworth, Clinical Team Leader. No patient outcome measures used.
  • The Isle of Wight Report[11] (April 2017)Described as a SIM project review report. Data generated between August 2015 – March 2017; Service users: n = 9 “high intensity” and n = 68 non “high intensity”; Outcomes: reports a reduction in S136 detentions and rudimentary cost saving calculations. No patient outcome measures used or interviews.
  • NHS Innovation Accelerator: Understanding how and why the NHS adopts innovation[12] (2018): Report by NHS Innovation Accelerator (NIA) on the impacts of innovations and innovators they support. Includes case study of SIM’s involvement in developing the Surrey High Intensity Partnership Programme (SHIPP). Service users: n = 16; Outcomes: reports a reduction in S136 use and police resources. A single narrative description of an incident with a service user is given as an example of cultural change. Officers responded to an incident with a service user and as instructed by her SHIPP care plan, did not detain her. She subsequently took an overdose. The case was investigated by the Independent Office for Police Conduct (IOPC), but no outcome was given for the service user or outcomes in relation to clinical professionals involved in compiling and / or supporting the care plan. No patient outcome measures used or interviews.
  • The Implementation of SIM London: Sharing best practice for spread and adoption[13] (June 2018): Described as a report to inform the “spread and adoption of SIM nationally” through the Academic Health Science Networks (AHSN) (p2). No outcomes reported, contains narrative descriptions about the implementation process across SIM London pathfinder sites.
  • SIM London: Support for a better life[14] (May 2020): Described as a report. Data generated between April 2018 – May 2020; Service Users: n = 103 “allocated to SIM” (p6); Outcomes: reports a reduction in emergency service contacts, rudimentary cost saving calculations and 4 brief ‘case studies’, which focus on service use and cost. No patient outcome measures used or interviews.

These evaluations have significant methodological limitations, and we encourage readers to access these documents themselves to appraise their quality. Outcomes relating to service users have not been captured in any meaningful, rigorous way, with a significant focus on outcomes pertaining to service use and cost. This is congruent with SIM’s focus on the ‘use’ of a service as opposed to the ‘user’, or person using the service[15]. Negative short and longer-term outcomes have not been routinely or rigorously captured, for example suicide and self- harm. An evaluation of the acceptability of the intervention to service users, and their experiences of it, has crucially not been reported.

Reflecting the lack of evidence, SIM is not recommended by NICE in their guidelines for BPD[16], or NICE’s separate guidelines for self-harm[17]. SIM directly contravenes large portions of NICE guidelines for the latter, particularly by advocating the withholding of potentially life-saving assessment and intervention across multiple agencies; providing ‘rewards’; not viewing each incident of self-harm as a separate event; and the use of coercion as a means to acquiring consent and compliance[18]. Multiple claims have been made by SIM and the HIN, that their interventions adhere to NICE guidelines for BDP[19, 20], however, we strongly contest these statements.

SIM is based on a conceptual model which relies on a crude behavioural and positive risk taking approach[21, 22]. The latter lacks empirical evidence in relation to service user outcomes and acceptability[23, 24], and SIM’s behavioural analysis conceptualised service users’ behaviour as “attention-seeking” and / or “manipulative”[25]. The conflicts with the empirical literature on the casual determinants of self-hard and suicide attempts, which indicates that they are a) overwhelmingly driven by an attempt to manage acute distress as opposed to being ‘socially motivated’ (i.e. ‘attention-seeking’)[26, 27]; and b) as a result, present a substantial risk factor for eventual suicide, something which is likely to increase if service users are forced to hide their self-harm and suicide attempts from services[28].

In 2016 Paul Jennings, who developed SIM, received an NHS Innovation Accelerator (NIA) Fellowship[29], which is awarded to “exceptional individuals” to “scale their high impact, evidence-based innovations through the NIA”[30]. NIA further states that the innovations they host are “supported by a robust evidence base”. Yet, we have not been able to identify a robust evidence base in relation to SIM or the HIN in 2021, 8 years since its initial pilot on the Isle of Wight.

NIA have a caveat attached to their endorsement of innovations, which specifies that “NIA does not perform independent scrutiny of the evidence base put forward by the applicant”[31]. They state that this accountability rests with NHS sites:

“All NHS sites remain accountable for their decisions and care provision/safety, and as such undertake their own scrutiny of NIA innovations before they decide through their local governance structures whether to use them or not. The NIA does not seek to duplicate, circumvent or replace these local decision-making processes. NHS sites are not mandated to take up NIA innovations.”[32]

In this context we ask:

  • Why have so many NHS organisations and Academic Health Science Networks across England enabled the rapid roll out of SIM, HIN, and interventions utilising similar components and principles?
  • What scrutiny did they conduct of the evidence base?

We will provide further statements in relation to evidence as necessary. This is a preliminary document, and we continue to analyse and collate information relating to SIM and HIN’s ‘evidence-base’.

In solidarity,

The #StopSIM Coalition

Copied to:
Information Commissioner’s Office (ICO), Sir Simon Stevens, CEO – NHS England, Lord David Prior, Chair – NHS England, Claire Murdoch, National Mental Health Director – NHS England, Martin Hewitt, Chair – National Police Chiefs’ Council, Sir Tom Winsor, Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Service.

References

  1. StopSIM Coalition. StopSIM Coalition Consensus Statement [Internet]. 2021. Available from: https://www.stopsim.co.uk/
  2. SIM and High Intensity Network Business Case [Internet], p. 7. Available from https://highintensitynetwork.org/img/resources/SIM_and_High_Intensity_Network_-_Business_Case_(Commissioner)_v4.docx [accessed 22 April 2021].
  3. Paul Jennings. What is SIM and the High Intensity Network? [Internet]. 2019 Mar 26; Daresbury Park Hotel. Available from: https://www.slideshare.net/InnovationNWC/paul-jennings-high-intensity-network-sim [accessed 22 April 2021].
  4. Catherine B. Matheson-Monnet, Paul Jennings. A Review of Quality Improvement [QI] Specialised Interventions in the USA and England to Reduce the Number of Police Mental Health Crisis Detentions and Provide Support to High Intensity Utilisers [HIUs]. Open Med J [Internet]. 2017 Sep 30;4(1). Available from: https://openmedicinejournal.com/VOLUME/4/PAGE/57/FULLTEXT/ [accessed 22 April 2021].
  5. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008 Sep 29;337:a1655.
  6. NICE. Self-harm in over 8s: long-term management. Clinical guideline [CG133]. National Institute for Health and Care Excellence; 2011.
  7. NICE. Borderline personality disorder: recognition and management. Clinical guideline [CG78]. National Institute for Health and Care Excellence; 2009.
  8. Paul Jennings. SIM Project Pilot Report 2013-2015 [Internet]. Available from: https://highintensitynetwork.org/img/resources/SIM_Pilot_Report_2013.doc [accessed 22 April 2021].
  9. Paul Jennings, Catherine B. Matheson-Monnet.  Multi-agency mentoring pilot intervention for high intensity service users of emergency public services: the Isle of Wight Integrated Recovery Programme. J Criminol Res Policy Pract. 2017 Jan 1;3(2):105–18.
  10. Paul Jennings. SIM Project Pilot Report 2013-2015 [Internet]. Available from: https://highintensitynetwork.org/img/resources/SIM_Pilot_Report_2013.doc [accessed 22 April 2021].
  11. Vicki Haworth, Ashley McGrorty, Paul Jennings. SIM Isle of Wight Report 2015-2017 [Internet]. 2017 Apr. Available from: https://highintensitynetwork.org/img/resources/PROJECT_REPORT_2_-_MARCH_2017.pptx [accessed 22 April 2021].
  12. NHS Innovation Accelerator. Understanding how and why the NHS adopts innovation [Internet]. 2018 Nov. Available from: https://nhsaccelerator.com/wp-content/uploads/2018/11/NHS-Innovation-Accelerator-Understanding-how-and-why-the-NHS-adopts-innovation.pdf
  13. Aileen Jackson, Josh Brewster. The Implementation of SIM London: Sharing best practice for spread and adoption [Internet]. 2018 Jun. Available from: The-Implementation-of-SIM-London-Report_HIN_-_SOUTH_LONDON_AHSN.pdf (highintensitynetwork.org) [accessed 22 April 2021].
  14. Paul Jennings. SIM London – Support for a better life 2018 – 2020 [Internet]. 2020 Dec. Available from: https://healthinnovationnetwork.com/wp-content/uploads/2020/12/SIM-London-End-of-Year-Report-2020.pdf [accessed 22 April 2021].
  15. Paul Jennings. SIM Project Pilot Report 2013-2015 [Internet]. Available from: https://highintensitynetwork.org/img/resources/SIM_Pilot_Report_2013.doc [accessed 22 April 2021].
  16. NICE. Borderline personality disorder: recognition and management. Clinical guideline [CG78]. National Institute for Health and Care Excellence; 2009
  17. NICE. Self-harm in over 8s: long-term management. Clinical guideline [CG133]. National Institute for Health and Care Excellence; 2011.
  18. SIM and High Intensity Network Business Case [Internet], p. 7. Available from https://highintensitynetwork.org/img/resources/SIM_and_High_Intensity_Network_-_Business_Case_(Commissioner)_v4.docx [accessed 22 April 2021].
  19. Paul Jennings. SIM Project Pilot Report 2013-2015 [Internet]. Available from: https://highintensitynetwork.org/img/resources/SIM_Pilot_Report_2013.doc [accessed 22 April 2021].
  20. Paul Jennings, Catherine B. Matheson-Monnet.  Multi-agency mentoring pilot intervention for high intensity service users of emergency public services: the Isle of Wight Integrated Recovery Programme. J Criminol Res Policy Pract. 2017 Jan 1;3(2):105–18.
  21. Paul Jennings, Catherine B. Matheson-Monnet.  Multi-agency mentoring pilot intervention for high intensity service users of emergency public services: the Isle of Wight Integrated Recovery Programme. J Criminol Res Policy Pract. 2017 Jan 1;3(2):105–18.
  22. South London and Maudsley NHS Foundation Trust, High Intensity Network. SLaM Operational Delivery Guide [Internet]. 2018. Available from: https://healthinnovationnetwork.com/wp-content/uploads/2018/06/SIM-Operational-Delivery-Guide.docx
  23. Gillian Reddington. The case for positive risk-taking to promote recovery. Mental Health Practice. 2017; 20(7):29-32. https://doi.org/10.7748/mhp.2017.e1183
  24. Imogen Blood, Shani Wardle. Positive risk and shared decision-making. Social Care Wales, 2018. Available from: https://socialcare.wales/cms_assets/file-uploads/Positive-risk-and-shared-decision-making.pdf
  25. Paul Jennings, Catherine B. Matheson-Monnet.  Multi-agency mentoring pilot intervention for high intensity service users of emergency public services: the Isle of Wight Integrated Recovery Programme. J Criminol Res Policy Pract. 2017 Jan 1;3(2):105–18.
  26. Alexander L. Chapman., Kim L. Gratz, & Milton Z. Brown. Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behavior Research and Therapy.  2006;  44(3), 371–394. https://doi.org/10.1016/j.brat.2005.03.005
  27. Gerrit Scoliers, Gwendolyn Portzky, Nicola Madge, et al. Reasons for adolescent deliberate self-harm: a cry of pain and/or a cry for help? Findings from the child and adolescent self-harm in Europe (CASE) study. Soc Psychiatry Psychiatr Epidemiol. 2009; 4(8), 601–607. https://doi.org/10.1007/s00127-008-0469-z
  28. Melissa K. Y. Chan, Henna Bhatti, Nick Meader, Sarah Stockton, Jonathan Evans, Rory C. O’Connor, Nav Kapur, Tim Kendall. Predicting suicide following self-harm: Systematic review of risk factors and risk scales. British Journal of Psychiatry. 2018; 209(4), 277-283. https://doi.org/10.1192/bjp.bp.115.170050
  29. NHS Innovation Accelerator. Staff. Paul Jennings [Internet]. 2017. Available from: https://nhsaccelerator.com/fellows-and-mentors/paul-jennings/ [accessed 22 April 2021].
  30. NHS Innovation Accelerator. Fellows and Innovations. [Internet]. 2017. Available from: https://nhsaccelerator.com/fellows-and-innovations/ [accessed 22 April 2021].
  31. NHS Innovation Accelerator. What the NIA offers. Selection Process. [Internet]. 2017.  Available from: https://nhsaccelerator.com/accelerator/what-the-nia-offers/selection-process/ [accessed 22 April 2021].
  32. NHS Innovation Accelerator. What the NIA offers. Selection Process. [Internet]. 2017.  Available from: https://nhsaccelerator.com/accelerator/what-the-nia-offers/selection-process/ [accessed 22 April 2021].