Concerns Regarding The Human Rights And Equalities Implications Of The High Intensity Network (HIN) And Serenity Integrated Mentoring (SIM)

Serenity Integrated Mentoring (SIM) and similar interventions associated with the High Intensity Network (HIN) are being rapidly rolled out across NHS England. SIM is designed for people who have not committed a crime but are in contact with mental health services, are frequently at high risk of suicide and self-harm and deemed “high intensity users” of emergency services. SIM’s key intervention components include a co-ordinated withholding of potentially lifesaving treatment by multiple agencies (A&E, mental health, ambulance and police services; 1) and the “coercive” (2) approach of a police officer as an interventionist.

As a coalition, we believe that SIM contravenes both the Equality Act (2010) and the Human Rights Act (1998). We are deeply concerned that organisations implementing SIM have not placed a greater emphasis on ensuring compliance with UK legislation. This statement will outline what protections these Acts provide, and will give examples of where we believe they are contravened by services implementing SIM.

Human rights

The UK is a signatory to various international covenants and conventions, including the Universal Declaration of Human Rights (3). For brevity, we will focus here on the European Convention on Human Rights, to which the UK remains a signatory as a member of the Council of Europe. These rights are incorporated in the Human Rights Act 1998 (4). There is extensive guidance and a body of case law which outlines how the European Convention on Human Rights may be applied and it places a range of obligations on public bodies, including the NHS and the police. Failure to comply does not require intent to harm to be unlawful (5) We have grave concerns that SIM is operating in breach of service users’ human rights.

Article 2 of The Human Rights Act relates to the Right to Life (6). According to Equality and Human Rights Commission guidance for public authorities (7), this may be breached not only by active harm but also by policy decisions that may undermine or threaten someone’s life or put their life at risk.  This guidance highlights that NHS trusts have an obligation, if someone is at high risk of self-harm or suicide, to take appropriate action to protect them (8).

A key SIM intervention component includes a “Response Plan” which coordinates the treatment given to an individual across multiple-agencies (9). We believe that SIM’s “Response Plans” are likely to be in breach of Article 2 in explicitly advocating withholding, or deterring people from using, services which might be life-saving. The Business Case for Commissioning SIM across NHS Trusts in England (10) states the following in relation to the impact a SIM Response Planis expected to have on health care professionals:

“Specifically, they can give doctors and nurses the confidence NOT to treat or respond in ways in which they would have felt compelled to before, such as:

  • Not requesting scans/x-rays/MRIs/blood tests
  • Not keeping the individual in the ED for observation
  • Not pursuing the individual if they decide to discharge themselves
  • Not requesting the police to find the individual or conduct a welfare check at home” (11).

The Business Case document further specifies that SIM “provides frontline responders with the confidence to trust response plans which advise them not to intervene” (12). The risk of what the document refers to as “accidental death” is managed through a reassurance that the service will not be held responsible for such potential deaths because it can be shown that SIM had supported the deceased in ways which were “lawful, proportionate and least restrictive.” We do not believe that withholding potentially life-saving treatment, in a manner which may result in avoidable death, is lawful or proportionate. 

An example of this potential breach in practice is provided in relation to the implementation of SIM in Surrey (13), known as the Surrey High Intensity Partnership Programme (SHIPP). Described as a positive “example of cultural change in action” in relation to a service user in serious distress, this publication states:

“The officers followed her SHIPP response plan and did not detain the person under the Mental Health Act. A short time later she intentionally overdosed after the police had left the scene and was admitted to A&E. The case was automatically referred to the Independent Office for Police Conduct (IOPC) as required in law. Having reviewed the case, the IOPC advised that the officers in question had no case to answer because they followed due procedure according to the clinically endorsed care plan.”

Whilst the individual officer may have no question to answer according to the IOPC, at a corporate level, the police service and the NHS have a duty to uphold Article 2, the Right to Life. It is our belief that the SIM model fails to comply with this responsibility and is operating in breach of these fundamental human rights.

The risk of drastic consequences is clearly highlighted through HIN / SIM literature. For example, the SIM operational delivery guide outlines that “High Intensity mentors have regular contact with high risk service users. These patients can often place themselves in risky situations and there is often a higher risk of accidental death. The death of a service user during their mentoring period can occur.” In these circumstances, “we strongly recommend contacting the National Lead for this Project” who will “professionally brief any investigating officers on the nature of high intensity work and the role and function of mentors” (14). Moreover “The death of a service user is covered within the initial training course” (15). This demonstrates an awareness of the potential for the loss of life of those under this service. However, there appear to be no sufficiently robust plans to mitigate this loss of life; service providers may wish to redefine preventable suicides, due to an organisations’ failure to provide services to an adequate standard, as ‘accidental’. However, we do not understand this to lessen the responsibility of a care provider to uphold the right to life. 

Equality Act 2010

In addition to breaches of The Human Rights Act, we believe SIM contravenes The Equality Act 2010 (16). This Act prohibits discrimination on the grounds of various “protected characteristics”, including disability, race, gender, sexuality and gender reassignment. Discrimination does not need to be intentional to be unlawful. This Act protects people from being treated unequally in society, including the use of public services.

Disability

Firstly, we are concerned treatment under the SIM model may constitute discrimination on the basis of disability. The Equality Act offers protection to those who have had a disability in the past as well as in the present.  A mental health condition or physical impairment, under the Equality Act definition, is considered a disability if it has a substantial adverse effect on “normal day-to-day activity” which has lasted (or is likely to last) more than 12 months, including recurring and fluctuating conditions (17). We understand that a significant number of service users receiving treatment under SIM are reported to have a diagnosis of Borderline Personality Disorder (18) or other long-term mental health conditions. They would, therefore, be considered disabled; their protection from discrimination is enshrined in law under The Equality Act (2010).

As previously outlined, SIM “Response Plans” coordinate the treatment given to an individual across multiple agencies (19). This appears to include limiting or preventing the individual from accessing care that is available to other members of the public who are not disabled, for instance if they are feeling suicidal or are physically injured. This includes limiting access to medical interventions such as blood tests and x-rays (20).

This demonstrates that SIM explicitly advocates withholding potentially life-saving treatments from disabled people. We strongly believe that this is an act of discrimination on the basis of disability. The Equality Act does make provisions for certain exceptions to the Act, if these are proportionate (21).  However, as we outlined in our statement relating to SIM’s ‘evidence base’ there is a lack of robust evidence that the quality and effectiveness of this intervention is equal to, let alone better than, treatment as usual or NICE recommended interventions (22), using equivalent resources. Therefore we do not believe it is proportionate or lawful for SIM to operate in a discriminatory manner, in breach of The Equality Act.

Gender

Furthermore, SIM may also contravene the Equality Act in relation to ‘sex’ [sic] as a protected characteristic. As stated in a set of promotional slides entitled SIM: How It All Started (23), “high intensity users” are typically female and have a history of sexual abuse or violence. Indeed it is well documented that individuals with a diagnosis of Borderline Personality Disorder (the diagnosis a sizable number of SIM service users have; 24) who are primarily women(25), are more likely than their counterparts to have experienced sexual abuse (26) as a precipitating factor in the distress they experience. If women who have been subject to gender-based violence or harassment are being treated less favorably because they are experiencing trauma related symptoms, this, in our view, is discriminatory. SIM appears far removed from government policy (27) aimed at countering violence against women and girls, supporting survivors and, it would seem, even basic standards of equality.

Race

Race is also a protected characteristic under the Equality Act (2010; 28). A government commissioned independent review of the treatment of, and outcomes for, Black, Asian and Minority Ethnic individuals in the Criminal Justice System (29), highlighted disproportionately negative treatment of some communities and a profound lack of trust. Within the wider context of negative treatment of minoritised ethnic groups, we are concerned about the impact of introducing police into the provision of health services for non-offenders, and how this could have a disproportionate negative impact for Black Asian and Minority Ethnic individuals. For example, in relation to the data protection concerns as outlined in our statement dated 26/04/2021 we understand this may have a disproportionate impact on ethnic minorities. NHS England found that after the Windrush scandal, some people from ethnic minorities were frightened to seek cancer care during the pandemic for fear that their data would be shared with the Home Office (30). Within this context, we understand that SIM has the potential to further exacerbate the fears and threats felt by minoritised Black Asian and Minority Ethnic individuals.

An Equalities Impact Assessment by Oxleas NHS Foundation Trust conducted in relation to SIM London identifies a potential for discriminatory action.  It states, “particular groups remain disproportionately subject to S136 of the Mental Health Act, so a project specifically targeting this aspect of mental health will reach these individuals” (31). It is well documented that Black people are overrepresented in instances of Section 136 detentions (32) and will therefore be likely to be overrepresented within SIM services which ‘recruit’ service users on the basis of repeated detentions (33). We are concerned by the lack of a robust plan to counter this discrimination within HIN / SIM to ensure service users are not subject to further discrimination.

Gender reassignment

We believe SIM may also contravene the Equality Act by discriminating on the grounds of gender reassignment, another protected characteristic. Transgender people often experience mental distress including suicidal ideation which has been linked to the hostile climate of transphobia and widespread discrimination (34).  This can be exacerbated by a long wait for an assessment for a Gender Recognition Certificate and hormonal, medical or surgical care.

One of the case studies in the SIM Pilot reportis of “Greg”, a trans man.  An extract from his case study states “The SIM team worked with Greg and explained that if he was to achieve his ultimate goal of gender reassignment surgery he would need to demonstrate emotional and behavioural stability before his GP would consider making the referral to specialist services” (35). However, the NHS does not consider mental illness or personality disorder a contraindication to a GP referral for gender dysphoria treatment (36).  A prior stipulation that a temporary withholding of treatment during a mental health crisis may be appropriate, has now been removed from best practice guidelines on accessing Gender Identity Clinic (37). A GP referral does not constitute gender dysphoria treatment from a specialist clinic.   We are therefore concerned that gender affirming treatment was withheld from Greg, and / or used as an incentive or reward by his SIM team. We believe that withholding such treatment on the basis of his disability as a breach of the Equality Act.  Fear of offending one’s clinician by turning down a recommended intervention such as SIM, however distressing, may have resulted in pressure to “consent” to SIM in order to get a referral to a gender identity clinic. We understand this leaves transgender people especially vulnerable to discrimination and ill treatment.

Sexuality

Additionally, evidence suggests there is a higher prevalence of sexual minorities diagnosed with Borderline Personality Disorder (38) (the primary diagnosis of many SIM service users; 39). Indeed, trauma associated with ongoing experiences of homophobia and heteronormativity may be experienced as a precipitating factor in some of the symptoms associated with this diagnosis (40). We understand it is highly probable this prevalence would be replicated in any service which works predominantly with people with this diagnosis. Despite this HIN / SIM do not appear to have any recognition of this, nor are there any resources or instruction on how the programme would support the specific needs or LGBTQ+ people; or mitigate against exacerbating this further. Indeed, the Oxleas NHS Foundation Trust Equality Impact Assessment states they did not, at the time of publishing, have information recorded about service users’ sexuality or gender reassignment(41) but suggest some evidence indicates this model may have a “high impact”; they recognised the need to collect this data in the future (42).

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 which appear to contravene The Human Rights Act and The Equality Act?
  • What are HIN / SIM doing to mitigate against further replicating discrimination on the basis of “protected characteristics”, including race, gender, gedner reassignment and sexuaity?
  • What scrutiny has been conducted regarding the legality of SIM?

We will continue to provide further statements expressing our concerns in relation to SIM and Human Rights. This is a preliminary document and we continue to analyse and collate information relating to SIM and HIN’s legal basis.

In solidarity,

The #StopSim Coalition

Copied to:


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. 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 4 May 2021].
  2. Paul Jennings. What is SIM and the High Intensity Network? [Internet]. 2019 Mar 26; Daresbury Park Hotel. Slide 30 of 65. Available from: https://www.slideshare.net/InnovationNWC/paul-jennings-high-intensity-network-sim [accessed 25 April 2021].
  3. Universal Declaration of Human Rights [Internet]. Available from: https://www.un.org/sites/un2.un.org/files/udhr.pdf [accessed 4 May 2021].
  4. 4.     Human Rights Act 1998. Available from: https://www.legislation.gov.uk/ukpga/1998/42/contents [accessed 4 May 2021].
  5. Public authorities under the Human Rights Act 1998 [Internet]. 2021. Available from: https://justice.org.uk/public-authorities-human-rights-act-1998/ [accessed 4 May 2021].
  6. Article 2: Right to life. Equality and Human Rights Commission [Internet]. 2018. Available from: https://www.equalityhumanrights.com/en/human-rights-act/article-2-right-life [accessed 4 May 2021].
  7. Human Rights: Human Lives, A Guide to the Human Rights Act for Public Authorities. Equality and Human Rights Commission [Internet]. 2014. pp. 11-12. Available from: https://www.equalityhumanrights.com/sites/default/files/human_rights_human_lives_a_guide_for_public_authorities.pdf  [accessed 4 May 2021].
  8. See Human Rights: Human Lives, A Guide to the Human Rights Act for Public Authorities. Equality and Human Rights Commission [Internet]. 2014. pp. 11-12. Available from: https://www.equalityhumanrights.com/sites/default/files/human_rights_human_lives_a_guide_for_public_authorities.pdf  [accessed 4 May 2021]. While less restrictive approach than in Rabone and Anor v Pennine Care NHS Foundation Trust (2012) might be adopted, careful consideration should, as far as we can tell, be given to the effects of not providing a service.
  9. SIM London: South London & Maudsley NHS Foundation Trust Operational Delivery Guide [Internet]. 2018. Section 26, ‘Response Plans’. Available from: https://healthinnovationnetwork.com/wp-content/uploads/2018/06/SIM-Operational-Delivery-Guide.docx [accessed 4 May 2021].
  10. 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 4 May 2021].
  11. 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 4 May 2021].
  12. SIM and High Intensity Network Business Case [Internet], p. 9. Available from: https://highintensitynetwork.org/img/resources/SIM_and_High_Intensity_Network_-_Business_Case_(Commissioner)_v4.docx [accessed 4 May 2021].
  13. 13.   NHS Innovation Accelerator: Understanding how and why the NHS adopts innovation. The Bayswater Institute, AHSN Network and NHS England [Internet]. 2018. p. 52. Available from: https://nhsaccelerator.com/wp-content/uploads/2018/11/NHS-Innovation-Accelerator-Understanding-how-and-why-the-NHS-adopts-innovation.pdf [accessed 4 May 2021].
  14. SIM London: South London & Maudsley NHS Foundation Trust Operational Delivery Guide [Internet]. 2018. Section 63, ‘Death of a service user while being managed by a mentoring team.’ See also Section 39, ‘The nature of High Intensity cases’. Available from: https://healthinnovationnetwork.com/wp-content/uploads/2018/06/SIM-Operational-Delivery-Guide.docx [accessed 4 May 2021].
  15. SIM London: South London & Maudsley NHS Foundation Trust Operational Delivery Guide [Internet]. 2018. Section 63, ‘Death of a service user while being managed by a mentoring team.’ Available from: https://healthinnovationnetwork.com/wp-content/uploads/2018/06/SIM-Operational-Delivery-Guide.docx [accessed 4 May 2021].
  16. Equality Act 2010. UK Public General Acts. 2010 c. 15. Available from: https://www.legislation.gov.uk/ukpga/2010/15/contents [accessed 4 May 2021]. (Primarily in Britain: equalities law in Northern Ireland has some differences.)
  17. Equality Act 2010 Guidance: Guidance on matters to be taken into account in determining questions relating to the definition of disability. Office for Disability Issues, HM Government [Internet]. 2011. Sections C5-C6, p. 29.  Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/570382/Equality_Act_2010-disability_definition.pdf [accessed 4 May 2021].
  18. 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; Paul Jennings. SIM Project Pilot Report 2013-2015 [Internet]. Available from: https://highintensitynetwork.org/img/resources/SIM_Pilot_Report_2013.doc  [accessed 4 May 2021].
  19. SIM London: South London and  & Maudsley NHS Foundation Trust Operational Delivery Guide [Internet]. 2018. Section 26, ‘Response Plans’. Available from: https://healthinnovationnetwork.com/wp-content/uploads/2018/06/SIM-Operational-Delivery-Guide.docx [accessed 4 May 2021].
  20. 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 4 May 2021].
  21. Justifying discrimination. Citizens Advice [Internet]. 2021. Available from: https://www.citizensadvice.org.uk/law-and-courts/discrimination/what-are-the-different-types-of-discrimination/justifying-discrimination/ [accessed 4 May 2021].
  22. NICE. Borderline personality disorder: recognition and management. Clinical guideline [CG78]. National Institute for Health and Care Excellence; 2009.
  23. Paul Jennings. SIM: How It All Started. Isle of Wight NHS Trust and Hampshire Constabulary [Internet]. 2015. Slide 7 of 24. Available from: https://www.iow.gov.uk/azservices/documents/2880-04-PJ-PB-SIM-MENTORING.pdf [accessed 4 May 2021].
  24. Paul Jennings. SIM Project Pilot Report 2013-2015 [Internet]. Available from: https://highintensitynetwork.org/img/resources/SIM_Pilot_Report_2013.doc [accessed 4 May 2021].
  25. R. A. Sansone, & L. A. Sansone. Gender patterns in borderline personality disorder. 2011. Innovations in clinical neuroscience, 8(5), 16–20.
  26. L. F. de Aquino Ferreira, F. H. Queiroz Pereira, A. Neri Benevides, & M. C. Aguiar Melo. Borderline personality disorder and sexual abuse: A systematic review. 2018. Psychiatry research262, 70–77. Available from: https://doi.org/10.1016/j.psychres.2018.01.043 [accessed 4 May 2021].
  27. Ending violence against women and girls strategy: 2016 to 2020 (accessible version). Home Office [Internet]. Chapter 2, Provision of Services. Available from: https://www.gov.uk/government/publications/strategy-to-end-violence-against-women-and-girls-2016-to-2020/ending-violence-against-women-and-girls-strategy-2016-to-2020-accessible-version#chapter-2-provision-of-services [accessed 4 May 2021].
  28. Equality Act 2010. UK Public General Acts. 2010 c. 15. Available from: https://www.legislation.gov.uk/ukpga/2010/15/contents [accessed 4 May 2021]. (Primarily in Britain: equalities law in Northern Ireland has some differences.)
  29. 29.   David Lammy MP et al. The Lammy Review: An independent review into the treatment of, and outcomes for, Black, Asian and Minority Ethnic individuals in the Criminal Justice System [Internet]. 2017. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/643001/lammy-review-final-report.pdf [accessed 4 May 2021].
  30. Ben Clover. Exclusive: Windrush scandal made ethnic minority people ‘fearful’ of using cancer services [Internet]. HSJ, 21 April 2021. Available from: https://www.hsj.co.uk/news/exclusive-windrush-scandal-made-ethnic-minority-people-fearful-of-using-cancer-services/7029939.article [full article behind paywall; accessed 27 April 2021].
  31. Equalities Impact Assessment. Service Change Equality Analysis. Oxleas NHS Foundation Trust [Internet]. p. 10. Hyperlinked on p. 5 of 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 5 May 2021].
  32. Detentions under the Mental Health Act. Ethnicity facts and figures [Internet]. Sections 3-4. Available from: https://www.ethnicity-facts-figures.service.gov.uk/health/mental-health/detentions-under-the-mental-health-act/latest [accessed 4 May 2021].
  33. Aileen Jackson, Josh Brewster. The Implementation of SIM London: Sharing best practice for spread and adoption [Internet]. 2018. ‘Identification of SIM cohort’. p. 6. Available from: https://highintensitynetwork.org/img/resources/The-Implementation-of-SIM-London-Report_HIN_-_SOUTH_LONDON_AHSN.pdf  [accessed 4 May 2021].
  34. J. McNeil, S. J. Ellis, & F. J. R. Eccles. Suicide in trans populations: A systematic review of prevalence and correlates. 2017. Psychology of Sexual Orientation and Gender Diversity, 4(3), 341–353. Available from: https://doi.org/10.1037/sgd0000235 [accessed 4 May 2021].
  35. Paul Jennings. SIM Project Pilot Report 2013-2015 [Internet]. p. 47. Available from: https://highintensitynetwork.org/img/resources/SIM_Pilot_Report_2013.doc [accessed 4 May 2021].
  36. Gender dysphoria services: a guide for General Practitioners and other healthcare staff. NHS England & Department of Health [Internet]. p. 4.  Available from: https://www.nhs.uk/Livewell/Transhealth/Documents/gender-dysphoria-guide-for-gps-and-other-health-care-staff.pdf [accessed 4 May 2021].
  37. Specialised Gender Identity Services for Adults; Report on outcome of public consultation and update to Equality Impact Assessment. NHS England [Internet]. 2018. p. 10.Available from:  https://www.engage.england.nhs.uk/survey/gender-identity-services-for-adults/user_uploads/gender-services-consultation-report-updated-equality-impact-assessment-v2.pdf [accessed 4 May 2021].
  38. C. Rodriguez-Seijas,T. A.  Morgan, & M. Zimmerman. A Population-Based Examination of Criterion-Level Disparities in the Diagnosis of Borderline Personality Disorder Among Sexual Minority Adults. 2021. Assessment. Available from: https://doi.org/10.1177/1073191121991922 [accessed 4 May 2021].
  39. Paul Jennings. SIM Project Pilot Report 2013-2015 [Internet]. p. 19.  Available from: https://highintensitynetwork.org/img/resources/SIM_Pilot_Report_2013.doc [accessed 4 May 2021].
  40. Hattie Porter. The politics of an unstable sense of self: on being a slightly mad queer. Recovery In The Bin [Internet]. 2020. Available from: https://recoveryinthebin.org/2020/02/27/the-politics-of-an-unstable-sense-of-self-on-being-a-slightly-mad-queer/ [accessed 4 May 2021].
  41. Equalities Impact Assessment. Service Change Equality Analysis. Oxleas NHS Foundation Trust [Internet]. pp. 6, 8. Hyperlinked on p. 5 of 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 5 May 2021].
  42. Equalities Impact Assessment. Service Change Equality Analysis. Oxleas NHS Foundation Trust [Internet]. pp. 6, 8. Hyperlinked on p. 5 of 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 5 May 2021].

N.B. Statement updated 06/05/21 with correction – replacing “Euorpean Council” with “Council of Europe”.