I would not be writing this if not for the people who created this site and started spreading awareness via Twitter. I had absolutely no awareness of SIM until then. It is because I do not understand what is happening that I write this. What I am aware of concerns me as a registrant with the Nursing and Midwifery Council and the values and the working practices that I hold. At face value there seems a lack of compatibility with the SIM model and my underpinning philosophy of what it means to be a mental health nurse. I do not endorse coercion and would like to see this removed from mental health care. What I can see with SIM is a model of introducing further coercive practices. Much of what follows will no doubt echo the concerns on this site, but I wanted to take a particular view from my perspective as to why I find SIM problematic. I pose many questions where I can see gaps in my understanding as to how and why this model has appeared. I don’t think these can be easily answered, but I think they are important questions because they highlight what I see as the lack of transparency and accountability in the actions taken for one of the largest changes to mental health service provision in recent memory. Below pulls together my immediate thoughts and questions the expansion of SIM, the evidence, the economics, the model’s approach, and its incompatibility with current policy.
- The SIM model has been introduced at more than a dozen mental health trusts (but likely more as this is not always called SIM), where police partnerships have been created to support ‘High Intensity Users’. This ‘intensity’ relates to the frequency of S136 use. All the High Intensity Network (HIN) materials https://highintensitynetwork.org/ indicate an intention to target all mental health trusts where crisis services are provided. This agenda appears to have been set in the initial pilot project report from 2016 (with 4 participants). The Health Innovation Network South London document ‘The Implementation of SIM London’ (2018) describes itself as guidance to support a national delivery of SIM. The document bases this intention on cost reduction from the pilot project of SIM and from four test sites across London. I would like to know whether the evidence base available supports a national roll out of this model. The literature available does not appear to reflect what I would suggest as robust levels of evidence or quality review processes suggestive of such a large-scale change to patient care. What appears available is a report of a small-scale pilot project conducted on the Isle of White and a follow up report of this. Neither of which are published in journals or peer reviewed. The former pilot study involving four participants was subsequently published in the Journal of Criminological Research, Policy and Practice in 2017. A feasibility study funded by the NIHR was published in 2019 which looked at three boroughs in London which used SIM and one which did not. The study reported that the ‘trial was too small to detect meaningful differences between the groups’ and concluded that the ‘service be urgently evaluated if it is to be widely used within the NHS’. I would like to know if this has happened, where data is held and when this will be available? I would also like to know whether data is available to substantiate claims for cost effectiveness on a wider scale. I would like to know why a national roll out is being implemented based on one small scale pilot project? Why or if recommendations from a NIHR feasibility study are not being used? NHS Innovation Accelerator supports SIM, describing a SIM project in Surrey (called SHIPP). No outcome data is published regarding this but reports of costs savings are used to justify the expansion across all of Surrey’s community mental health teams. I would like to know how NHS Trusts that have implemented the SIM principles are managing their data and what they are doing with it?
- In March 2018 the South London and Maudsley published an Operational Delivery Guide for SIM, claiming ownership of SIM development across the UK ‘This Operational Guide is the recommended policy document for all High Intensity teams across the UK’. The document states that Sir Bruce Keogh ‘requested that SIM be expanded across all NHS Mental Health Trusts in England and Wales as part of the NHS Innovation Accelerator Fellowship. The SLAM team acknowledge the recommendation by Sir Bruce Keogh to be part of a scaled up national programme that addresses the needs of high intensity mental health patients’. I would like to know the underpinning rationale behind Sir Bruce Keogh’s recommendation for a national expansion of SIM, where data that supports this is and the process by which this recommendation was made?
- The follow up report to the pilot project states a number of ‘service user outcomes’ including better physical health, improved support and improved relationships with family and friends. There is no outcome data to support these claims or in any other material that I have seen. The claims most often ascribed to SIM are the reduction in S136 use and cost savings because of reduced time in beds allocated and mental health act assessments. The costs that are calculated are not clear or transparent. For example, the pilot project follow up report includes reductions from a different service, Street Triage. Although the intentions of the pilot project are to support the service user the project is born from the success of Street Triage which helped divert service users and reduce the use of S136. The cost benefits of doing so are detailed from the beginning of SIM and would surely be a significant incentive for any health care provider. Matching this with meaningful support would surely be a win win situation. However, I am not entirely sure that anyone ever suggested that saving money will improve patient outcomes! And as such I would like to see the evidence of improved outcomes for the person it has been applied to. I would I like to see a detailed health economics analysis for the costs of SIM from the actual test sites as well as for the projections of cost benefits.
- The model. My understanding of the exact process of the model is hazy because the details are not available. It involves integration, so a police officer sits within a community mental health team, or number of teams. ‘Response’ plans are written for the person by the ‘mentors’. My concern is that firstly, this is not mentoring and secondly the plans have a coercive element. The plans provide behavioural expectations and what happens ‘if their behaviours have breached pre-agreed boundaries’ (SLAM, 2018). From the information on the HIN site, available presentations and NHS policy documents I can summarise the model as follows from what I can piece together. A response plan is drawn up, with or without the persons involvement. The aim of which is to change the person’s responses to their crisis. Usual crisis ‘behaviours’ are to be avoided, for example public self-harm, suicide, distress, which can result in S136 and bed occupancy and assessment. Certain methods to do this include the withdrawal of treatment programmes, the withdrawal of emergency care and the understanding that police powers will be used as a consequence for not following the plan. These are all from the case examples detailed in HIN materials. The language used in documentation blends what it calls ‘green’ and ‘blue’, health and law, together under SIM which is ‘authoritarian’ and ‘strict’. The legal consequences being ‘arrest’, a ‘CBO’ which is a criminal behaviour order and ‘S35 TRO’ (I do not know what this is). The aim of which is ‘behavioural compliance’ and is ‘coercive’ – please note these are direct quotes from SIM materials. The move towards a more coercive, threatening, criminalising mental health service is utterly at odds with the outcomes detailed in the recent Independent Review of the Mental Health Act, which sets out recommendations for government. Of which, increasing choice and reducing compulsory detention is just one aim. I would like to see any data available which details what is being used by police in response plans for people, how and when these are being implemented and what the consequence has been for the person. The MHA review recommends investments in prehospital emergency care involving the ambulance and service and police where necessary, not increasing the criminalisation of people with mental health problems at the expense of the reducing S136 use.
- Mentoring. I cannot see how mentoring takes shape in SIM. Mentoring is mentioned and something called a ‘mentoring contract’, but there is little detail as to how mentoring is used to support a person. Mentoring is about the facilitation of personal development, one based on an enabling and cultivating relationship that is empowering. I cannot see how this can occur where there is the opposing dynamic of coercion and compliance involved. My concern is that the language used, such ‘mentoring’ and ‘serenity’ are masking what is a strict behavioural compliance process that a person has little control over. I would like to see evidence of where supported mentorship has occurred and how this has been received by the person.
- The HIN published a ‘Quality and Safety Programme 2020’ flyer which listed 42 aspects that it does or complies with. This seems to be some kind of performance indicator. I will look at 4 of which that relate to aligning with key care policy and therapeutic approaches. HIN states it is developing its trauma informed approach. Trauma is cited throughout the documents, relating to service users who have experienced trauma. There is no recognition or application of a trauma informed approach in any material besides the acceptance that people in crisis may have experienced some trauma. A TIA is one based on trust, transparency, support, empowerment, choice and an understanding of how trauma can permeate through a person’s life. Safety is also critical, as in the person feeling safe. I would like to see supporting material that aligns with this, how it is put into practice and where the coercive and controlling aspects are mitigated for where someone has experienced trauma. Otherwise this model may well be contributing to the trauma or retraumatising a person, therefore rendering any therapeutic benefits void. Another statement is that SIM aligns with ‘DBT and CBT therapy teams’. I am not sure how this happens and would like to see where this has occurred. Again, SIM states to align to principles such as those used in DBT. DBT principles are based on validation of feelings and acceptance. Validation will not occur if coercion is being used to instigate a behavioural change against a person’s wishes. There is a claim to align with NICE BPD guidance, although I would like to see where and how it does this to an extent that it follows the ethos of the NICE guideline. The design of SIM is at odds with the practice of not excluding a person from a health or social care services because of their diagnosis or because they have self-harmed (NICE, 2009).
- Language. The materials produced by HIN for SIM use language that stereotypes and uses common assumptions about a person. The focus of SIM is largely on people who have a diagnosis of borderline personality disorder or emotionally unstable personality disorder and the rationale as to why a person does what they do when in crisis e.g. self-harm or make attempts to end their life. SIM, deviating from NICE guidance and evidence which indicates that behaviours related to suicide and self-harm are not reinforced when emergency clinicians are nice to them (or unkind for that matter) and are much more complex emotional states, are ones that can be moderated through strict behavioural approaches overseen by threat of conviction. The term ‘accidental’ suicide is used in material. This concerns me as new terms are being introduced. This has the potential to undermine the complexity and nuances of self-harm and suicide and set division in place. How can a person be deemed to have had an ‘accidental suicide’? the phrase is utterly nonsensical as suicide is that act of taking one’s life. To accidently end your life implies that those responding to the person are making a judgement that the person doesn’t really want to kill themselves, they are doing this for another reason. This ignores the evidence that tells us that where someone self-harms they are 50 to 100 times more likely to end their life. There is a real risk of lethal outcomes to a model which starts to insinuate, question and falsely reduce/undermine risk.
- The use of language centres on ‘behaviours’ and there is a theme that the person in crisis is fulfilling a need which is being met by crisis services. The use of such terms, including ‘reinforces maladaptive coping’, ‘learning a behaviour’ as sole reasons a person uses crisis services implies and permeates the stereotype of a person with a diagnosis of personality disorder as attention seeking and not genuine.
- There is no user/recipient feedback, outcomes or contributions detailed except an interview with a nurse in the original pilot study. The feasibility study undertook qualitative data with service users but did not report any data due to the low number of participants making the report susceptible to breaching confidentiality. I have not seen any contribution of services user in the design and implementation of any SIM model. This is not in the direction of current NHS mental health agenda for developing co-production and inclusion. In the SLAM implementation document it states that ‘The SLAM team agree to adopt a strong co-production framework within their project planning and ensure that all project design and review processes have strong and effective service user involvement’, I would very much like to see what happened and the outcome of this. I worry that the missing voice of the person in the process of implementing this model has come at the cost of alienating and angering those that it is intending to support.
And I suspect that if that voice were not missing to start with it would more than likely say that SIM was a terrible idea. But I don’t want to make assumptions. I would like answers and I would like to see a better system in place whereby decisions to start or trial new ways of working are made in a transparent, accountable and properly co-produced ways without the threat of criminalisation.
Will Murcott is a mental health nurse and senior lecturer with The Open University and can be found on Twitter @billymurcott
SIM info and sources
The High Intensity Network webpage which provides some detail on SIM and a resource section where the pilot study and follow up can be found.
Information about SIM on the NHS accelerator webpage
The NIHR funded feasibility study for SIM can be found here
For a detailed critical observation on SIM and behaviourism see the blog post https://www.psychiatryisdrivingmemad.co.uk/post/behaviourism-bpd-and-the-high-intensity-network and critical commentary from Allan House Prof of liaison psychiatry https://profallanhouse.co.uk/?page_id=141