Open letter signed by more than 200 professionals aims to stop ‘harmful’ mental health schemes

More than 200 mental health, social care and academic professionals, as well as 20 organisations, have called for NHS England to halt its Serenity Integrated Mentoring (SIM) and other similar schemes.

SIM is a model of care for mental health services developed by an ex-police sergeant Paul Jennings. The coalition, however, says the scheme as it stands criminalises mental distress and is unethical.

Read the full letter below:

A Professional challenge to NHS England - An open letter in solidarity with the #StopSIM Coalition

Dear NHS England,

We have come together, as a group of mental health, social care and academic professionals, to write this open letter to express our concern, dissent and disappointment in relation to NHS England's response to Serenity Integrated Mentoring (SIM) and similar harmful approaches that are in common practice across our mental health crisis care systems.

We stand in solidarity with the #Stop SIM Coalition, and all who have had their mental distress criminalised both prior to, and throughout SIM, and call on NHS England to publish the joint Stop SIM policy that has been coproduced between NHSE and the Coalition, and which NHSE has now drawn back from in favour of an NHSE position on SIM and similar programmes.

The StopSIM coalition has provided time, investment, and commitment to working with NHSE over a 15-month period to develop policy and guidance that would support human rights and ensure that people who are in mental health crisis receive the treatment and support they both need and are entitled to. We believe that to discard this work in this way, with no discussion with those involved or affected by these inhumane practices, undermines the investment and trust that had been extended by both individuals and the coalition to the statutory organisations involved in these practices. Whilst the sentiment of the NHSE position statement is consistent with the aim to stop the implementation of SIM and related practice, we believe that the failure to publish the policy, without consulting or informing the Stop SIM Coalition as the key partner, has instead resulted in further disempowerment, disillusionment and ultimately harm to patient-provider working relationships and the representation and rights of those with lived experience of our mental health systems as a whole.

The collaboration that took place which led to a coproduced policy had the potential to be revolutionary in terms of its demonstration of true co-production with those who have lived, and living experience, of mental health services. However, the decision not to publish, and to fail to communicate with key partners in relation to the change in position, is, in our view, neither accountable nor acceptable.

Serenity Integrated Mentoring and similar schemes - sometimes described as HIN (High Intensity Network) or similar, include the involvement of police and the criminal justice system in the delivery of non-emergency mental health care and the use of criminal sanctions in response to acute mental distress. This approach is in direct conflict with development elsewhere in the sector and the requirements of both the Mental Health Act and Human Rights Act, and commitments made in the UN Convention on the rights of disabled persons.

The use of such tools as behavioural contracts which are used in these schemes, and in direct contradiction to NICE guidelines, include the threat of sanctions such as Criminal Behaviour Orders, arrest and imprisonment if they are not upheld. The Business Case for Commissioning SIM (UCL, 2019[i]) across NHS Trusts in England advocates sharing private medical records with police officers to develop “SIM Response Plans” that give health professionals “the confidence” to withhold clinical care from people under SIM who present to emergency services in crisis. Criminalisation of mental distress and withholding of medical care puts NHS Trusts in breach of both the Mental Health Act[ii] Code of Practice (para 22.2 People who are subject to criminal proceedings have the same rights as everyone else) and ultimately at risk of breaching positive obligations to uphold the human rights of those within their jurisdiction.

SIM materials, from conference presentations made public during the initial scrutiny in 2021, demonstrated derogatory attitudes from staff towards patients, such as comments that the scheme is helpful because staff no longer "dislike patients". Since the concerns were raised however, many of these documents and reports have been removed from the internet and are no longer available via their original sources. We believe this constitutes a lack of transparency by our public sector and call for organisations to apply their duty of candour in relation to whether these types of schemes are/have been in use in their areas and any potential harm that has arisen as a result.

It was through the commitment of the Stop SIM coalition that the nature of these schemes became public knowledge, with statements calling for inquiry into these practices subsequently made by mental health charities, and the major professional associations whose members are involved in delivering mental health services. The harm associated with the co-delivery of mental healthcare and policing was not initially identified by professionals involved, by the professional networks who incubated the first schemes, or by NHS England or the professional organisations who gave awards to the early schemes for ‘innovation’. This should cause us all to pause for thought about why those who were involved or aware of such schemes did not speak out.

On 10th March a letter from Tim Kendall, NHS England’s national clinical director for mental health, was released setting out NHSE’s position on SIM and similar schemes. We cannot disagree with the points raised in this letter, which clearly sets out elements of this model which need to be eliminated from practice and addresses the underpinning attitudes of professionals that at best lack compassion and at worst demonstrate active dislike of patients.

However, we were shocked to read responses from the Stop SIM Coalition, stating that the release of the letter was not approved by them. The Stop SIM Coalition had been promised that the joint policy they spent 15 months’ co-designing would be released to the public, so that patients were able to educate and protect themselves and to guarantee accountability if individual Trusts continue with SIM or SIM-like schemes.

The Stop SIM Coalition’s response can be read in full here.
https://stopsim.co.uk/2023/03/13/we-call-on-nhs-england-to-publish-the-joint-stopsim-policy-in-full-immediately/

We believe that it is essential that the NHS response to concerns relating to SIM and similar approaches, and to the decision not to publish the policy is transparent. This was recognised in the early statements from professional associations in response to the negative publicity about the schemes[iii]While the letter from Tim Kendall specifies that the SIM approach is not endorsed by NHSE, there is a long history of similar statements and directives being made without prompting change in systems and culture. NICE guidance on self-harm dating back to 2004 and 2011 indicates that patients must be treated with respect and dignity and that discriminatory responses are inappropriate. Despite this, in 2023, it remains necessary for NHS England to release a position statement informing employees that discriminatory practices and attitudes to patients who self-harm and/or are suicidal are unacceptable.

The Stop SIM Coalition’s work highlighting the way in which a narrow, poorly evidenced understanding of dependency and the impact of trauma has been used to stigmatise patients within these schemes has been invaluable. The response of NHSE is disappointing and will cause significant damage, with some lived experience campaigners saying they are no longer able or willing to participate in involvement work.

While NHS England and some NHS Trusts have publicly distanced themselves from SIM and similar models, the signatories to this letter are aware of continued use of criminal sanctions and oppressive attitudes towards people in crisis seeking help from emergency and mental health services, as evidenced by both anecdotal and review evidence (e.g. safeguarding adults reviews, DHRs, NCISH, Coroner findings etc.).

Without a robust policy in place and public accountability, crucial system change will be impossible. We understand that the CQC requires policy documentation in order to consider the recommendations within Tim Kendall’s letter during its inspections.

In summary, we are asking that:
- NHSE demonstrates leadership and commitment to co-production by immediate publication of the joint policy.
- The framework for monitoring of the requirements on Trusts outlined in Tim Kendall’s letter is made transparent to the public, with information about how to raise concerns where such practices and schemes continue.

We ask that other academics, professionals and students who may read this letter support service users by writing to their local Trust to seek assurance about how these practices will be phased out.

The signatories to this letter are listed below, and unless an organisation is also listed each signatory has provided their own view rather than that of their organisation.

We await your response.