[Acknowledgement: In 2021, when the shit hit the fan for SIM, professionals and organisations with connections to the High Intensity Network attempted to remove as much information on SIM as possible from the public domain. Much of the information presented in this blog is only publicly available thanks to the hard work of mental health/Mad/lived-experience campaigners and activists, such as the StopSIM Coalition and '@Sectioned_'. My thanks go to them.]
Serenity Integrated Mentoring (SIM) came back into the spotlight two weeks ago, after NHS England backtracked on publishing a joint policy, worked on by the StopSIM Coalition over the past 15 months (see: StopSIM). Because of the renewed interest in SIM, including from people who weren’t aware of the original campaign in 2021, I thought it might be helpful to provide a timeline and critical description of the history of SIM, including where it originated, and its spread through mental health trusts in the UK. I won’t be doing a critique of the actual “intervention” itself, because it would get too long. For an overview and critique of the behaviourist theory behind SIM, see my previous blog on the topic. For a thorough clinical, academic, and legal analysis of the concerns about the SIM “intervention”, see the StopSIM Coalition’s multiple public statements.
Serenity Integrated Mentoring (SIM) is a “model of care” introduced to NHS trusts and police forces by Sergeant Paul Jennings (originally from Hampshire police) and his company, the High Intensity Network. It was promoted and funded for a national roll out by the NHS Innovation Accelerator, and the AHSN Network. SIM is a joint intervention between the police and healthcare services, which places police officers into the mental health teams of patients at high risk of self-harm and suicide, who are also considered “high intensity users” of emergency services. SIM teams use numerous tactics, including threats, coercion, and care plans which direct professionals to withhold care, to reduce the patient’s use of services. Following a large survivor-led campaign in 2021, which among other things revealed the fabrication and gross distortion of data by Paul Jennings, the High Intensity Network closed down and a number of mental health trusts pledged to end their SIM programmes. While the High Intensity Network no longer exists to run the SIM training and coordination, many original SIM programmes still exist, including locally modified or adapted versions.
I would like to note that while Paul Jennings is a central figure within this blog - with descriptions of his activities over an eight year period - SIM is not the responsibility of one man. In fact, having trawled through 10 years of SIM history, one of the things which stood out to me strongly was the immediate and enthusiastic support SIM received from NHS staff. This was not because SIM was some new brilliant idea that no-one had thought up before, but rather because SIM echoes back to staff their thoughts, feelings and frustrations with certain patient groups, legitimising negligence and abuse, whilst centering staff feelings and well-being. SIM is simply a name and logo for the type of treatment many people have experienced for years. That it was so quickly funded and rolled out across the country with no evidence to support it, reflects just how deeply those prejudices are embedded within the NHS. Stopping SIM will take more than closing down SIM programmes. To truly stop SIM, the beliefs which underlie the intervention need to be challenged and rooted out of staff and services.
SIM: A Timeline
Street Triage: Operation Serenity
2012
In 2012, following the example of the introduction of Crisis Intervention Teams in the USA (where mental health training and assistance was provided to support police attending mental health related calls) three short-term street triage trial schemes were introduced in the UK. The first trial began in the North East of England in August 2012, in which a small group of mental health staff were located in a police control room, to support call handlers and officers. The second began in Hampshire/Isle of Wight in November 2012, in which a mental health nurse partnered with a police officer to attend mental health related incidents. The next began at the beginning of 2013 in Leicester, and had the same set up as Hampshire/Isle of Wight [1-3].
(Strangely, despite clear evidence that the Hampshire/Isle of Wight pilot existed, a number of reports evaluating the pilot schemes, including one conducted by Northumbria University in 2015, and one by University College London in 2016, do not mention the Hampshire/Isle of Wight initial scheme in 2012, or include it as one of the nine official street triage pilots in 2013 [4,5]).
2013
In 2013, following these trials, the Department of Health invested £2 million in funding nine pilot street triage teams across England [6]. The pilot scheme on the Isle of Wight (which was not one of the nine) was called “Operation Serenity”, and was led by Sergeant Paul Jennings from Hampshire Constabulary. Between 2012-2013, Operation Serenity branched out into three different areas [7]:
Mental health nurses accompanied police officers on patrol after 5pm, 2-3 nights a week
Mental health staff were placed in the police control room, to support call handlers and officers, and speak to people who rang in crisis
The development of the Integrated Recovery Programme (IRP)
Integrated Recovery Programme: Conception
During the pilot scheme on the Isle of Wight, it came to the attention of Paul Jennings and the street triage team that a small group of individuals were being seen by services, and detained under Section 136 of the Mental Health Act, at a much higher rate than others in the area. Over the time the pilot was running, officers used Section 136 detention powers 171 times for 69 people. It was recorded that eight individual women had made up 32% of all these detentions during the trial period [8]. All eight women had a diagnosis of BPD, a secondary diagnosis of anxiety or depression, and a history of trauma, including abuse, neglect, and domestic violence. Hampshire Constabulary named them “high intensity users”. All eight women were under mental health services, but were reportedly making little “therapeutic progress”, and were apparently described by services as “unmanageable” [9].
In May 2013, Sergeant Paul Jennings began designing the “Integrated Recovery Programme” (IRP) (which would later become SIM) as a new method to manage these specific eight women. Several years prior to this, Paul Jennings had experienced a period of mental illness, which had led to him being arrested, accused of harassing family members. In a 2016 document, he states that this experience was the driving force behind designing and implementing the IRP, and later, SIM, as he felt it gave him some insight into the situation. He describes the following as his thought process on what to do with the eight “high intensity” women [10]:
“What if we introduced a police officer into the care pathways of these 8 service users? An officer could bring a different set of boundaries to the behaviour being displayed [..] they could also highlight and openly discuss the more serious consequences if the individual continued to make the same choices. [..] I spoke to the staff looking after these 8 individuals, I persuaded 6 of the 8 patients to speak to me and I named the idea: Integrated Recovery Programme (IRP). I started with a blank sheet of paper and no clinical training.”
The apparent main aim of this new “model of care” was that the chosen patients displayed “improved personal accountability, social awareness and participation in recommended pathways”. This was suggested to potentially reduce the risks that the patients posed to themselves and to the community, which specifically included “the negative occupational impact on mental health staff who were involved in their care”. The following hypothetical questions were asked, to inform the programme design [12]:
“Could the police proactively support the NHS with these increasingly unmanageable and institutionalised patients who were failing to make any real clinical progress?”
“Could the police be directly involved in the mental health treatment pathways of these patients?”
“Could NHS staff integrate police officers directly within treatment sessions?”
Integrated Recovery Programme: Development
So, hypothetical questions in hand, Paul Jennings (self-described as having “no clinical training” [13]) eagerly set about designing the programme, based on a collection of unfortunate misunderstandings and misappropriations of simplistic behaviourist theories, borderline personality disorder clinical prejudice, and stigmatising suicide/self-harm myths [14-18]. From the start, the development of the programme was fundamentally flawed by the overarching belief that all “high intensity users” were engaging in risky behaviour as a means of seeking attention - something he heavily associated with personality disorder (in particular BPD/EUPD).
In Paul Jennings’ writing, he describes repeatedly how the patients under the programme had “behavioural disorders” and were at a high risk of dying accidentally while doing risky things (such as attempting suicide) for attention. One early SIM report states: “Statistics tell us that the highest risks of death are usually posed by the patient accidentally dying from the circumstances or environment that they have intentionally chosen for themselves. Examples could include slipping and falling from heights, fatal road traffic collisions or poisoning from drug overdoses.” [22] This is actually a very common healthcare myth surrounding patients labelled with personality disorder, which has little to no evidence in support of it [23,24]. (For a more in-depth discussion of the perceived “risk of accidental death”, see my previous blog on the topic).
Paul Jennings believed that by responding and treating such people as if they were genuinely suicidal, healthcare staff and emergency service workers encouraged them to keep repeating this “behaviour” [25]. The IRP was designed to ensure all healthcare and emergency service workers responded in the same manner to the people under the programme, which involved the cessation of ordinary service responses (such as the use of Section 136, and treatment in A&E) and the presence of a police officer in mental health appointments to place pressure on the patient to change their “behaviour”.
“NHS staff reported that whilst they had tried more assertive techniques of communication, fundamentally they did not have the sanctions or consequences that could either encourage co-operation or promote more acceptable behaviour.” [26]
“The bottom line however is that when it comes to stopping high harm, high risk behaviour, the NHS professional can only advise on the likely impact. In this specific conversational context they are just nurses and doctors - they have no behavioural grip - they don't make the patient really reconsider the risks of how they are behaving and the risks of repeating the same behaviour. If sitting on a multi-storey car park works, gets the patient cared for, noticed, protected, loved, safe - then they will repeat it - and repeat it. [...] The answer lies in changing the outcome of their behaviour from something that worked historically to something that now doesn't work - and then repeating that 'negative outcome' until the patient works out that "this behaviour doesn't work for me anymore". This is the only way, but it will only work if we all agree on our collective response and have the courage to be consistent.” [27]
The few initiatives in the UK and North America aimed at “high intensity” service use predominantly involve the inclusion of mental health staff in control rooms and street triage teams. The IRP was reported to be the first intervention which embedded a police officer directly in the mental health treatment pathway of patients [28]. This meant the design was started from scratch, with no guidelines to follow, no frameworks or previous initiatives to emulate, and no studies demonstrating the clinical effectiveness of such an intervention. No patients were involved or consulted during the design and development of the IRP. There also appeared to be absolutely no thought given to seeking ethical approval or undertaking a risk assessment or equality impact assessment for what was essentially a clinical trial for a new intervention. Freedom of Information requests to the involved organisations, including Hampshire Constabulary, the Isle of Wight NHS Trust, the Isle of Wight CCG, and the University of Southampton revealed that no information was held by any of them regarding ethical approval, risk assessment, or equality impact assessment for the IRP. Despite a research assistant being embedded in the IRP multidisciplinary team (MDT), a search of the University of Southampton’s Ethics and Research Governance Online (ERGO) system, revealed that the IRP pilot was not even recorded by them [29-32].
The design started with the creation of a word cloud, with the use of a handful of mental health policing documents, and the NICE guidelines for BPD [33]. No explanation was given for the choice of the documents, or whether any kind of literature search was carried out.
Following the creation of the word cloud, a set of core principles were created for the IRP professionals to reinforce in their patients:
“We are responsible for the consequences of our actions and we need you to understand what the consequences of your actions will be if they continue.
Developing emotional resilience skills in the community is important to your recovery.
Detention within a mental health ward does not develop your coping skills. We should all try to avoid it at all costs.
Positive risk-taking by professionals helps you to take responsibility. A Response Plan will guide responders in making decisions that are in your best interests.
We will help you managing your life and developing coping skills.”
2013-2014
Integrated Recovery Programme: Implementation
In June 2013, just weeks after Paul Jennings first considered creating a new model of care for the eight locally identified “high intensity users”, the NHS allowed a police officer with no clinical training to openly recruit extremely vulnerable mental health patients into a totally novel, untested, and high risk clinical intervention, which had no ethical approval, risk assessment, or external supervision, based entirely on a word cloud from five documents. There is no indication that anyone, either in the NHS or the police service, raised concerns over this.
I’ll give you a minute to take some deep breaths and let that sink in.
So… The IRP was up and running, and Paul Jennings was allowed access to the eight women, via mental health services, managing to "recruit" six of them to the programme. In IRP and SIM documents, only four of the women have their outcomes reported, two appear to disappear. This discrepancy was explained following a Freedom of Information request to Hampshire Constabulary, who released a collection of redacted emails from 2018/19, regarding the IRP [34]. Within these emails, it is revealed that Hampshire Constabulary were deeply concerned by the data and outcomes reported by Paul Jennings as part of his subsequent SIM training and recruitment materials, and could not support his claims of success.
In one email, a member of Hampshire Constabulary described how two of the women initially recruited into the IRP in 2013 had been entirely removed from the data because of their negative results: one had left the programme and died, and the other had been hospitalised. One of the remaining four women had been reported as having zero involvement with services for the second year of the pilot, when in reality, she had left the programme, and continued to have high levels of contact with police and emergency services, also experiencing at least one period of hospitalisation in an acute mental health ward.
Unfortunately, despite these serious concerns, senior officers failed to bring this to the attention of the public.
The four women have their case studies presented in a number of pieces of IRP and SIM literature, including the IRP evaluation. A very large amount of personal information is shared about them, including: age; gender; diagnoses; occupation; family structure and dynamics; family members occupations; family members criminal histories; number of children; living situation of children and parents; history of child abuse; history of domestic violence; history of sexual violence; criminal history (including “crimes” for which they had not been charged or convicted, and description of criminal justice services involved with); history of self-harm and suicide attempts (including methods and suspected methods); history of hospital admissions; descriptions and history of physical health problems and treatments; descriptions of mental health care received; historic and ongoing crisis behaviour; speculation about behavioural motivation; speculation about the veracity of rape and abuse allegations; descriptions of interpersonal interaction styles; etc, etc. There is no indication that any of the women were asked or consented to such a large amount of extremely personal information being shared about them, or consideration of the potential for them to be identified (particularly given the extremely small geographic region which they are from.) The descriptions of the women are so detailed, it is possible to pick out which of them have their case studies used in other material, despite them having their names changed between documents.
Jane: Jane’s outcome is described as positive, despite her continued resistance to being involved in the IRP. The evaluation states: “After several months of mentoring, it was a final threat of arrest and legal intervention that persuaded Jane to stop all disruptive behaviour [..]”. She was reported as being discharged from mental health services.
Gena/Geena: Gena’s outcome is described as positive, despite it being reported that during her time in the programme her eating disorder worsened. It was stated that “clinical staff felt this was a sign of clinical progress” but the reasoning behind this strange statement was not given. She was found guilty of grievous bodily harm for stabbing her boyfriend, and was given Community Behaviour and Probation Orders.
Susan: Susan’s outcome is described as positive, as it was reported she no longer engaged in “public crisis behaviour”, however, her gambling difficulties remained, and she continued to be vulnerable to predatory men who would come to her flat and take financial advantage of her.
Tina: Tina’s outcome is described as positive, as her public suicide attempts stopped, but not her self-harming at home. During her time in the IRP, therapeutic programmes were withheld and she was threatened with a Community Behaviour Order “if her disruptive behaviour continued”. It was stated that she “resisted” this threat, and was subsequently discharged from mental health services to “reinforce this message and boundaries”. She re-accessed services, was allocated a new care-coordinator and withdrew from the IRP, however, remained “mindful that the same consequences [were] always an option again”.
The IRP evaluation pre-print contains a graph outlining the use of Section 136 powers over the IRP period (displayed below) [35]. It is not stated anywhere, however, whether the reduction in the use of S.136 is related to a reduction in need, or because officers were simply instructed to not detain the women as part of the IRP intervention model. Following the previously discussed FOI to Hampshire Constabulary, it is also clear that the “18 months after” data for at least one of the women is entirely untrue [36]. It seems most likely that this is Jane, but could also be Tina.
In October 2014, before finishing the IRP pilot and collating the data, Paul Jennings reports that he recruited a “specialist clinical team”, and wrote the ‘Serenity Briefing’ crisis response training package, aimed at teaching multi-agency staff (including police, fire service, NHS etc) how to use his crisis response approaches [37]. The creation of this training package before the IRP had even finished or been evaluated strongly indicates that Paul Jennings was less interested in the actual outcomes of the IRP, and more invested in the idea that, whatever the evidence suggested, he was right. This can be seen in the manipulation of the data subsequently produced, and his continued assertion that data wasn’t important: “I just knew that it would work [..] We don’t always have to have data, as long as the leader can tell you that it’s going to work, you need to be able to trust that leader to make it happen.” [38].
2015
Integrated Recovery Programme: Evaluation
The IRP pilot ran from July 2013 to the end of December 2014. The key outcome measures chosen to evaluate the IRP were [39]:
“To reduce the risks posed to users themselves and to members of the public [operational benefits]:
To reduce the number of s136s detentions under the Mental Health Act 1983
To reduce the number of ambulance deployments, attendance at A&E emergency departments and number of calls to mental health services
To demonstrate a significant change in patterns of behaviour i.e. internalisation of the need to participate in recommended pathways [clinical and social benefits]
To reduce the occupational impact on the mental health staff who directly manage them
To seek the views of the multi-disciplinary team/s of healthcare professionals about the effectiveness, benefits and limitations of the new multi-agency mentoring model and its potential for future roll out.”
To evaluate the clinical and social aims, semi-structured interviews were conducted with all the members of the multidisciplinary team. They were asked their opinions on the progress of the women, and the IRP strengths and limitations. To evaluate the operational aims, data relating to service use (detention under Section 136, calls to mental health services, attendance in A&E etc) were collated and compared from before and after the implementation of the IRP [40].
Mental health professionals commented that “[The people in the programme] may never thank you for it but inside they know it is exactly what they needed.” They described being more confident at risk assessment and management, as they felt professionally safer with a police officer involved in the decisions to withhold care. They also felt they had a stronger foundation in case any of their patients died [41].
The views and experiences of the women under the IRP were not sought as part of the evaluation [42]. A reduction in service use; discharge or self-discharge from mental health services; and the movement of crisis “behaviour” (including self-harm and suicide attempts) from public places to private places, were considered successful outcomes for the women. No consideration was given to the potential that service use had decreased not due to a lack of need, but due to fear.
“All four HIUs clearly internalised the need to no longer misuse emergency public services. [..] They were empowered to do something positive i.e. take responsibility for their actions and take better care of themselves and NOT to do something negative i.e. not calling the police, not calling the ambulance or not going to A&E to get the ‘hit’ of compassion they so craved.” [43]
It was acknowledged during the evaluation that the programme could have negative effects on the patients involved, including, feeling disempowered due to the loss of previous safety nets; embarrassment and discomfort due to the police presence; a potential for an increase in formal prosecution outcomes; and an increase in risk taking and crisis “behaviours”. It was also noted that professionals should “always be prepared for malicious accusations” against themselves or others, from the people under the programme [44]. An explanation for this statement was not given.
Integrated Recovery Programme to Serenity Integrated Mentoring
February 2015 saw the evaluation of the IRP model, and discussion within the MDT of moving forward with a more permanent programme. The MDT contained; “1 NHS Mental Health Consultant -1 Psychiatrist -1 NHS Clinical Psychologist -7 NHS community care co-ordinators -1 NHS ward nurse -1 university research assistant -1 specialist MH police sergeant -1 police constable working in a MH support role” [45]. The SIM Pilot report, published in 2018, states that in this February meeting, the MDT “identified that 5 out of the 6 patients had made significant progress in many of the areas [staff] had measured.” However, as previously discussed, the documents released from Hampshire Police following an FOI request, indicate that these outcomes are untrue. One of the six women had died, one had been hospitalised, and another had left the programme, continuing to have high levels of contact with emergency services and mental health services [46].
Awash with denial and displaying dysfunctional team dynamics indicative of groupthink [47,48], all members of the MDT agreed that the IRP pilot should be rolled out as a full scale programme, for the “mutual benefit” of both patients and professionals. It was noted that the clinical environment had undergone a change during the IRP, as patients were made aware of the legal sanctions which could be brought against them. The language and behaviour of the MDT reportedly became more integrated: “police officers started to sound a bit like nurses and nurses a bit like police officers.” [49]
As Paul Jennings worked on developing the programme, the IRP continued to work with vulnerable patients, recruiting more into the programme throughout 2015. Two further case studies are provided in the SIM Pilot report [50]:
Greg: Greg was recruited to the programme in February 2015. As a trans man, Greg was seeking a referral to Gender Identity Services. Despite full recognition that such a referral would go a long way in resolving Greg’s recent crisis, the referral was deliberately postponed, in the most exceptionally shocking display of transphobia, until he could “demonstrate emotional and behavioural stability” under the IRP. Greg’s outcome is described as positive due to the reduction in his use of services, however, it is not clear whether this was because of the IRP or (as his crisis demand graph shows) he was simply experiencing an unusual and isolated period of crisis, which resolved itself after a short time.
Steve: Steve was recruited to the programme at the end of August 2015, and had a history of severe self-harm, requiring multiple surgeries. His outcome is described as positive, as after 12 weeks he self-discharged from mental health services and stopped calling the police. His attendance at A&E did not appear to change however, nor did the number of ambulance deployments. No indication is given to suggest Steve’s self-harm had stopped, and no data was collected or reported from the end of 2015 onward. We have no idea if Steve immediately bounced back to services, still struggling.
In March 2015, Paul Jennings attended the British and Irish Group for the Study of Personality Disorder (BIGSPD) annual conference, held that year in Leeds. Following the conference, he decided to change the name of the programme from Integrated Recovery Programme to Serenity Integrated Mentoring, providing three reasons for the change [51]:
“To remove the word ‘Recovery’ which I felt placed too much pressure on everyone in a SIM case to ‘perform’; a valid point that was made at the BIGSPD 2015 conference.
To introduce the word ‘Mentoring’. One of the earliest lessons learnt was to promote to each person with lived experience, a deeper sense of personal responsibility. Mentoring gently promotes this message.
To add the ‘Serenity’ brand name, to highlight the origins of the model.”
And so SIM was born. The main area of focus for development in this new model was the concept of “mentoring”. This was considered a preferential style of patient management, as it “requires the patient to actively reflect and to discover their own life solutions” while “re-negotiat[ing] the clinician-patient relationship from a model of ‘unconditional service provision’ to ‘conditional but compassionate support’.” The SIM mentoring model places a heavy emphasis on patient responsibility, and reduces the patient’s “expectations” of being actively supported by services. As Paul Jennings describes: “this approach requires more discipline and effort from the service user which slowly enables them to build the skills, resilience and coping mechanisms required for a healthier life.” [52]
The SIM model was subsequently compared to the Integrated Offender Management (IOM) programme, which uses a cross-agency response to manage “persistent and problematic” offenders within local communities [53]. Quotes below from SIM and IOM:
The comparison and conflation of mental illness (including experiencing crises, self-harming, and attempting suicide) with “offending” is stark. In the SIM Pilot report, Paul Jennings states: “Is it fair that we have an entire National Offender Management Service (NOMS) dedicated to managing problematic and complex people after they have reached a prison cell but we don’t have any national service supporting problematic people who just happen to choose another complex coping behaviours?” He continues on to describe how people who “gravitate towards criminal behaviour” probably just have a different type of personality disorder [54].
Throughout a number of documents, and on his personal social media accounts, Paul Jennings (quite possibly coloured by 17 years as a serving police officer) consistently displays the desire to bring criminal justice systems into mental health services, and repeatedly indicates that he sees no separation between the two - mental health patients are just criminals who haven’t yet offended.
In defending how SIM brings police into clinical spaces, he states that it is vital to note that SIM is only for people who have already had “contact” with the criminal justice system (which includes being “supported by police officers in public places”); people who are at risk of such; and anyone else who clinicians feel would benefit from the approach [55]. (So pretty much anyone and everyone.)
SIM: Scaling-up
“Now in year 3 of this journey, (with many service users now making excellent progress and with validated statistics), we can focus on expanding the conversation outside of our immediate area to other CCGs, NHS providers and police forces. This vision was developed early on [..].” [56]
Now this is just my opinion, but I strongly believe there were two main motives behind SIM, and behind its appeal to healthcare professionals and providers, which were heavily leaned into during the SIM national roll out. Within the early literature, a strong emphasis was placed on the emotional and professional comfort of mental health and emergency service workers. This is reflected across the design of the IRP, which specifically included a reduction in“the negative occupational impact on mental health staff” as a desired outcome; the implementation of the IRP, which focused on patients and patient "behaviours" most disruptive and upsetting to staff, not the patients themselves; and the evaluation of the IRP, which only considered the opinions of staff, failing to include thoughts, opinions, or experiences of any of the women who had been under the programme [57]. Staff comments praising the IRP included: “I dislike [my patient] less now”, and “I don’t dread coming to work anymore” [58].
Dr Rob Andrews, A&E consultant and Isle of Wight ambulance service clinical lead, stated that SIM was an invaluable intervention for “managing” patients which emergency services did not want to deal with. He even went as far as describing how SIM allowed services to deny “high intensity” patients the “gratification” which accompanies hospital attendance and admission. Such a statement indicates a very clear punitive motive, and a strong resentment directed at people he perceived as attending his A&E department for emotional benefits [59]
The next clear motivator for the intervention was the apparent potential for reduced financial costs to services. Right from the start, there was a focus on cost-saving, and how this would be perceived by care providers and commissioners. The IRP evaluation states: “The IRP was not designed to save money. However, it was found to have the potential to make substantial savings.” [60] As the IRP was being scaled up to be rolled out to other regions as SIM, the literature begins to become saturated with money-saving graphs and figures.
In 2015, Paul Jennings made some of his own financial calculations of cost saving, using his flawed and fabricated patient data from the IRP pilot. He describes firing up his calculator to make “some very crude calculations into the costs of caring for one specific service user.” [61] Paul Jennings used the data of Jane, who he felt “best demonstrated” the high intensity profile. Jane, who also appears to be Katherine in another document, is, in my opinion, the woman from the original four in the IRP most likely to be the person revealed in the Hampshire Constabulary FOI emails to have had her data fabricated following her leaving the IRP - erasing all subsequent times she accessed services, and reporting it as zero [62].
Paul roughly calculated how many different services Jane accessed between 2010-2013 and averaged out a cost of £16,968 per year over the three year period. At the beginning of the IRP, eight women were identified on the Isle of Wight who were considered “high intensity users”. The Isle of Wight has an approximate population of 140,000 people, so, extrapolating from these figures, Paul Jennings suggested that “high intensity users” could make up 0.0057% of the general population, which across England and Wales (with an estimated 60 million people at the time) would indicate there to be 3424 “high intensity users”. Using Jane’s costing, he estimated that this could incur costs of £58.1 million per year. Which, as Jane was reported as having zero service use following her time under the IRP, would suggest a £58.1 million saving.
SIM documents state that from August 2015 to January 2016, Paul Jennings completed a five month secondment with the UK College of Policing in New York as a Visiting Professor at John Jay College of Criminal Justice. He also describes acting as a "critical friend" in mental health service delivery to the New York Police Department, and attending and graduating from the NYPD Crisis Intervention Team (CIT) training course [63]. However, I can’t find any sources produced by someone other than Paul Jennings which can confirm this.
2016
In February-March 2016, back in the UK, Paul Jennings approached professionals trained in health economics to help him with his financial data. Matt Winkler, a health economist from Wessex Academic Health Sciences Network (Wessex AHSN) subsequently supported Paul Jennings in calculating the potential financial benefits of SIM. Paul Jennings commented:“You will see that the figures are impressive and the costs we can save are substantial if we use methods like SIM. [..] “With Wessex AHSN’s assistance, we have produced new data that suggest quite startling cost reductions.” [64]
It was felt that the data suggested, firstly, SIM could significantly reduce operational costs within two years, and secondly, could be used “proactively”, to target patients who were not “high intensity users”, but who were “beginning to show signs of intensive behaviour”, which included newly referred patients displaying “high-risk symptoms”. This was described as an “upstream” approach, which would “ensure these crisis costs are never incurred” [65]. This is an interesting change of direction from an intervention which was previously described by Paul Jennings as only being for patients who had already had contact with the criminal justice system and who fit the profile of a “high intensity user”. SIM was now being conceptualised as a means of managing a much larger patient population, placing police into the healthcare teams and appointments of people who were not “high intensity users”, to use the tactics of coercion and legal threats to ensure they stayed that way.
Throughout 2016 SIM moved swiftly through the process of being scaled up, with literature and financial data being produced to present service commissioners and organisations a supposedly legitimate and cost-saving intervention. A SIM logo was created, using the outline of the graph made by Wessex AHSN, from the fabricated and erroneous data.
In August 2016, Health Education Wessex funded a mental health nurse specialist to support workforce development of SIM in Hampshire [66].
In October 2016, supported by Wessex Academic Health Science Network, Paul Jennings was awarded an NHS Innovation Accelerator (NIA) fellowship [67]. The NIA is an NHS England initiative which is partnered with the country’s 15 Academic Health Science Networks (AHSNs) and hosted at UCLPartners. Launched in 2015, the purpose of the NIA is to accelerate uptake of “high-impact” innovations, which may benefit patients, staff, and populations across the NHS [68]. As a fellow, Paul Jennings received intensive support from the NIA, including professional links and networking opportunities, access to learning programmes, a bursary, and mentoring from professionals including Dr Geraldine Strathdee, former National Clinical Director for Mental Health, NHS England [69,70].
In terms of its support of SIM, according to NHS England, the NIA “invites applications from exceptional individuals representing innovations that meet a real need.” The applications then undergo “a robust, multi-stage assessment process involving a college of expert patient, clinical and commercial assessors. This panel is drawn from a wide range of organisations including NHS England and NHS Improvement, AHSNs, the National Institute for Health and Care Excellence (NICE) and The Health Foundation.” [71]
Interestingly, this description of a robust and heavily scrutinised assessment process does not appear to have taken place with Paul Jennings and the SIM model. In a webinar about supporting mental health post COVID-19, Paul Jennings describes that he was supported and approved by Laura Boyd, the national programme lead for the NIA, despite having little to no data to back up SIM. He states: “Certainly, that’s my experience of the NIA. I came onboard in 2016, not with a huge amount of data, I just knew that it would work, and Laura and her team trusted me, and here we are, 4 years later with multiple teams across the country… We don’t always have to have data, as long as the leader can tell you that it’s going to work, you need to be able to trust that leader to make it happen.” [72]
Paul Jennings and SIM were supported by the NIA from 2016-2019 [73], during which time SIM was subsequently selected by the AHSN Network, and saw a massive national roll-out, recruiting 23 mental health trusts, and setting up at least 27 individual SIM teams across the country [74]. This mass uptake of SIM programmes was only possible due to support from the NIA, as Paul Jennings confirms: “Without the support of professional health networks and national funding, it will be a monumental challenge for us to build SIM into a larger programme. We have developed and embedded SIM at a local level and prove that it works. Now we simply need support to expand it into a national network.” [75]
While it was the NIA who first supported SIM, making the national network possible, in turn, the NIA fellowship was made possible by the support of staff from the Wessex Academic Health Science Network [76]. In 2016, Wessex AHSN set up their ‘Awards Support Service’, to support companies and innovators to “apply, and be successfully shortlisted, for national awards”. In their 2016-2017 annual review, they state: “We have also supported one innovator - Paul Jennings at Serenity Integrated Monitoring (SIM) - to successfully apply for the National Innovation Accelerator programme.” [77]
Shockingly, through the FOI release of a number of emails from Hampshire Constabulary, it seems that Wessex AHSN were aware of concerns around Paul Jennings' data, and had been contacted by Hampshire Constabulary, regarding the fabrication of data, and the use of erroneous data to create misrepresentative and unethical charts and graphs [78].
It is unsurprising then that the StopSIM Coalition reported in 2023 that the AHSN network, in particular Wessex AHSN, had refused to work alongside StopSIM during the coproduction of a national policy with NHS England (subsequently withheld from publication by NHS England) condemning SIM and SIM-like approaches. According to the Coalition, the AHSN Network refused them access to key information which was shared with NHS England, refused to speak with them or attend meetings in which they were present, and presented legal challenges to block the publication of the policy. The StopSIM Coalition stated: “They have acted in a way that makes it clear that they are significantly invested in minimising reputational damage”. [79]
September-October 2016 saw the creation of the PAVE (Pro-Active Vulnerability Engagement) programme under Leicestershire Partnership NHS Trust [80]. PAVE, described by Paul Jennings as independent from SIM but with the same SIM design [81], is a team specific to Leicestershire, which brings together mental health services, police, and substance use services, to work with “high demand”, “challenging” individuals, to reduce service use. PAVE is still running to this day, and received a commendation in the 2017 Positive Practice in Mental Health Awards [82].
At the beginning of October, Paul Jennings attended the European Conference on Law Enforcement and Public Health, in Amsterdam, giving a presentation on SIM [84]. He later announced that “in June 2017, the first SIM team launched in the Netherlands” [85] (described in more detail later). Later in October, SIM won the HRH Prince of Wales Award for Integrated Approaches to Care at the Nursing Times Awards [87]. In November 2016, Paul Jennings attended Wessex AHSN’s ‘A Lifeline for General Practice conference’, promoting the “benefits and results” of SIM.
2017
High Intensity Network: Development
Now an NIA Fellow, responsible for leading the scale up and national roll-out of SIM, Paul Jennings left his position as a Mental Health Sergeant with Hampshire Police and was officially employed by the NHS. Between November 2017 and October 2018, funding was provided by NHS RightCare, who contracted through the Isle of Wight NHS Trust and the Isle of Wight CCG. His first area of focus was creating a network “brand”, including a digital platform, alongside the SIM model of care, so that national SIM teams would all be connected [88]. This was the beginning of the ‘High Intensity Network’, which Paul Jennings would later incorporate as a private limited company.
In March 2017, the next SIM team was established in Surrey. Following discussions between Surrey and Borders Partnership NHS Foundation Trust and the Surrey Police lead for mental health regarding management of “high intensity” patients, the Surrey Police mental health lead visited the Isle of Wight to look at SIM. Following this visit, Surrey and Borders Trust and Surrey Police both individually secured internal funding for a limited SIM trial in one small geographical area. This was supported by Paul Jennings.[89]
The initial trial in Surrey showed a decrease in the use of Section 136 detention powers. Once again, it is not revealed whether the use of S.136 reduced due to a reduction in need, or because the SIM programme is designed to encourage police not to use S.136 powers. Whatever the reason, the local services were impressed by this reduction and they were able to secure additional funding for a further year (April 2018 to March 2019). Staff numbers increased, and the programme expanded to cover all 13 CMHTs across the district. The new programme was named ‘Surrey High Intensity Partnership Programme’ or ‘SHIPP’ [90].
A case study published by the NIA, promoting the “innovations” which they had funded and accelerated, described how police in Surrey initially felt concerned about following the high risk SHIPP approach, stating: “there can be concern regarding professional responsibility if a user were to die following a care plan rather than the usual police protocol of taking them to a safe place. The SHIPP team spent a lot of time touring the county to work with operational police officers and other emergency staff to explain how to use the care plans.” [91] To highlight how police attitudes were beginning to change, the NIA included an example of an incident in which officers did not use S.136 powers to detain a person who was under the SHIPP programme, but instead left the scene without providing support (pictured above). The person subsequently overdosed and was admitted to hospital. It is not clear whether the person died, or suffered long-term harm from the overdose, however, following an investigation by the Independent Office for Police Conduct (IOPC), the officers were reassured that because they had followed a clinical care plan, they weren’t going to face any professional consequences. For some reason, this was considered a positive and successful example of SHIPP.
The SHIPP programme is still running to this day, and has plans to expand into child and adolescent mental health services [92].
The Great SIM Roadshow
2017 is where SIM and the High Intensity Network really take off, and Paul Jennings is seemingly on a permanent tour of the UK, travelling between events, conferences, training days, and multiple organisations to give talks and presentations about SIM and the High Intensity Network. The speed at which SIM begins to pick up pace is where we can start to see seriously concerning actions from organisations. Still leaning heavily on his fabricated and erroneous data from the Isle of Wight IRP pilot, Paul Jennings is able to “sell” the concept to service providers and commissioners, as the manipulated data indicates that this intervention will potentially save services an inordinate amount of money.
March 2017 saw Paul Jennings return to the British and Irish Group for the Study of Personality Disorder (BIGSPD) annual conference, held that year in Inverness. This time he was accompanied by Vicki Haworth, the Innovation Lead for the Isle of Wight NHS Trust, and Ashley McGrorty, a Service User. Paul Jennings, working on recruiting more services to SIM, presented a paper entitled: “SIM: An invitation to join a new NHS England funded High Intensity Mentoring Network”. [93]
In May 2017, Paul Jennings attended a seminar on “Behaviour that Challenges”, led by the University of Leeds, in collaboration with the Prison Reform Trust, The National Autistic Society and NHS Improvement. Paul Jennings gave a presentation, entitled: “Crisis driven behaviour – meeting ‘their’ needs (not our own)” [94].
On 24th May 2017, SIM won the HSJ Value in Healthcare Awards for “Clinical Support Services” and “Mental Health”, and were highly commended for “Workforce Efficiency”. On the HSJ Solutions website, where the awards are recorded, HSJ published an article describing SIM’s background and work [95]. Within this article, it states that SIM was
supported by “strong data that has been gathered using both qualitative and quantitative methods”, and that SIM staff “always seek the feedback from service users who have been supported by SIM at every opportunity”. As previously discussed, both of these assertions are untrue. The article goes on to describe how SIM was “proven” to reduce operational costs to teams by up to 92% - a figure which appears on a number of SIM documents. In the emails released by Hampshire Police following an FOI, Hampshire Constabulary specifically state they cannot support the “92% reduction” figure, asserting that this data does not represent the true picture in relation to police incidents [96].
I’m left wondering how much research was carried out by the awarding body before shortlisting and subsequently presenting SIM with three awards, and whether HSJ should consider re-evaluating these awards, with a view of retracting them due to SIM’s publication of false and misleading data. (Data described as “hugely inaccurate”, “misleading”, “erroneous” and “unethical” by Hampshire Constabulary [97]). In any case, it's clear that the success of SIM is ultimately based on the false data presented by Paul Jennings in the SIM literature. Looking no further than SIM’s celebration of itself, several organisations, including HSJ, presented SIM with a collection of awards. These awards then served to bolster Paul Jennings belief in the programme, and provided all the evidence other organisations needed, to fund and implement SIM within their services. SIM was suddenly a “multi award-winning” intervention, and the presentations and documents produced by Paul Jennings wasted no time in loudly declaring this fact.
The SIM Business Case, produced by Paul Jennings and Vicki Haworth, describes how SIM won the ‘Mental Health’ category at the HSJ Value Awards 2017, and was the “only mental health related project” being supported by the NIA programme at that time (pictured right). The document goes on to conclude from these points, “This means that [SIM] has been assessed for its clinical results and its scalability. NHS England would like SIM to be used across the entire health service” [98]. Given that the Health Service Journal is a news service, we can be left to assume that the comment regarding NHS England relates to the NIA Fellowship, as that is an NHS England initiative. In July 2021 the AHSN Network published a response to an FOI regarding their previous support of SIM and the High Intensity Network. Within this response they give an overview of the role of the NIA, stating that “Unlike AHSN Network National Programmes, the NIA does not provide direct support to NHS sites to implement NIA innovations. Innovations on the NIA are not mandated and there is no directive to roll them out nationally.” [99]
While I cannot state with certainty that the language used in the SIM Business Case is deliberately misleading, it does appear that it is misrepresenting itself and the meaning of its affiliation with the NIA; using this misrepresentation to aid recruitment of other services to the High Intensity Network.
In the emails released by Hampshire Constabulary following an FOI, Hampshire Constabulary raise concerns about the manner in which SIM was being promoted and advertised throughout the country [100]. One email actually describes the SIM recruitment materials as an “aggressive sales pitch”, suggesting that the manner in which SIM was represented appeared to be “a method of unfairly bringing pressure on other trusts to join the network”. This includes describing trusts as having "live SIM teams" when they did not. They also raised concerns that despite Paul Jennings no longer working for Hampshire Constabulary, he was still attending events in his police uniform, and the Hampshire Constabulary crest was still appearing on promotional material.
This misrepresentation appears to be the case across a number of SIM documents and presentations. The High Intensity Network was strongly presented as a police and NHS endorsed, award-winning, “international” movement, with outcomes that would save healthcare Trusts and emergency services massive amounts of money and resources - and yet, at that time, was still entirely based on the false data produced from four patients on the Isle of Wight.
Similar concerns about misrepresentation were raised in 2021, during the survivor-led campaign against SIM and the High Intensity Network. Twitter users commented on the organisations and individuals listed on the High Intensity Network’s website, which indicated that they worked with the High Intensity Network, or endorsed SIM. In May 2021, Chief Constable Mark Collins was advertised on the High Intensity Network’s website as mental health lead for the National Police Council, providing “pivotal” support to the organisation, when he had in fact resigned and relocated to the British Virgin Islands earlier that year. Two weeks after this was flagged by mental health activist, @Sectioned_ , Chief Constable Mark Collins was removed from the website [101].
The same activist also raised concerns about the advertisement of an American branch of SIM, named “Integrated Mentoring United States” (IM-US), which was supposedly set up in 2018. Angela Lockhart (identified as "Project Manager - United States") was one of only four people listed on the High Intensity Network website contact page (including Paul and Kimberley Jennings), indicating she had central involvement with the High Intensity Network. Paul Jennings had previously stated that “three SIM based teams” were live in St Paul, Minnesota, and he was supporting their “growing network” [102]. However, after researching Angela Lockhart, @Sectioned_ was not able to find any public mention of this apparent US scheme, or Angela’s supposed involvement in it [103].
The logo of the mental health blogging organisation, Mental Elf, was also spotted on the High Intensity Network website, listed on a banner of organisations the High Intensity Network supposedly worked with. When asked on Twitter about their affiliation with the High Intensity Network, a member of Mental Elf responded to indicate that they did not know why their logo was on the website. It was subsequently removed.
A number of SIM documents, including the published IRP evaluation, state that “Operation Serenity, IRP and SIM were deemed outstanding” by the CQC in 2014 [104]. The reference provided for this directs people to a document called “Monitoring the Mental Health Act 2012/2013”, which has since been moved to the National Archives. Upon searching that document, it contains no mention of Operation Serenity, IRP or SIM. The street triage teams mentioned within the document do not even include Hampshire/Isle of Wight [105]. When looking through the CQC inspections of the Isle of Wight NHS Trust for 2014, Operation Serenity (the street triage team, not IRP/SIM) is mentioned several times by the CQC, and described positively in terms of mental health staff accompanying police to mental health related incidents on Friday and Saturday evenings. The Integrated Recovery Programme and Serenity Integrated Mentoring model were not described or mentioned at all, let alone called “outstanding” [106,107].
On the High Intensity Network website, a web page existed presenting questions about SIM, with accompanying answers. One of the questions asked “Has any team that has started ever stopped because it didn’t work?”
The answer states: “No, in fact the four oldest teams have expanded the number of staff to cover a wider area”. The teams listed include; Surrey, Wiltshire, Essex, and London. Despite the oldest teams being the Hampshire and Isle of Wight teams (Isle of Wight NHS Trust and Solent NHS Trust), where Paul Jennings initially set up the SIM programme, they are mysteriously absent from the list. In the emails released by Hampshire Constabulary following an FOI, Hampshire Constabulary reveal that after Paul Jennings left the police and began his work on rolling SIM out nationally, the team from the Isle of Wight NHS Trust and Solent NHS Trust ended their SIM programmes, moving away from the original methodology, and did not want to be associated with the High Intensity Network [108]. This directly contradicts the statement that the oldest teams were still going strong, and that no-one had ever stopped their SIM programme.
This slide (pictured below), which is found in a number of SIM presentations [109,110], shows data for a patient under SIM Essex: 12 months before SIM, and four months on SIM. When looked at without much scrutiny, a column filled with “0” values, and a much smaller financial cost, could appear to show a positive SIM outcome.
When given a little more consideration, it becomes clear that this isn’t the case. In the SIM column, it states that Patient A was in hospital for 122 days of the four months on SIM. 122 days is four months and half a day; meaning the entire time Patient A was under SIM, they were an inpatient for all but one afternoon. The 12 month pre-SIM column shows a higher incidence of ambulance calls, A&E attendances etc, however, not only does the pre-SIM column display a time period three times the length of the SIM column, it also shows that Patient A was living in the community for five of the 12 months. It makes sense that the use of emergency services would decrease while in hospital. Further to that, when averaged, the quarterly cost pre-SIM works out to be £44,388.37 - this means that for the four months on the SIM programme, Patient A’s care costs increased by £8441.03.
These are just a few of the copious examples. In isolation, many of these inconsistencies, inaccuracies, and omissions could be considered simple misunderstandings or mistakes, however, together (and when coupled with the ongoing use of fabricated and misleading data) it paints a picture of deliberate and systematic dishonesty, attempting to market the High Intensity Network as bigger, more successful, and more connected than it actually was. For an organisation tasked with designing and teaching a clinical intervention targeted at extremely vulnerable mental health patients, such a lack of organisational integrity is deeply concerning.
Moving on, back to the timeline… At some point between March and June 2017 (there are conflicting accounts of when), the High Intensity Network launched their website and the beginnings of their digital platform.
Paul Jennings continued to promote SIM through numerous events and presentations across the country, including:
29th June 2017: Paul Jennings attended the University Hospitals Coventry and Warwickshire annual Medici event. “An evening to celebrate innovation, build connections and imagine possibilities”. The NIA describe SIM as “solving a £16m problem” [111]
4th July 2017: SIM won the “Managing Long Term Conditions” award at the Patient Safety Awards, and was highly commended for “Best Innovation in Public Sector“ [112]
15th August 2017: Paul Jennings gave a TEDxNHS talk about his experience of mental illness and the SIM programme.
5th September 2017: Paul Jennings attended the second National Mental Health and Policing Conference, hosted by the National Police Chiefs’ Council and College of Policing, attended by HRH the Duke of Cambridge.
11th September 2017: Paul Jennings attended the Health and Care Innovation Expo in Manchester.
22nd November 2017: Paul Jennings attended the 2017 Summit of the NHS Innovation Accelerator (NIA), which “celebrated the 2016 Fellows and welcomed the 11 new Fellows joining the programme in 2017”. In attendance were staff from the NIA team, along with delivery partners from NHS England and England's 15 Academic Health Science Networks (AHSNs), plus a host of NHS stakeholders. Paul Jennings gave a talk about the past year of work with SIM, and singled out London's Health Innovation Network and Wessex AHSN as being particularly supportive [113,114].
24th November 2017: Paul Jennings attended the Improving Mental Health Crisis Care Conference in London. Bobby Pratap (Senior Programme Manager, Crisis and Acute Mental Health Care, NHS England, now Deputy Head of Mental Health) tweeted that he “loved” hearing from Paul Jennings about working with people “who use services most intensively” [115]. Images from the slides show Paul Jennings continuing to use the same flawed financial data from the Isle of Wight IRP pilot.
Between 2017-2019 a SIM project was piloted in the Netherlands. The “Stevige Structurele Begeleiding” project (“Sturdy Structural Guidance”), or SSB, was led by Dr BW Koekkoek from HAN University of Applied Sciences [116]. Around 15 professionals and 15 “clients” were assigned to participate in the pilot study, which used mental health professionals and police to “both offer help and indicate boundaries - because that appears to be important for this group [of clients]”. The results of the pilot indicated that there were a number of obstacles in the design, and as such they ended up with 5 clients being supported by four groups of professionals. It was reported that “The trial focused on the 'hard core of complicated people' with highly disruptive and risky behaviour. The cooperation between the police and mental health services resulted in fewer nuisance reports and more mutual trust between the care providers on both sides.” [117] The SSB project is described in a report on “confused persons” in 2019, but little is revealed in the way of wider outcomes of the pilot, and no data is provided (such as service use and financial costs) [118]. It is unclear whether the pilot continued after 2019.
In November 2017, with the agreement of the London Mental Health Transformation board, a trial of SIM was agreed to be carried out in London. The Metropolitan Police and four mental health Trusts (Oxleas NHS Foundation Trust, Camden and Islington NHS Foundation Trust, South London and Maudsley NHS Foundation Trust, and South West London and St George's Mental Health NHS Trust) were signed up as “pathfinder” sites for SIM to be trialled [119]. This would later expand to nine Trusts across London.
2018
In April 2018 the Academic Health Science Networks selected SIM as of one of seven programmes for national adoption and spread across the AHSN Network during 2018-2020 [121]. The High Intensity Network, NIA, UCLPartners, Imperial College Health Partners, and AHSNs worked in partnership with the Metropolitan Police, London Ambulance Service and the mental health Trusts to implement SIM across the assigned London boroughs. The Metropolitan Police and Health Education England provided the funding for the officers, training, and supervision [122].
The “main aim” of SIM London, as described across a number of different documents from multiple London NHS Trusts (including privacy impact assessments, equalities impact assessments etc) was not improvement in patient quality of life, a reduction of incidents of crisis, improved therapeutic uptake, or any other patient-centred objective. Rather, the main aim was a “reduction in the use of Section 136” in the target population [123,124]. It is clear that SIM London was designed predominantly as a money saving exercise.
Following SIM being selected by the AHSN Network, there was now funding and resources for the full national roll out of SIM, as well as the creation of a clinical network to connect all the SIM teams across the UK through the digital platform. It was suggested that “by the end of 2018, ten mental health trusts will have live SIM based teams, and by the end of 2019 it is predicted that over 50% of all trusts nationally will also have teams based on SIM core principles.” [125] As part of the AHSN Network national roll out, information was shared across NHS Trusts encouraging the adoption of SIM, once again citing the Isle of Wight IRP pilot as the evidence base that SIM was safe and effective. As an example, a Freedom of Information request to Devon Partnership NHS Trust reveals that the South West AHSN sent the Trust information on SIM, describing the IRP pilot as showing “significant clinical improvements”, stating: “crisis calls to police and ambulance services reduce and are often eliminated. Admissions to A&E reduce significantly, and individuals and families of mental health service users felt more supported” [126]. Devon Partnership NHS Trust subsequently set up a SIM team under the name, “High Intensity Partnership”, or HIP (described later).
On 19th April 2018, eight months after beginning planning, SIM London was launched, with an event held at New Scotland Yard to celebrate. Guest speakers at the launch included, Superintendent Mark Lawrence, Professor Matthew Cripps, Chief Constable Mark Collins, Dr Matthew Patrick, Dr Geraldine Strathdee, Assistant Commissioner Martin Hewitt, PC Julia Davis, and a SIM patient and their family member” [127].
In May 2018, SIM went live across six London boroughs: Greenwich, Southwark, Kingston and Richmond, Camden and Islington. Each borough was provided with a SIM police officer funded by the Metropolitan Police and each mental health Trust trained one or more care coordinators to work with the SIM police officer, also providing a clinical supervisor for each officer.” [128]
In June 2018 Paul Jennings announced that the High Intensity Network was looking to expand into child and adolescent mental health services, and posted on Twitter, looking for CAMHS teams who were interested in the SIM approach for their patients diagnosed with “emerging [personality disorder]”.
On 18th July 2018 Paul Jennings visited Lancashire and South Cumbria Integrated Care Partnership to support the implementation of SIM in the North West. Between 2018-2020 four teams were set up across the region (East, Fylde Coast, Lancaster & Morcombe, and Central). Following FOI requests in 2021, Lancashire and South Cumbria NHS Foundation Trust attempted to distance themselves from SIM by stating that they held absolutely no information about the SIM programme which they had run for two years, and that it had been funded by their commissioners, not themselves [129].
From 2020 onwards, Lancashire and South Cumbria NHS Foundation Trust and healthcare partners renamed their SIM teams “Frequent Attenders Teams”, or FA’s, which according to the Trust only involve the police “if the service user carries out criminal behaviour” [130]. Despite their insistence that the Trust was not linked to SIM, tweets from healthcare professionals indicate that the Trust was involved in supporting other healthcare organisations in setting up SIM programmes (pictured below). Lancashire and South Cumbria NHS Foundation Trust Frequent Attenders Teams are still running, and from their own publications appear to be the same SIM model [131].
Between August 2018 and April 2019, Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust set up a SIM team. Staff received the three day training course 16-18th October 2018 [132]. The High Intensity Network website stated that a second team was to be launched in 2021 [133].
In September 2018, Derbyshire HealthCare NHS Foundation Trust set up their SIM team, named “Joint Engagement Team”, or JET.
Between 23-26th September 2018, Paul Jennings attended the ISQua Conference in Kuala Lumpur, Malaysia, to speak about SIM, presenting a paper entitled “High Intensity Mental Health Crisis: How do we reduce the frequency and risk posed by repeat callers to emergency and healthcare services.”
On 10th October 2018, the Metropolitan Police published an interview for World Mental Health Day with London SIM officer, PC Paolo Resteghini. In it, the officer states: “I work in partnership with a care co-ordinator, with a dual approach to our care; the care co-ordinator provides clinical support and I provide criminal input to the crisis response plan. [..] Serenity Integrated Mentoring is the present and future of Mental Health. The project has been proven to work in a number of places. For example, there has been a significant reduction of section 136 patients in the Isle of Wight. I believe this can also be achieved in London.” [134]. The SIM officer describes his confidence that SIM is the “future” for mental health and will be effective in London, based on having seen the misleading and fabricated data from the Isle of Wight IRP pilot.
On 11th October 2018, Paul Jennings gave a talk about SIM and the High Intensity Network to Leicestershire Partnership NHS Trust and Leicestershire Police. This is interesting, given that these organisations had run the PAVE programme since 2016, which was advertised on SIM materials as being a SIM model and part of the High Intensity Network.
On 6th November 2018, Paul Jennings was guest speaker at the Metropolitan Police Service Borough Mental Health Liaison quarterly training day.
As previously discussed, once Paul Jennings left his position as a Mental Health Sergeant with Hampshire Police in 2017, he was officially employed by the NHS. Between November 2017 and October 2018, funding was provided by NHS RightCare, who contracted through the Isle of Wight NHS Trust and the Isle of Wight CCG. By the end of this period, Paul Jennings and his wife, Kimberley Jennings, had decided to take SIM forward as a formal business venture. The High Intensity Network was subsequently incorporated as a private limited company on 27th November 2018, with Paul as the National Network Director and Kimberley as the National Network Coordinator [135].
Paul and Kimberley Jennings were subsequently contracted directly, through the High Intensity Network, by the AHSN Network, who were funded in part by the Isle of Wight NHS Trust. Between 2018-2020, the AHSN Network paid the High Intensity Network £206,797 [136].
At the beginning of December 2018 Paul Jennings was interviewed by Holyrood Events about digital healthcare (pictured below). He described that “being able to turn a simple idea into a nationally recognised solution” was his greatest success story.
Later in December 2018, Gloucestershire Health and Care NHS Foundation Trust set up their SIM team, named “Gloucestershire High intensity Network”, or GHIN [138].
2019
In January 2019 the first online training course was launched by the High Intensity Network: “An Introduction to High Intensity Patient Management” [139].
In 2019 a further 21 SIM teams were reported to set up across the UK, including 12 teams in London. On World Suicice Prevention Day 2019, Paul Jennings stated: “As an organisation that is only 3 years old, we have come a long way. We are proud that we are now leading new conversations across the UK’s 58 mental health trusts, 43 police forces, 10 ambulance trusts and all A&E departments. We are now collectively exploring ways in which we can all safeguard people within our communities who experience regular thoughts of self-harm and who demonstrate their distress in highly frequent, impactful and sometimes harmful ways.” [140].
In 2019, a feasibility study was conducted, looking at the possibility of conducting a randomised controlled trial of SIM in London. The study was funded by the National Institute of Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRC), and conducted by UCL. The study was described as an initial exploration of whether a full evaluation of SIM would be feasible. It did not evaluate the SIM intervention in terms of its clinical or financial effectiveness, but did provide a small analysis of both. Two applications were subsequently made in 2019 to NIHR by UCL for funding to evaluate SIM in terms of its cost effectiveness; the well-being and social functioning of patients; patients’ and professionals’ experience of SIM; barriers and facilitators of implementation; and whether SIM reduced emergency service use; however, for some reason, NIHR rejected both applications [141].
The feasibility study concluded in September 2019. The data analysed within the study were limited, with a small sample size and short follow-up period. The study compared two NHS Trusts which had implemented SIM (Oxleas and Camden & Islington: 22 patients) with one which had not (Barnet, Enfield, and Haringey: 10 patients). The economic analysis conducted by the study “did not identify any cost savings in service use associated with SIM”. Patients were found to attend A&E less and were arrested less, but this was true for both SIM and non-SIM patients, and was not noted to be statistically significant [142].
The feasibility study ultimately concluded that SIM was “currently practiced without a substantial evidence base” and recommended that it “be urgently evaluated if it is to be widely used within the NHS.” [143] Between that recommendation and the closure of the High Intensity Network in 2021, no such evaluation took place, despite further national roll out. At the time of writing, in March 2023, at least 12 SIM or SIM-like programmes continue to operate nationally. It will soon be four years since this recommendation for an “urgent” evaluation was made, and yet SIM still continues to operate across the country, entirely unevaluated.
In April 2019, a second online training course was launched by the High Intensity Network [144].
Between April and July 2019 two SIM teams were set up in different locations under Essex Partnership University NHS Foundation Trust: SIM Mid Essex, and “Southend High Intensity Focus Team” or SHIFT [145]. In November 2020 this was expanded to include another team in Castlepoint and Rocheford.
Following a SIM pilot meeting on 23rd May 2019 (facilitated by South West AHSN) Livewell Southwest CIC set up a 12-month SIM pilot alongside Devon Partnership NHS Trust, covering North Devon and Plymouth - naming their joint team the “High Intensity Partnership”, or HIP [146]. In 2020 Devon Trust stated that: “Livewell Southwest Community Interest Company
joined forces with the police to help people in the Plymouth community who have frequent and intensive episodes of crisis behaviour to lead safer, healthier lives. The Serenity Integrated Mentoring pilot project identifies people with behavioural issues who are the most familiar faces at A&E or Place of Safety and works with them to help manage and change their behaviour” [147]. One of the HIP documents released under FOI states: “This intervention is designed to work with service users who have behavioural disturbance which they have capacity to change, so normally Emotionally Unstable or Anti-Social Personality Disorder would be the diagnosis.” [148] Incredibly, in their 2021 programme report, the Devon HIP team actually described their SIM programme as “trauma informed”, stating: “The HIP pilot has been a testimony to what can be achieved when a trauma informed, preventative, partnership approach is applied using supportive, clinically approved governance and the boundary setting of the criminal justice system.” [149] Mental health professionals and police reported that they liked the approach and requested to keep the programme running. According to the StopSIM Coalition, HIP is still in operation across both Trusts [150].
On 18th June 2019 Paul Jennings held a SIM workshop event at the Macdonald Tickled Trout Hotel in Preston, Lancashire. The presentation is very interesting to look through and displays a new marketing tactic which I haven’t seen in any of the previous literature I’ve looked at. As part of his presentation, Paul Jennings sourced a report from the Lancashire Integrated Care Board, which reviews mental health services and pathways across Lancashire. Within the report, staff share their frustration with patients labelled with BPD/EUPD, highlighting high numbers of this patient group in crisis and inpatient care, which is described as “a significant challenge for the system”. Staff comment: “Those with personality issues are being medicalised and put in wards which is not appropriate” [151]. It is also noted that third sector organisations felt like “the poor relation”, and got no acknowledgement. Now armed with an understanding of the local frustrations and service difficulties, Paul Jennings used this information to pitch SIM as a targeted solution to these exact problems (pictured above) [152].
In August 2019 the “High Intensity Network” name was trademarked [153].
In September 2019 Hertfordshire Partnership University NHS Foundation Trust worked with Hertfordshire Constabulary to set up a trial of SIM with the Trust’s Adult North West Community team, seemingly as part of their personality disorder pathway. Minutes from a meeting of the Trust’s Board of Directors in 2021 describe how the pilot was interrupted by COVID-19, and was placed on hold until the beginning of 2021. After the concerns raised by the public campaign against SIM in 2021, the Trust did not proceed with reinitiating a formal SIM programme, however they stated they have continued to work with the police to “support” patients felt to be using services frequently [154].
In November 2019, Norfolk and Suffolk NHS Foundation Trust set up their SIM team, “Joint Engagement Team”, or JET, receiving training throughout October and November from the High Intensity Network [155]. After the public campaign against SIM in 2021, the Trust announced that they had ended their programme [156].
In December 2019, Avon and Wiltshire Mental Health Partnership NHS Foundation Trust set up their SIM team, “Police & Health Integrated Mentoring”, or PHIM, in Swindon. This would later expand to north east Wiltshire in 2020. Upon the closure of the High Intensity Network, Avon and Wiltshire Mental Health Partnership NHS Foundation Trust ended their PHIM teams, and both the NHS Trust and the local police forces have attempted to downplay or deny their involvement in the scheme [157,158].
2020
Things start to slow down in 2020 in terms of the spread of SIM. This could be related to several factors. A very large percentage of mental health trusts across England had now signed up to SIM at this stage, or been approached and turned it down, so less marketing was required. The beginning of 2020 also saw the start of the COVID-19 pandemic, which will have reduced the number of events and presentations Paul Jennings could organise and attend.
Between 18-20th February 2020, staff from Wakefield Police, South West Yorkshire Partnership Foundation Trust, Yorkshire Ambulance Service, Well Women Centre, West Yorkshire Liaison & Diversion, Wakefield Metropolitan District Council, and Mid Yorkshire Hospitals NHS Trust attended the High Intensity Network three day training course [159]. Wakefield CCG subsequently funded two nurses to roll out a SIM team locally. Wakefield Police stated that the SIM team’s aim was “to try and stop those in need from spiralling into crisis and potentially crime.” [160]
In June 2020, Cambridgeshire and Peterborough NHS Foundation Trust set up a SIM pilot, which was initially approved to run from July 2020 - July 2021. Induction training commenced in June, while the three day training event occurred in November 2020 [161].
In September 2020 during a webinar about supporting mental health post COVID-19, Paul Jennings stated that SIM was currently managing 150 people, and in the Covid period between April-September had lost two people to suicide. Describing the loss, he stated: “We’re managing about 150 so losing two, whilst absolutely tragic to us, is not so devastating as we thought it would be.The theme behind why they decided to end their life was not their diagnosis but the fact they just felt so isolated.” [162]
In May 2020, SIM London released a report on the two year long trial across a number of London boroughs, during which time 108 patients had been allocated to the SIM programme. The report gives mixed reviews of costs and service need, both increasing and decreasing with individual patients, with an overall decrease in costs. It states that: “The report provides an overview of the SIM London programme to date; an interpretation of the cost savings should be viewed with caution as this is not an economic return on investment study. The cost savings of the original SIM site (Isle of Wight) were accrued over four years whereas the programme has only been running for two years in six boroughs and a considerably shorter time frame for the remaining 13 boroughs in London. Moreover, there is no assessment of the counterfactual – what would have occurred without SIM.” [163]
In November 2020, Paul Jennings applied to have the name and logo of “HISAFE” trademarked [164]. HISAFE is described as a mobile phone app which “enables digital crisis care plans to be formulated as part of the wider Serenity Integrated Mentoring (SIM) model of care.” [165]
The key features of HISAFE included:
Enabling emergency services and healthcare professionals to access a patient’s crisis plan through a “national crisis plan database”.
Local systems flagged if a patient had a HISAFE record, including crisis plans related to specific crisis behaviours.
Crisis plans were sent to the emergency service professionals who were responding to the person.
Responders were encouraged to follow the plans.
HISAFE was part of the High Intensity Network’s ever expanding collection of digital projects, including the “HINDATA Portal”, which collated SIM patient data (eg. demographics, service demand, behavioural changes, monthly observations, etc); the 136DIGITAL project, which appeared to track the use of section 136; “Hot Spot Care Tracking”, which appeared to map geographical crisis spots and movements for individuals; and HITRACK mental health crisis plans, which included masses of personal information about people, available to emergency services, including: name, age, date of birth, gender, ethnicity, height, address, originating NHS Trust and police force, NHS number, medical information, friends/family contacts, social situation/needs, patient safe places/people/routines, mental health “offences”/arrest risks, mentoring log, and response plans to specific crisis “behaviours”. Listed in these behaviours was everything from social media use, a range of self-harm methods, and sexual history, including “sexual promiscuity”, “sexual prostitution”, and “sexual risky behaviour”. It seems that HITRACK either became HISAFE, or HISAFE was the mobile phone app version. It is unclear whether any of these systems (which could potentially breach GDPR and human rights laws) are still in operation within the ongoing SIM teams across England.
2021
The AHSN partnership with the High Intensity Network between 2018-2020 formally ended on 16th March 2021 [168].
Between 22nd-26th March 2021, Paul Jennings returned to the Conference on Law Enforcement and Public Health, this time held in Philadelphia, giving a presentation on SIM and the “progress made, the core lessons learnt and the operational and clinical challenges still ahead.” [169]
#StopSIM: The End of the High Intensity Network
At some point between the end of March and the beginning of April 2021, a tweet was shared from a person under a SIM programme who was asking for legal help regarding their mental health care situation. While some mental health activists had been talking about SIM and sharing concerns for a number of years, this tweet appeared to act as a catalyst, from which a massive online campaign was quickly launched. Very suddenly, mental health patients, survivors, Mad people, neurodivergent people, and others on Twitter began to research SIM and share screenshots of documents, powerpoints, and the HIN website, along with serious concerns, anger, fear, and disbelief at the existence of the SIM programme. People used the hashtags #StopSIM and #HighIntensityNetwork to share their findings, which became more and more disturbing and shocking over the days.
At the beginning of April 2021, a group of activists came together to form the StopSIM Coalition, quickly setting up social media accounts, an email address, and a website, from which to coordinate a campaign against SIM and the High Intensity Network. Members of the coalition worked to quickly source, record, and download as much available information as possible about SIM and the High Intensity Network. As the public campaign picked up traction, organisations (including the High Intensity Network, NHS England, and the AHSN Network) quickly removed masses of information from the public domain. They were clearly aware that these documents could cause them problems.
On April 21st, the newly founded StopSIM Coalition sent their Coalition Consensus Statement to officials within NHS England, the National Police Chiefs Council, and Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Service. The Coalition outlined their concerns about SIM and SIM-like programs, which related to SIM’s “evidence, legality (including GDPR, Human Rights and Safeguarding), aims, governance and ethics.” [170] They called on NHS England to:
“Halt the rollout and delivery of SIM with immediate effect, as well as interventions operating under a different name, which are associated with the High Intensity Network (HIN).
Conduct an independent review and evaluation of SIM in regards to its evidence base, safety, legality, ethics, governance and acceptability to service users.
Respond to this statement within 7 days to communicate the actions taken by NHS England.”
This statement was the beginning of a further five extremely thorough, well-researched, and powerfully written statements, which covered concerns about SIM’s evidence base; privacy and data protection; the human rights and equalities implications; the lack of patient/lived experience involvement in the development and implementation of SIM; and safeguarding concerns. These are all available on the StopSIM website, in accessible formats, and I recommend reading them all.
On April 17th 2021, following a number of tweets directed at the High Intensity Network in which people requested information about the evidence base of SIM, and questioned the legality and ethics of the SIM programme, Paul Jennings announced via Facebook that they had made the decision to suspend their Twitter account (pictured on the left). Despite refusing to hear feedback from the public, and characterising genuine concern and distress as “deeply unfair, personal, factually incorrect, and malicious”, he stated, “We remain fully open to receiving feedback from any source”. This Facebook post attracted a number of comments, which again questioned the legality and ethics of SIM, and expressed deep concern about the programme. The next day, the High Intensity Network Facebook account was deactivated. Paul Jennings’ personal LinkedIn account was also deactivated.
On April 26th a public petition was launched by the StopSIM Coalition, calling on NHS England to immediately halt the roll out and delivery of SIM, and conduct an independent review and evaluation of SIM in regards to its evidence base, safety, legality, ethics, governance and acceptability to patients [171]. In less than a month the petition had over 40,000 signatures.
On April 29th, an article in the Disability News Service outlined the StopSIM campaign, and the formation of the StopSIM Coalition. Paul Jennings was contacted for comment, and the article stated: “Jennings said he would “totally and utterly welcome” an independent review of SIM. He said: “We know we are not a gold standard model yet. We know this whole health and justice movement is in its first decade of something probably like 70 or 80 years of evolution before you get close to it, so we totally welcome any review.” He added: “It is my wife [a former police member of staff] and I running this network, with the sporadic support of some NHS teams, and it is a major weakness of the programme that we are not supported more by NHS England. Why is a care programme for the most traumatised patients in the NHS being run by two ex-cops from their spare room on the Isle of Wight?”” [172].
Throughout April and May 2021, members of the public and the StopSIM Coalition kept up pressure on charities and professional bodies to provide position statements on SIM and the High Intensity Network. Some responded immediately, forcefully condemning the use of SIM and SIM-like approaches. Some took longer to respond or provided vague and non-committal responses. Some never responded, and to this day still have not spoken out against SIM, or made their position known on the criminalisation of suicide and self-harm.
On 11th May 2021, Tim Kendall, the National Clinical Director for Mental Health at NHS England, published a letter addressed to the Medical Directors of mental health trusts across England, asking for a review of all SIM programmes [173]. The letter stated: “[NHS England and Improvement] does not mandate the “SIM” model and at this time is not formally endorsing or promoting its spread. The model was selected to be part of the NHS Innovation Accelerator programme in 2018 and supported by the Academic Health Sciences Network as a 2-year programme with the aim of improving care for an under-served group of patients who experience poor outcomes. However, in light of the lack of evidence base for the interventions provided by this model and the concerns raised by patient groups about how it is being implemented, I am asking all Medical Directors to review where SIM or similar models are being provided to ensure that they are in line with NICE guidelines for patients with personality disorder and self-harm care, as well as patient confidentiality and data sharing laws. The review should include engagement with patients’ about their experiences of the service, as well as service leads, and should consider the concerns that have been raised in the correspondence sent to NHSE/I.”
On the same day, an article was published about SIM in the Health Service Journal, in which Paul Jennings was quoted as saying: “our journey though NHSE as a model that was chosen through rapid scale and spread has been very disjointed… So, yes, there are currently lots of academic and clinical holes in what we do but it hasn’t been for lack of trying. That doesn’t mean to say what we’ve done isn’t high quality, it doesn’t mean our hearts are not in the right place and it doesn’t mean SIM is the wrong solution. SIM is a really good solution…it is not perfect. Nothing is. But it is so much better than what is being offered, which is nothing.” [174].
Behind the scenes, members of the StopSIM Coalition and others involved in the campaign had started submitting Freedom of Information requests to relevant organisations, including Hampshire Constabulary, and the Isle of Wight NHS Trust. On 27th May, Hampshire Constabulary released the explosive emails which described false and misleading data, and the long held concerns about SIM and the High Intensity Network. The FOI was shared on Twitter the next day, and within hours the High Intensity Network website was taken offline.
By the beginning of June, the High Intensity Network emails were switched off, responding with an automated message which read: “The High Intensity Network is now closed permanently. Thank you to everyone who supported our amazing 8 year journey and to the service users who made such great progress and were such an inspiration. Paul and Kimberley Jennings”.
On June 3rd Paul Jennings was again interviewed by the Disability News Service, who asked for comments on the emails released by Hampshire Constabulary. Paul Jennings denied any wrongdoing and said he had not in any way been dishonest at any time, stating: “There is a very complex back story involving former colleagues at Hampshire Police which has been going on for years and has been the subject of a review by the Hampshire Police Professional Standards Department for several weeks now. I can’t say anything more at the moment.” He confirmed that the High Intensity Network was now closed down, with the online portals switched off, the website closed down, and the emails off. “Whether individual organisations continue this line of work is now down to each of them… they will ironically be less transparent, less accountable, less measured and less safe outside of a national programme… so if this campaign thinks it has won, it hasn’t. We are good people trying to make the world a better place. We have served the public for over 20 years each and have not lied once whilst at work. When we get our energy back, we will carry on being these people, operating with these standards.” [175]
On 16th June, the i newspaper printed a special report on SIM, which included an interview with an NHS whistleblower who described how he had been forced to refuse care to a woman who had attempted suicide because she was under a SIM scheme. He stated: “This isn’t about helping the person, it’s about rubber stamping this person as ‘difficult’ or branding them ‘resource heavy users’ and then you can kick them out. [...] The whole thing is reliant on misogyny because we are dismissing the distress of abused women, by its very nature. It is set up to discount the anxieties and cries for help that come from women who have been systemically, serially abused.” [176]
A letter to patients at Oxleas NHS Foundation Trust, South London and Maudsley NHS Foundation Trust, and South West London and St George's Mental Health NHS Trust (pictured below) described that since March 2020, these trusts had held concerns about how the activity data for SIM was gathered and processed by the High Intensity Network. In March 2021, as these concerns had not been addressed, Oxleas NHS Foundation Trust, South London and Maudsley NHS Foundation Trust, and South West London and St George's Mental Health NHS Trust decided not to renew their contract with the High Intensity Network. The letter stated that there would be a review into the local SIM programme, which would include the experiences of staff and patients.
In September 2021, the South London Partnership (SLP) published the promised report, reviewing the implementation of SIM at Oxleas NHS Foundation Trust, South London and Maudsley NHS Foundation Trust, and South West London and St George's Mental Health NHS Trust [178]. The report states that: “Since March 2020 South London Partnership (SLP) have coordinated efforts to address concerns about the governance framework and data quality for the SIM model in south London Trusts. Since March 2020, funding was provided to High Intensity Network Ltd with conditions linked to these issues. These conditions were not met by [High Intensity Network] Ltd and SLP decided not to fund [High Intensity Network] Ltd beyond March 2021.”
The concerns regarding information governance included: inconsistent data harvesting and exporting processes; no mention of GDPR in the original SIM Information sharing agreements; no information sharing agreement which addressed the exporting of data from SLP Trusts to the High Intensity Network portal; and inconsistent data validation processes in place; etc. The report noted that “On reflection, the SLP Trust leads identified that the role of the AHSN (Health Innovation Network) and its relationship to the mental health Trusts was not fully understood. This has implications for data sharing, accountability and carrying out due diligence”.
Staff and patients were given surveys to explore their views and experiences of SIM [178]. Staff were surveyed anonymously “to increase the potential for feedback and comment”. Patient surveys were not conducted anonymously, with care coordinators having access to their completed surveys. Given that the care-coordinators were part of the SIM scheme, it seems utterly absurd that patients would have to share their surveys of SIM with their care-coordinators, and makes it much less likely that people would have felt able to share concerns, upsets, and dissatisfaction with the SIM programme. Only nine out of 47 patients responded to the survey asking for their views. Within the responses were a mixture of positive and negative views on SIM, which included some stating they did not want SIM to end, and some stating that SIM had made them worse and police should not be involved in the provision of mental health care.
Staff views were again mixed, and included those who wished for SIM to continue, and those who had concerns about the programme. One staff member commented: “Seems to be used disproportionately with women who are victims of trauma. It seems quite uncompassionate and that it essentially serves to meet the needs of the services rather than the service users. It seems that it doesn't solve any problems in the long run, and that the model fundamentally doesn't work if it will be ended at some stage. I was not trained on the SIM model and therefore have felt largely out of my depth. I find it concerning that the police staff have such limited understanding of trauma-informed practice” [179].
Following the public campaign, a number of mental health trusts closed their SIM teams, while others modified them to not include the police. Some have claimed they no longer have SIM teams, when they still do. A full list of teams can be found on the StopSIM website, here.
Over the summer of 2021, members of the StopSIM Coalition continued to submit Freedom of Information Requests to mental health trusts, police forces, and coroners offices across England, seeking any information about past or present SIM teams. Many of the organisations approached, either refused to respond; provided minimal information; or attempted to downplay their involvement with SIM and the High Intensity Network, blaming commissioners or neighbouring organisations.
At the end of 2021, the StopSIM Coalition began working with NHS England and other stakeholders, to co-produce a policy about SIM and SIM-like programmes.
2022
In January 2022, the National Institute of Health and Care Excellence (NICE) published a draft of the updated clinical guidelines on self-harm, which for the first time included specific instruction to not use punitive or criminal justice approaches as an intervention for frequent self-harm [180].
In January 2022, Tim Kendall (National Clinical Director for Mental health, NHS England) gave an update about the review he had requested in May 2021 from Medical Directors across mental health trusts in England, stating: “We’ve reviewed returns from Mental Health Trusts which provide some assurances that all Trusts are aware of the concerns raised by @StopSIMMH campaign. We’ll be working with @StopSIMMH & other patients and professionals to seek consensus on principles of care for people who present to services frequently. NHSE/I will issue further guidance this Spring following this engagement. However, I'd like to be unequivocal now in my view that punitive approaches to people who self-harm, such as withholding care or threatening criminal sanctions, are entirely unacceptable and likely to be harmful. We do not know how commonplace these practices are, but we have seen patient and professional feedback that shows it occurs in some places. I was very pleased to see @NICE take this stance in its updated draft self harm guidance this week.” [181]
In April 2022, the Disability News Service reported that they had attempted to obtain the reviews of SIM programmes, which NHS England had requested all mental health trusts across England undertake in 2021. Despite multiple attempts to contact NHS England with a freedom of information request for the reviews, the emails were unlawfully ignored [182].
In September 2022, the Disability News Service reported that NHS England had finally released the reviews to them, which indicated that many mental health trusts had recognised that SIM was a flawed and inappropriate intervention, however many tried to justify their use of SIM. The article states: “One, in response to an NHSE question about whether the trust sought to “reduce use of care” through sanctions, appeared to accept that it had adopted a “conditional” approach to care, which “could be perceived” by service-users as “coercive”. Another review by a trust spoke of changing the name of its scheme “because the SIM branding is harmful to patient perception of the model and to the organisations involved”.[..] Another review admitted that, although police officers were not “specifically involved in the Mental Care of the patient… it could be said that at times there was a blurring of roles”.” The reviews made it clear that while some mental health trusts had abandoned SIM, many similar schemes were in operation across the country, under different names [183].
2023
#PoliticallyInconvenient: NHS England Withholds the Policy
The StopSIM Coalition worked with NHS England and the other stakeholders for 15 months on the policy regarding SIM and SIM-like programmes. The coalition described how the policy “clearly defines SIM through identifiable practices that must be eliminated from use. It also includes an acknowledgement from NHS England that their endorsement of SIM has caused harm to patients, an apology for this, and commitments to make changes to prevent this from happening again. It also includes a commitment from the Care Quality Commission to consider how trusts are implementing changes the policy sets out whilst carrying out its inspections.” [184]
The publication of the policy was repeatedly delayed, and on Friday 10th March 2023 (without consulting the StopSIM Coalition or other stakeholders) NHS England suddenly reversed their decision to publish the policy, publishing a short letter instead [185]. The StopSIM Coalition stated that despite strong support from many officials, NHS England’s Communications Office had refused to sign off on releasing the policy, describing it as “politically inconvenient”. Wessex AHSN (Paul Jennings’ biggest supporters, and the main organisation behind the roll out and implementation of SIM nationally) were described as a significant part of why the policy was not published, as they presented legal challenges to block its publication [186] .
There is currently an ongoing campaign, demanding NHS England release the policy. Numerous professionals and people working as Experts By Experience have pledged to withdraw from ongoing work with NHS England until they release the policy.
In a blog published by MedAct, the coalition stated: “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.” [187]
An open letter from professional allies of the StopSIM Coalition has been published, supporting calls for NHS England to release the policy. At the time of writing it has almost 150 signatories. To add your name, follow this link.
To finish, I would like to extend my solidarity and love to the StopSIM Coalition. NHS staff quickly and quietly rolled out an intervention across the country which they knew was unethical, and in some areas, unlawful. Many were aware it was based on erroneous and misleading data; many were aware that it had no evidence base; many were aware that it would be unacceptable to patients and their families. And yet, despite this, Trust after Trust established SIM teams, and staff celebrated each other for their apparent achievements, at fancy dinners and award ceremonies, plastering each other's gleeful faces and trophies all over social media. It took the unpaid, unacknowledged work of people with lived experience to expose this egregious injustice done to mental health patients across the country. By refusing to release the policy fully condemning SIM, NHS England have compounded their initial wrongdoing, and have shown the StopSIM Coalition, and all those treated under SIM programmes, the most incredible disrespect. I imagine they believe they can get away with it, that eventually the dust will settle and we will all go away and forget any of this ever happened.
They are wrong.
We're not going anywhere.
Wren
References [I had many SIM documents downloaded before their removal from the public domain. If you would like a copy of any of these documents please get in touch.]
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. Journal of Criminological Research, Policy and Practice. 2017;3(2):105–18.
Mental Health Network NHS Confederation and Association of Chief Police Officers. Mental health and policing: Improving crisis care. NHS Confederation Mental Health Network. London: 2015.
Dyer W, Steer M, Biddle P. Mental Health Street Triage. Policing. 2015;9(4):377–87.
Reveruzzi B, Pilling S. Street Triage: Report on the evaluation of nine pilot schemes in England. University College London. London; 2016.
Dyer W, Steer M, Biddle P. Mental Health Street Triage. Policing. 2015;9(4):377–87.
Reveruzzi B, Pilling S. Street Triage: Report on the evaluation of nine pilot schemes in England. University College London. London; 2016.
Jennings P, Haworth V, Dominey R. Developing a model of care to improve mental health crisis response. Nursing Times. 2017;113(10):27.
Jennings P, Haworth V. Specialist Support For High Intensity Mental Health Crisis: Developing a National Research Network. 2016.
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. Journal of Criminological Research, Policy and Practice. 2017;3(2):105–18.
Jennings P, Haworth V. Specialist Support For High Intensity Mental Health Crisis: Developing a National Research Network. 2016.
Jennings P. SIM: Serenity Integrated Mentoring. [Powerpoint]. Isle of Wight NHS Trust. Hampshire Constabulary; 2016.
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. Journal of Criminological Research, Policy and Practice. 2017;3(2):105–18.
Jennings P, Haworth V. Specialist Support For High Intensity Mental Health Crisis: Developing a National Research Network. 2016.
Jennings P, Haworth V, Dominey R. Developing a model of care to improve mental health crisis response. Nursing Times. 2017;113(10):27.
Jennings P. Untitled Presentation. [Powerpoint]. High Intensity Network; 2020.
Jennings P, Haworth V. SIM Business Case. High Intensity Network; 2018.
Jennings P. South London and Maudsley NHS Foundation Trust SIM Operational Delivery Guide. SIM London. South London and Maudsley NHS Foundation Trust; 2018.
Jennings P. SIM Project Pilot Report July 2013 - February 2015. 2018.
SIM London Support for a better life. April 2018-May 2020. Health Innovation Network South London; 2020.
Jennings, P. Suicide Prevention Day - A message from our National Director. [Internet] High Intensity Network. 2019. [cited 19 April 2021] Available at: www.highintensitynetwork.org/news/page-4/sort:News.date/direction:desc
Serenity Integrated Mentoring (SIM) and the High Intensity Network (HIN) - A freedom of information request to Devon Partnership NHS Trust [Internet]. WhatDoTheyKnow. 2022 [cited 2023Mar21]. Available from: https://www.whatdotheyknow.com/request/serenity_integrated_mentoring_si_16#incoming-1851730
Jennings P. SIM Project Pilot Report July 2013 - February 2015. 2018.
Temes C, Frankenburg F, Fitzmaurice G, Zanarini M. Deaths by Suicide and Other Causes Among Patients With Borderline Personality Disorder and Personality-Disordered Comparison Subjects Over 24 Years of Prospective Follow-Up. The Journal of Clinical Psychiatry. 2019;80(1).
Neeleman J. A continuum of premature death. Meta-analysis of competing mortality in the psychosocially vulnerable. International Journal of Epidemiology. 2001;30(1):154-162.
Jennings P. High Intensity Mental Health Crisis: a highly complex problem requiring new forms of training, clinical compassion and professional confidence.. Linkedin.com. 2018. Available from: https://www.linkedin.com/pulse/high-intensity-mental-health-crisis-highly-complex-problemjennings?trk=public_profile_article_view&s=09
Jennings P. SIM Project Pilot Report July 2013 - February 2015. 2018.
Jennings P. High Intensity Mental Health Crisis: a highly complex problem requiring new forms of training, clinical compassion and professional confidence. [Internet] Linkedin. 2018. [cited 19 April 2021] Available from: https://www.linkedin.com/pulse/high-intensity-mental-health-crisis-highly-complex-problemjennings?trk=public_profile_article_view&s=09
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. Journal of Criminological Research, Policy and Practice. 2017;3(2):105–18.
Integrated recovery programme 2013-2014 - A Freedom of Information request to University of Southampton [Internet]. WhatDoTheyKnow. 2021 [cited 2023Mar14]. Available from: https://www.whatdotheyknow.com/request/integrated_recovery_programme_20_23#incoming-1792367
Integrated recovery programme 2013-2014 - A Freedom of Information request to NHS Hampshire, Southampton and Isle of Wight Clinical Commissioning Group [Internet]. WhatDoTheyKnow. 2021 [cited 2023Mar14]. Available from: https://www.whatdotheyknow.com/request/integrated_recovery_programme_20_22#incoming-1797887
Integrated recovery programme 2013-2014 - A Freedom of Information request to Isle of Wight NHS Trust [Internet]. WhatDoTheyKnow. 2021 [cited 2023Mar14]. Available from: https://www.whatdotheyknow.com/request/integrated_recovery_programme_20_21#incoming-1813680
Integrated recovery programme 2013-2014 - A Freedom of Information request to Hampshire and Isle of Wight Constabulary [Internet]. WhatDoTheyKnow. 2021 [cited 2023Mar14]. Available from: https://www.whatdotheyknow.com/request/integrated_recovery_programme_20#comment-103632
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. Journal of Criminological Research, Policy and Practice. 2017;3(2):105–18.
Integrated recovery programme 2013-2014 - A Freedom of Information request to Hampshire and Isle of Wight Constabulary [Internet]. WhatDoTheyKnow. 2021 [cited 2023Mar14]. Available from: https://www.whatdotheyknow.com/request/integrated_recovery_programme_20#comment-103632
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. [Preprint]. 2017.
Integrated recovery programme 2013-2014 - A Freedom of Information request to Hampshire and Isle of Wight Constabulary [Internet]. WhatDoTheyKnow. 2021 [cited 2023Mar14]. Available from: https://www.whatdotheyknow.com/request/integrated_recovery_programme_20#comment-103632
Jennings P. SIM Project Pilot Report July 2013 - February 2015. 2018
Supporting mental health post COVID-19: Learnings from the NIA. NHS Innovation Accelerator; 2020 [cited 2023Mar15]. Available from: https://vimeo.com/459332160
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. [Preprint]. 2017.
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. Journal of Criminological Research, Policy and Practice. 2017;3(2):105–18.
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. [Preprint]. 2017.
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. Journal of Criminological Research, Policy and Practice. 2017;3(2):105–18.
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. [Preprint]. 2017.
Jennings P, Matheson-Monnet C. Multi-agency mentoring pilot intervention for high intensity service users of Emergency Public Services: The Isle of Wight integrated recovery programme. Journal of Criminological Research, Policy and Practice. 2017;3(2):105–18.
Trust in collaboration introduces a project aiming to help people with high intensive patterns of behaviour, eliminating the need for crisis calls and reducing hospital admissions [Internet]. HSJ Solutions. 2017 [cited 2023Mar16]. Available from: https://solutions.hsj.co.uk/story.aspx?storyCode=7016754&preview=1&hash=4353AA141EE278076B0BF0AC3EFEB33F
Integrated recovery programme 2013-2014 - A Freedom of Information request to Hampshire and Isle of Wight Constabulary [Internet]. WhatDoTheyKnow. 2021 [cited 2023Mar14]. Available from: https://www.whatdotheyknow.com/request/integrated_recovery_programme_20#comment-103632
Mannion R, Thompson C. Systematic biases in group decision-making: implications for patient safety. International Journal for Quality in Health Care. 2014;26(6):606-612.
Cleary M, Lees D, Sayers J. Leadership, Thought Diversity, and the Influence of Groupthink. Issues in Mental Health Nursing. 2019;40(8):731-733.
Jennings P. SIM Project Pilot Report July 2013 - February 2015. 2018.
Jennings P. SIM Project Pilot Report July 2013 - February 2015. 2018.
Jennings P. SIM Project Pilot Report July 2013 - February 2015. 2018.
Jennings P. South London and Maudsley NHS Foundation Trust SIM Operational Delivery Guide. SIM London. South London and Maudsley NHS Foundation Trust; 2018.
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Jennings P. SIM Project Pilot Report July 2013 - February 2015. 2018.
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DAY 1: Tuesday 21st March 2017 [Internet]. BIGSPD. 2017 [cited 2023Mar22]. Available from: https://bigspd.org.uk/wp-content/uploads/2018/09/programme_for_bigspd_annual_conference_2017.pdf
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Mental Health. [@Sectioned_]. (26 April 2021) The #HighIntensityNetwork website still includes the inaccurate claim that HIN/SIM is endorsed by Chief Constable Mark Collins in his role as. Twitter. [Tweet]. Available at: https://twitter.com/Sectioned_/status/1386643094372864001
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Mental Health. [@Sectioned_]. (6 May 2021) The #HighIntensityNetwork website prominently features Angela Lockhart as SIM "Project Manager - United States" > https://highintensitynetwork.org/contact Grand title! She's one of. Twitter. [Tweet]. Available at: https://mobile.twitter.com/Sectioned_/status/1390262016129085443
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NHS Accelerator. [@NHSAccelerator]. (29 June 2017) Inspiring @MHinnovator highlights @SIMintensive at #UHCWmedici evening and how it’s solving a £16m problem @nhsuhcw. Twitter. [Tweet] Available at: https://twitter.com/NHSAccelerator/status/880499149308907521
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Burroughs, A. [@Andy_Burroughs]. (27 Nov 2017) Paul Jennings of SIM singles out Health Innovation Network and Wessex as most supportive AHSNs at NIA Summit. Twitter. [Tweet] Available at: https://twitter.com/Andy_Burroughs/status/933349726476480512
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Pratap, B. [@BobbyPratapMH]. (24 Nov 2017) Love hearing @MHinnovator talk about work with ppl who use services most intensively. Id v highly recommend meeting these. Twitter. [Tweet]. Available at: https://twitter.com/BobbyPratapMH/status/934032877687377920
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Today we're highlighting one... - Metropolitan Police Service [Internet]. Facebook. 2018 [cited 2023Mar16]. Available from: https://www.facebook.com/metpoliceuk/posts/2006904792699816?__tn__=K-R
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