RCPsych calls for urgent and transparent investigation into NHS Innovation Accelerator and AHSN following HIN suspension

Statement / comment
14 June 2021

2021 marks the 60th Anniversary of the Suicide Act (England and Wales) 1961 and the 55th Anniversary of the Criminal Justice Act (Northern Ireland) 1966, which decriminalised suicide and suicide attempts across the UK. Before this, people who attempted suicide could be prosecuted and imprisoned. This was a big step forward in recognising that suicide attempts should be responded to with compassion, care and support rather than punishment.

In recent years, an increase in mental health need and pressures on NHS mental health services has resulted in increasing demand on emergency services, including call-outs to the police. Members and fellows of RCPsych, along with service users and carers have expressed concern about this, and about an apparent increase in the use of criminal sanctions – such as prosecution, anti-social behaviour orders and criminal behaviour orders – for alleged offences related to suicidality and suicide attempts, such as wasting police time or public nuisance offences.

Within this climate, a scheme of mental health and police collaboration was developed in England called Serenity Integrated Mentoring (SIM). This involves twice weekly visits by an allocated police officer ‘mentor’ to patients who have previously had police involvement in at least two mental health emergencies. Where people remained unwell and continued to self-harm, attempt suicide or report suicidality, in some cases they were prosecuted and imprisoned or community protection notices were applied which required them to stop self-harming or calling for help, with imprisonment as a potential sanction if they breached the notice.

Earlier this year, the StopSIM Coalition highlighted concerns about the approach of the SIM model, which include the lack of consent, the low threshold for police involvement and criminal sanctions, limited safeguards about sharing of clinical information, and lack of co-production. Evaluation of the model was limited to the impact on service demand, without considering clinical benefit, and there were apparent irregularities about research integrity and consequent roll-out across England.

The College shares these concerns and has also considered concerns about the professional duties of psychiatrists and human rights considerations. It is important to acknowledge that these concerns do not only relate to extreme or highly complex cases. Eligibility for SIM and similar criminal justice interventions is set at a low bar, and there is a risk that this can lead to diversion from established, evidence-based approaches to clinical treatment of mental illnesses.

We welcome statements from Tim Kendall and Claire Murdoch asking NHS mental health trusts to review their use of SIM approaches and how they scrutinised its evidence base as advised by the NHS Innovation Accelerator. We urge them to take steps to ensure that reviews are conducted swiftly, uniformly and the results are published so that lessons can be learned across the system. 

SIM approaches are based on a model developed by a private company, the High Intensity Network (HIN) which was piloted in the Isle of Wight from 2013. The College is extremely concerned about emails released by Hampshire Police saying that the data used to show the efficacy of the HIN trial was misrepresented and used in a way that was “not ethical” and that as a result, they discontinued its use in 2017. We note that in subsequent media reports, the owner of HIN has denied this.

The College has been told by a spokesman for Hampshire Police that their mental health lead made staff at the Wessex Academic Health Science Network (AHSN) aware of concerns with the Isle of Wight trial evaluation, and what they saw as a misrepresentation of the data by the original developer of the SIM model, which was “not ethical”. Nevertheless, the Wessex AHSN supported the spread and adoption of SIM across the country throughout 2018 -20, in line with NHS England’s commissioning of the AHSN Network and its programme in 2018.  

We urge NHSE/I to launch a separate investigation into the AHSN response to the concerns raised by Hampshire Police and if the evidence base originally put forward by HIN was interrogated by the NHS Innovation Accelerator. The findings should be made public to ensure any lessons are learned. 

We understand that HIN is in the process of shutting down. Many trusts continue to operate their own versions of the SIM model and it is critical that consideration is given to ensuring these patients continue to get the best care as this process runs its course.  

We would like to take this opportunity to thank all those involved in the StopSIM Coalition and other individuals, including our members and fellows, who have expressed concerns, for uncovering this issue. We acknowledge that it has been patients subject to these approaches who have had to do the work of identifying concerns. There will be some difficult learning here; any review must examine why professional frameworks did not identify or act on these concerns.

The questions raised by the HIN and SIM approaches are just one aspect of a highly difficult area related to the interface between policing and mental health, including how to best respond to mental health emergencies and care models for preventing mental health crises. Criminal justice responses to suicide attempts and self-harm have a long history. The enactment of the Suicide Act (England and Wales) 1961 and the Criminal Justice Act (Northern Ireland) 1966 clearly moved the response into the health care domain. We wish to reaffirm that psychiatrists must make the care of our patients our first concern, and consider the fundamental ethical principles of fairness, respect, equality, dignity and autonomy in all we do. Where interventions have a risk of harm, it is important that we only recommend these where there is clear evidence of benefit.

Across the UK, while mental health teams and emergency services are working hard to provide the best care that they can, things do sometimes go wrong. There are many examples of good quality services and it is important that we learn from these, as well as learn from approaches where patients have been harmed. We believe that a wider examination is needed to identify good practice and agree on common approaches which are properly resourced so that all patients, wherever they are, have access to well governed evidence-based services that respect their dignity and manage their distress.