This case study features in the NHS Innovation Accelerator’s year three research report, Understanding how and why the NHS adopts innovation.
Serenity Integrated Mentoring (SIM) is a model of care using specialist police officers within community mental health services. It works to support people who access mental health services who are struggling with complex behavioural disorders and often request emergency services whilst making limited clinical progress. Together, they co-produce crisis response plans to help the person find alternative ways of dealing with their crises that reduces risk, impact, harm and intensity.
It is common for police to use Section 136 of the Mental Health Act to take people to a safe place and where Approved Mental Health Professionals will assess whether the person can be discharged or requires further detention under the Mental Health Act. The result is often a ‘revolving door’ with patients moving in and out of police custody and mental health wards.
SIM was developed by NHS Innovation Accelerator (NIA) Fellow, Paul Jennings. In October 2012 Paul co-led ‘Operation Serenity’, one of the UK’s first Street Triage response teams, where a police officer and mental health nurse co-respond to crisis calls in the same vehicle. Paul quickly learnt that whilst Street Triage was enabling more accurate clinical decisions to be made at the scene of the crisis, the project was not stopping a small number of service users from requesting emergency care. He realised that these more emotionally intensive patients needed a different model of care because mental health clinicians did not have all the skills or tools required to reduce these high-risk behaviours alone.
SIM combines the best clinical care with compassionate but consistent behavioural boundary setting to reduce harm, promote healthier futures and reduce repetitive patterns of crisis from impact on 999 and other emergency care teams and avoid Section 136 detention.
In 2017 following discussions between the Lead for Complex Cases in Surrey and Borders Partnership NHS Foundation Trust and the Surrey Police Lead for Mental Health on how to deal with high intensity users in the county, the Surrey Police Lead visited the Isle of Wight to look at the SIM approach.
Both the Trust and Surrey Police were impressed by the results achieved on the Isle of Wight. Each secured a small amount of funding from their respective organisations and, with the help of the NIA Fellow, set up a limited trial in one area of Surrey.
The initial trial funded a police officer to liaise with the community mental health teams who were responsible for specific high intensity users. An overseeing committee was formed, chaired by the Lead from Surrey and Borders Partnership, with representatives from across the mental health trust, the police force and other emergency services, which meets monthly.
In order to recruit high intensity users and to develop and use the care plans, a considerable programme of joint work between the police and mental health trust had to be undertaken. This included:
- Specification of criteria for joining the programme, including the design of a referral form
- The design of the care and response plans (to be easy to use under crisis conditions)
- Inclusion of care and response plans in all relevant information systems and an agreement to share information
- An educational programme to reach all operational police officers and members of emergency services to explain how they should use the care plans
- Management procedures for the monthly meeting of the multi-agency stakeholders
The trial demonstrated a decrease in the use of Section 136 and therefore a reduction in the use of mental health and police resources.
Roll out across Surrey
The trial evidence of resource savings meant that Surrey and Borders Partnership NHS Foundation Trust and the Surrey Police were able to make the case to secure additional funding for a further year (April 2018 to March 2019). The police team was increased to one full-time and two part-time police officers and Mental Health Trust funding enabled coverage to extend to all 13 Community Mental Health Recovery Service teams across Surrey and North East Hampshire.
Rather than replicate SIM in its entirety and insist that every team adopt the SIM name, the NIA Fellow works to ensure that the eight core components of SIM are replicated, enabling local teams to develop both their own project identity and wider project design. SIM in Surrey therefore became SHIPP – Surrey High Intensity Partnership Programme – reflecting the contrasting context of Surrey with the Isle of Wight.
Currently, funding for the intervention is still time-limited in both partners. The Leads in both partners are now creating cases, for the third time, to get future funding for SHIPP.
There is wide support for the programme but in both organisations the request is for hard evidence of benefits and in particular cost savings. Staff are now systematically gathering data about each crisis and have sought help to use the data to make a strong economic case for the resource savings that are being achieved.
Multiple champions: Interviewees were agreed that the reason SHIPP has become embedded so quickly is that it has had a strong, passionate and stable team with members from both organisations driving it from the beginning. The two Leads had the vision and the contacts, and the Isle of Wight trial provided the evidence to get backing for the initial pilot. The first dedicated police officer and the mental health staff had the energy and drive to push for operational action, to spread the word in the police force, and a neighbourhood sergeant became the uniformed ‘ambassador’ for the programme.
Evidence of impact: In addition to the reduction in Section 136s, there have also been emergent outcomes and case studies of people becoming more stable. This has given the approach credibility and helped to cement the reputation of the programme.
Effective engagement: Adopting the model was expected to be challenging in a county like Surrey with a wide geography and complex organisational landscape. The answer according to the Mental Health Lead has been a relentless and continuing focus on communication: reaching everybody involved with the message of SHIPP and the part they needed to play if it was to be successful.
Supporting cultural change: For the police, following a care plan is unknown, and can be perceived as high risk. A fundamental aim in the police force is to reduce risk to the public, whilst mental health professionals know risks in treatment may be needed if people are to find a route to recovery. In addition, 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.
In August 2018 there were 16 people on the SHIPP programme who had signed up to a set of behaviours that would avoid emergency service call out. By this date there had been significant achievements:
- Several people had left the programme because they were no longer high intensity service users
- Interviewees were agreed that the programme was succeeding by helping users manage their lives more effectively
- Significant reduction in the number of Section 136s and the savings of resources more than outweighed the cost of the service for both the mental health trust and the police force
- Over and above the specific gains there has been a steady build up of trust and understanding between the partners and reportedly, more understanding of mental health issues in the police force
SHIPP is not only making better use of mental health and police resources but is changing the lives of some highly vulnerable people. Demand for the service is growing: there is a backlog of referrals and the mental health trust staff in particular would like the programme to accept referrals for people at risk of becoming high intensity users.
There is now a national plan to roll out SIM as well as a clinical network to connect all the SIM based teams across the UK (www.highintensitynetwork.org). The AHSNs are supporting this process as part a two-year national programme. 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. Many sites considering the adoption of SIM are seeking the advice of Surrey about the practical implications. The staff of both Surrey and Borders Partnership and the Surrey Police emphasise that every area has to adapt SIM to fit within the local context.
In addition to the national drive to introduce SIM, there is also a ground-level driving force spreading it. High intensity users quite often require the attention of emergency services beyond the geographical boundaries of their local police and NHS Trust. The services supporting people from Surrey are requesting the care plans of these individuals, and gradually people are finding that wherever they go they receive the same treatment. The High Intensity Network is now working to develop a single, digital platform across the police, ambulance and mental health networks so that high intensity response plans can be found quickly.
Example of cultural change in action
In 2017, Surrey response officers responded to someone who had just started to engage with SHIPP. These officers had begun to trust response plans for the first time as well as the SHIPP team who had briefed them to do so. They had started to understand that over-reactive decisions, made in fear, did not help the patient but actually gave the message that high-risk behaviours would be ‘positively reinforced’ by 999 teams (meaning that it would encourage the patient to repeat the high-risk behaviour). The officers followed her SHIPP response plan and did not detain the person under the Mental Health Act. A short time later she intentionally overdosed after the police had left the scene and was admitted to A&E. The case was automatically referred to the Independent Office for Police Conduct (IOPC) as required in law. Having reviewed the case, the IOPC advised that the officers in question had no case to answer because they followed due procedure according to the clinically endorsed care plan. This conclusion has helped allay officers’ concerns about following care plans. Surrey as a force are now moving quickly to be institutionally confident that response plans co-written with a mental health clinician and the patient are the safest processes to follow and that they promote risk reduction and recovery more effectively than previous types of crisis care protocols.
1. Julia Davis, Police Sergeant, SHIPP Team, Surrey Police
2. Paul Jennings, National Programme Manager – High Intensity Network, NHS England, NIA Fellow
3. Gemma Jones, Approved Mental Health Professional Surrey County Council, Surrey and Borders Partnership NHS Foundation Trust
4. Ian Manners, Neighbourhood Police Sergeant, Surrey Police
5. Amy McLeod, Former Mental Health Lead, Surrey Police (now with Surrey County Council)
6. Lee Sawkins, Current Mental Health Lead, Surrey Police
7. Sarah Swan, Consultant Clinical Psychologist, Surrey and Borders Partnership NHS Foundation Trust
8. Mel Tomlinson, Consultant Nurse for Complex Cases, Surrey and Borders Partnership NHS Foundation Trust