Making History, One Life at a Time

Simon Pickthall, Vanguard, Director LivesthroughFriends

Ten years ago, in a small conference room in a South Wales hospital, 12 people made history – although, as is often the case, they did not realise it at the time.

In April 2016, the Social Care and Wellbeing (Wales) Act enshrined in law the principle of understanding ‘what matters to citizens’.  This may not sound important.  But it completely transforms the practice of social care in Wales.

It would be too much to say that
the link between the two events was direct. But the meeting that day triggered a winding journey that began with discovery of a radically different method of working that forever altered their view of what social care could be.  The Vanguard Method has at its core the need to understand ‘what matters’ in the lives of people who receive services.   Part of it requires those delivering the service to ask those receiving it how it matches what matters to them.  When the group posed the question to those receiving social care, they found it was far different from what they were getting. What they wanted was simple – a system that listened to them rather than pass them from one professional to another.  They wanted help with things that were important to them, not standard packages of services picked off the shelf of the social care supermarket.

The things that people felt important in their lives were simple, too: meaningful and loving relationships; a sense of contributing to society, rather than being a burden and feeling in control of their own decisions.  These responses brought some to tears.  Those in need of social care wanted the same things we all do.

For the 12, comparing what their system delivered against what mattered to citizens receiving them was a shock.  The system gave them
all the impersonal processing they didn’t want and none of the basic human requirements that they did.  It dawned on them that, with the
best of intentions, they had created a system that removed people’s choice, made them dependent on statutory services and drove impersonal services into their homes.  Studying
the system revealed that repeat demand was very high – the services handed out were not treating the root causes of why people needed help.  Counterproductively, when money was short, the threshold for receiving even this help was raised, so that when people finally qualified for care, their condition had deteriorated and their cases were correspondingly more complex and difficult to treat.

Legislation got in the way

This powerful experience – the real force of the Vanguard Method – had
a profound and lasting effect on the 12.  Determined not to let the status quo endure, they led the redesign of their system explicitly to deliver what mattered to people in their local communities.  But they kept hitting against the obstacle of current social care legislation. The legislation forced practice
to be ‘deficit-based’ – focusing on people’s needs and weaknesses, rather than building on their strengths. In addition, the services people received were what had been commissioned by commissioners, not what mattered to them.

At this point the leaders could have accepted the legislation as it stood, doing their best to work around the current constraints.  Embracing their ambition, however, they resolved to bring ministers and civil servants into the work to experience what they had seen themselves.  Step by step their work, and that of others pursuing a similar journey, led to the fundamental change in thinking around how social care and health should be delivered that we see today: legislation that makes delivering social care and health according to ‘what matters’ a legal responsibility.  Transforming thinking to tackle and then alter legislation, the ultimate system condition – this is a staggering achievement.

The right thing to do?

As these responses show, there is no doubting what people receiving services think about the new approach:

• ‘The last social worker used to come once and then we’d never see them again.  It’s lovely to know you have somebody to contact’
• ‘In 20 years, you’re the first ones who’ve really listened to me’ 

• ‘It’s been helpful and efficient.  We feel happier that we’ve seen the same faces throughout.  You may not think you have done a lot, but you’ve really supported us’ 

• ‘He’s talking to me for the first time in years’ (a carer talking about her husband) 

• ‘We would have been in a terrible state without you.  I’m sure my husband would still be in hospital now’ 

• ‘If I had not known about this service, I would have admitted this person into hospital’ (GP) 


The effective thing to do?

But is it an effective use of resources? Through focusing ruthlessly on what matters to citizens, public-sector organisations in Wales have:

• More than halved the percentage of referrals leading to statutory funded packages of care, from 24.1% to 10.9% 

• Reduced residential and nursing care placements by 28% 

• Cut average domiciliary care packages from 12 hours to 9.7 hours a week 

• Reduced contacts into social services by 48% 

• Underspent community care budget for seven consecutive years 

• Reduced the number of assessments by 30%, and re- referrals from 46% to 10%

In other words, focusing on what matters is not only inexpensive: it provides better outcomes for less resource.  Not just more but better for less – who could be against it?

How to do it

Here is not the place to go into detail about how to do it.  But by now you get the picture.  You study the system.  You ask those whom you exist to serve ‘what matters’ to them; how they would like to live their lives?  Compare their answers with what your system currently delivers.  What would have to be true for you to be able to deliver the desired outcomes? 


The answer is both less and more than you think.  Consider the group meeting in the South Wales hospital.  It took a long weekend to challenge all their previous assumptions about social care in practice.  It took six days to understand what their system was delivering from the perspective of citizens and build a plan to transform it.  It took five years to make so much difference to people’s lives that legislation was changed to institutionalise a different way of thinking and working.  To change history.   So where to start?  Try 12 people in a room.