Thursday, 9 February 2017

No such thing as a free lunch? A review of a Review Check


by Carla Rosenthal, Participation Officer

and the PAVO Mental Health team

“No thank you, I do not want to spend six days doing a ‘Vanguard Method System Review Check’ that I know nothing about,” was the common response when I was tasked with the job of organising this event back in March 2016.

“But the results could be used to directly influence housing and mental health services in Powys!” I would counteract when confronted with such replies.

“Great! Tell me what I have to do and I’ll give up six days in my extremely busy working life to come along.”

“Uuuummmm, I’m not quite sure what happens but you have to turn up in Llandrindod, then go to either Welshpool or Brecon, do something there, then come back to Lland’od and it will all make sense.”

“Expenses paid.”
“Lunch provided - every day.”

Eventually, in November last year, individuals working in Third Sector mental health organisations came along to participate in the now legendary, Vanguard Method System Review Check. All I can say is, if you missed it, you missed a goody and despite no-one really knowing what it was all about to start with, by the end of the process, thinking had changed, systems had been unpicked, harrowing tales re-told and sceptical participants left feeling enlightened and in some cases, enriched.

In a nutshell, two teams of 4 - 6 individuals spoke to people we knew in and around Welshpool and Brecon about their experiences of emotional ill health. We examined their contacts with both statutory and voluntary services and found out what had been beneficial and empowering and what had been a waste of time or caused additional distress. The ongoing work was collected on lots and lots of large pieces of paper and got stuck on every available wall in the PAVO offices (white tack only!) then the findings from both teams were collated and clear and simple messages were pulled out.

It came as no surprise to discover that (amongst other things) people across Powys were frustrated by long waiting lists for psychological therapies and fed up with re-telling their story numerous times to a variety of professionals. However, it also became clear that the help, support and advice offered by the likes of MIND and Ponthafren was invaluable and in some cases, life saving.

The six day exercise meant that assumptions weren’t simply what we had heard over the years but provided definitive hard evidence to show service providers who may wish to look at where improvements could be made. The learning that Third Sector providers took away should ensure continuation of people-centred services and a commitment to delivering what matters to those who need it, being at the heart of their service provision - all done without having to spend any extra money.

Following on from the Review Check experience, I tend to question things more and find myself asking, “Why am I doing this? What is the point? Where is the benefit? Could this be done differently or more efficiently?” It’s not a bad way to approach things but sometimes, change needs to come about slowly and not everyone will query things in the same way. Maybe they need the opportunity to go on a Vanguard Method System Review Check . . . ? They might even get a free lunch.


NB: After submitting this blog post, Jackie pointed out that she still didn’t know exactly what the Review Check was all about, so in answer to her questions, please see below:

Why was the Review Check done in the first place?

Information given by Adrian Jones, Supported Housing Manager at Powys County Council:

“At its meeting on 6 January 2016, the Supporting People* Management Board decided to fund an intervention into the housing related support needed for people with mental health issues to live independently in the community with as high a quality of life as possible. The scope of the project was to cover North Powys and South Powys for any person of adult age with mental health issues. The costs of the project would cover the engagement of an external facilitator to use the Vanguard Method of Check and to cover the costs of involvement of staff and volunteers of third sector agencies specialising in mental health, none of whom are (currently) funded by Supporting People.”

* The Supporting People Programme provides the framework by which housing related support services are commissioned and funded within Wales.

Where did Housing fit into all this?

“Housing Related Support plays a key role in the system of early intervention and prevention, which is now being developed through locality-based response by the Council as part of its implementation of the terms of the Social Services and Well-being Act (Wales) 2014. From the point of view of Supporting People, the project was one of co-production to learn about the end-to-end experience of people with mental health issues when they ask for help and to establish a way of working to promote well-being in the lives of people and do the things that matter to people, as is now the requirement by law under the terms of the Act.”

What exactly is the Vanguard Method System Review Check?

Taken from Vanguard Consulting website:

In order to move organisations from a command and control to a systems thinking logic, Vanguard developed a version of Deming/Shewhart’s ‘Plan-Do-Check-Act’ cycle (Deming 1982 p88), with the emphasis on confronting managers starkly with the failings of the current system by starting at ‘Check’.

The first part of check provides a sound understanding of a system as it is and identifies waste and the causes of waste.

‘Check’ asks:

  • What, in reality, is the purpose of this system?
  • What is the nature of customer demand?
  • What is the system achieving?
  • How does the work flow?
  • What is value work and what is waste?
  • Why does the system behave like this?

Can you give some examples of some of the exercises you carried out.

Most of the time was spent talking to people who have had experience of the mental health system and use the services provided by statutory bodies and those provided by organisations such as Gwalia Housing Support, MIND groups or Ponthafren. We would ask them questions such as, “What matters to you? What does a good day look like? What would make your life better?” We then went on to map their flow through the system.

Give an example of something that was unpicked in a system currently used.

An example would be looking at someone’s journey from when they had first gone to see a GP about a mental health issue, to being referred to a psychiatrist for an assessment. Usually, drugs are prescribed and appropriate therapy might be offered. However, the waiting list for psychological therapies is unacceptably long.

What were some of the simple and clear messages that were revealed that we didn't know before?

Most things are common knowledge, but the evidence collected showed that people do not want to be passed from pillar to post, telling their story time and time again to others who take little or no notice. Waiting lists for talking therapies are off-putting, medication is often prescribed with no alternative offered and people want to be able to live their lives in the way they want to without being forced to conform to an unattainable ideal of ‘normal’.

What could change as a result of the Review Check?

One of the great things about this review check was the way that the third sector organisations got to grips with the process. We know that at least some of the groups involved are keen to have their own ‘check’ to make sure that they are really meeting people’s needs in the way that is best for those people.

It showed us how inter-linked everything is and how we can all support each other to make changes. It is certainly a challenge, but we know that at PAVO and in the wider third sector there is a lot of interest in working with statutory bodies to see how our learning can support this kind of thinking at a wider level in the mental health system. We are confident that there would be interest in this from the statutory services too, especially with the developing emphasis on prevention and early intervention. Everyone wants the system to work for people, the Vanguard Review Check process can show how very established systems can sometimes just keep doing what they just keep doing and that a fresh look can show where there are blockages and how to meet people’s needs more effectively, so that more people can be helped, often at lower cost too. 

What will happen now?

We will continue to support this process as an effective way of making changes that start with the people who use (or avoid) the services. Implementing change to deliver the right thing at the right time does need some careful consideration before real benefits can been made. It also needs everyone involved to be united towards the same goals and be willing to look at things with a fresh perspective.


  1. So the guy who ran the course got paid and out-of-pocket expenses such as petrol weren't available - for people with their own mental health expertise who might otherwise have volunteered. How can we get people more involved in shaping services with this sort of approach?

  2. Dear Anonymous - I'm glad you raised this as you are right and it is always good to have this stated explicitly - people should always have at the very least their expenses for taking part and we would always insist this was the case. In our blog this clearly hasn't come across properly. The email invitations to take part went out widely through our networks, which include directly to people who use services and to other organisations who publicise opportunities like this to people who use services and this invitation clearly stated that travel expenses were available.
    Thanks for reading the blog and taking the trouble to comment.
    Jane Cooke Senior Officer Mental Health Team

    1. I see, although it does seem that participation could be more effective if there was a way of either paying people to take part (based on the value of their lived experience), or at least organising things around the individuals who suffer from distress. For example, six days at 9-5 is a large commitment, and however well done the process was I'm sure they could have had more people who have contact with services involved.
      Often people can be presented with a situation where they are the only unsalaried person in a meeting room - not that it's particularly relevant to this post, which was interesting, but it's such a shame and results in so few participants. Can't the local MP siphon off a few expenses for local citizens to do a few good deeds?

    2. Dear Anon
      With regard to your suggestion that our Powys MP’s siphon off some expenses, I can’t, of course, possibly comment!
      I agree that the time commitment for the Vanguard check is intense. The up-side is that this process generates a level of energy and total connection with the issues and services under review. We did have a group of people who wanted to contribute but who didn’t want to commit to that time scale, and we called upon these people for their views and experiences.
      I agree with your views that people should be paid for their time and expertise especially when they are involved in more formal arenas. Occasionally we have managed to do this to some extent when we have been approached by an outside agency to recruit people who use services for a short term bit of work, we have been successful in negotiating more than expenses. It is only occasionally however. With these short term pieces of work that are more focussed on one topic, I think that there are a lot of non-monetary rewards, it can be a great boost to confidence and can re-connect people with skills and qualities they had lost faith in, or learn new skills, make new contacts and feel very good about the contribution they are making
      In the more formal settings some of this can also be true but there are also potentially a lot more challenges, such as the amount of work involved, the style and purpose of the meetings/Boards, and not least the purpose of being a representative in these settings which can be at times be to express challenges and criticisms of existing services.
      Coincidently we have recently learnt that there is to be a training session in London on 27th March looking at the issue of paying people for their time and expertise. We will be offering the opportunity for two of the reps that we work with to attend this conference. Meanwhile we will be putting some thought into the best way of taking this forward.
      Thank you for your thoughtful and thought provoking contribution.
      Anybody wanting to be a ‘Rep’ or volunteer with the Patient’s Council or have their say at one of the Stand Up! Meetings please do get in touch with us.

    3. Thanks Jane - and I really do agree about the non-monetary rewards of getting involved with things. People doing things because they believe they're important is a solid starting point. People being valued for their lived expertise is a work in progress. The training sounds great too.