96 Developing Services for Older People and their Families Oldman, C. (1990) Moving m Old Age. New Directions in Housing Policies. London UMSO. Office of Population Censuses and Surveys (OPCS) (1994) People Aged 65 and Over London: HMSCX Rawsun, D. (l99fl) Coinwcrcmf Enterprises ami Slieltmd Homing. Oxford: Anchor I lousing Association. Rolfe, S., Leather, P. and Mackintosh, S. (1993) Available Options. Oxford: Anchor Housing Trust. Salmon, C. (1993) Caring Eniironmentsfor Frail Elderly People. Harlow: Longman Sixsmith, A. and Sixsmilh, J. (1991) 'Transitions in home experience in later life.' Journal of Architectural and Planning Research S, 3,181-191. Simmons, M. (1994) 'Old folks quite at home.' The Guardian, 30 November Slavid, R (1994) 'An innovative approach to care.' Architects journal. 27 July Social Housing (1993}' /inchor'sSilver (ubilee brings new approach to elderly care' Social Housing 15,6, 9. Tindale, P, (1992) Towards 2000: Designing Housing far Fruit Elderly) People. Oxford: Anchor Housing Trust Tinker, A. (1994) 'The role of housing policies; in the care of elderly people.' In OECD Caringfnr Trail Elderly Peojtle: New Directions in Care. Pans: OECD. Valilis, M. (19&8) Housing for Elderly I'Mjik. London: Architectural Press. Wertheimer, A. (1993) tnnovai'nx Older People's Housing Projects. London NFHA, Zarb, G. (1991) 'Creating a supportive environment; meeting the need* ot people who are ageing with a disability' In M. Oliver (ed) Research Highlights in Social WorkU, Social Work-1 hr.abh:d faivlc and Disabling Environments. London: Jessica Kingsley Publishers Chapter 6 1 Was Given Options Not Choices7 Involving Older Users and Carers in Assessment and Care Planning Fiona Myers and Charlotte MacDonald This chapter explores tlie reality for service users and their family carers of their involvement in care planning and the extent of the opportunities to exercise choice in how their needs are met. Central to the rhetoric of community care is the principle of greater user and carer involvement. As articulated in the White Paper 'Caring for People (Department of Health 1989), and in subsequent official guidance, Ihe objective is to give users and carers 'a greater individual say inhow they live their lives and the services they need to help them to do so' (Department of Health, 1989). Nonetheless, thereiswhat could bo called a 'hesitancy' apparent in policy statements. While seeking to redress the balance of power there is, at the same time, a recognition lh.lt this shift is not absolute Unlike consumers of other services, for Umts and carers, ultimately it is 'the assessing practitioner who is rtiponsiblc for defining the user's needs' (SSI/SWSG 1991, p.53). I'm liter, the involvement of users and carers in the decision making xess is not the same as handing over decision making authority or It resources to act on those decisions. a number of commentators have noted, there is a potential Hmdiction between a policy which seeks to promote consumer 4« and participation while also seeking to ration and prioritise lUrvos (Allen, Hogg and Peace 1992, Ellis 1993, Caldock 1994). Lloyd •1), who analyses this tension in terms of competing 'liberal' and KMViuive' discourses, suggests there is an incompatibility between Hptn up' approach emphasising the individual's role in defining i^ftiivn in1* ds, selecting and controlling the delivery of services and, i Inn ii.-. r>; nble to seek redress, with □ 'top down' approach 98 Developing Services ftr Older People and their Families whore 'management' assesses need and allocates scarce and rationed resourcm. This tension at the heart of community care policy is not of abstract political or philosophical interest, but makes itself felt at the grassroots level of policy implementation For frontline workers it can mean, as North (19(J3} suggests, having to act both as 'neutral advisers' and as 'gatekeepers' to scarce resources. For people seeking support, even if encouraged to participate, the opportunities to act as empowered consumers may be constrained by the limited range of options from which to choose. Allen e! at (1992) found from their study in England, completed immediately prior to the introduction of the new community care procedures, that older people tended to have no choice over what went into their package and that participation was limited to agreeing with what was offered Given the contradictory nature of the policy, the question this raises is whether, from the accounts of service users and carers, any progress has been made in shifting the balance of power. From Interviews undertaken following the implementation of community care, this chapter explores some of the implications of this tension for older service users and informal carers. The study The data on which this chapter draws comprise part of a larger Scottish Office funded study being undertaken in four regions in Scotland by the Social Work Research Centre at the University of Stirling. In the course of the study data from a number of different sources are being collected. First, the completion by workers of case monitoring forms for people referred for comprehensive assessment, both at the time of assessment and after a period of nine months (or on case closure), provides information on the social circumstances, identified needs and services provided to 247 people, of whom 144 (58%) are aged over f>5 years. Second, interviews with 65 social work department practitioner; explored their perspective on the introduction of community can-policies and procedures (MacDonald and Myersl995). Third, users ami carers identified through the case monitoring forms, were interviews I about the assessment and caTe planning process. Follow-up interview, are currently in progress aiming to explore their experience of thi implementation of care packages. '1 Was Ctven Options Sot Choices' 99 The main focus of this chapter will be the responses of the older users and their informal carers, ^>ut to set the context it may be useful just to briefly sketch a picture of the practitioners. The practitioners Although all the workers in the sample were employed by Social Work Departments, they did not all come from a social work background. Included in the sample were people from nursing, occupational therapy and home care backgrounds, as well as one health visitor and one community alarm organiser. A number of the practitioners had specialist expertise in working with older people. In one region, for example, die worker had been an elderly specialist social worker, another had been a social worker attached to a social work team for older people, but these were in some respects atypical. The majority had previously worked as generic workers, or as specialists in learning disabilities or child care. As a result they were not necessarily experienced in the needs of older people With the exception of concerns around recognising dementia and the legal implications, this lack of experience was not, however, reflected in their demands for further training In terms of their attitudes toward involving users and carers in the process, the majority of practitioners expressed support for greater Consumer participation. However, what also became apparent from llii'ir comments were the obstacles to realising this goal. Some of these stemmed from the structural constraints within which workers were having to operate, in particular the prc-determined eligibility criteria Ami the limited options from which to offer people choices. Aspects of practice could also, unwittingly, serve to undermine the involvement Kflf users and carers. For example, workers differed among themselves ; to tin- degree to which they let users and rarer* see, sign jnd retain ■Dies of assessment of needs forms and care plans. Third, workers Hlggfstitl barriers which stemmed from the users and carers them-Mtvcs, not just arnimunicarion difficulties, but also difficulties of com-Vtheiision on the part of a confused user or someone with dementia, kill ii >ii.illy, workers perceived what they felt was a reluctance on the ft ul some users to take up the mantle of the infoimed consumer. Wr people in particular were felt to be particularly uncomfortable h Hie proffered gift of participation. One worker commented, 100 Developing Services for Older People and their Families T;or a lol of the older people/ part of their need is for someone to do it for them, and not to have the hassle of finding a place for respite or pl\oning round for care services ' Other studies suggest that this reliance may be due not to age per se, but to the sense of powerlessness on the part of users and carers, and a desire for a knowledgeable and assertive advocate to act on their behalf (Robertson 1993). Meethan and Thomson (1993) also found a tendency for users and carers not only to defer, but to seek to hand over power. This apparent handing over of power may be a positive choice in the way that a 'client' would employ a lawyer or other technical specialist to act as broker, but it may also be an acknowledgement of the asymmetrical power relationships within the welfare market. Workers not only have the knowledge of the market, and the skills to circumnavigate its complexities, but are also keyholders in their own right. As such, users and carers, although encouraged to be partners, may not experience it as a partnership founded on equality. Users and carer* The users and carers were identified from the case monitoring forms. Workers were asked tn approach all the people included in the main study to ask if they were willing to be interviewed. Inevitably with this approach workers will tend to sift out people who they feel would be unable to participate, perhaps because of a communication problem or dementia People with whom the worker had no further contact or those with whom the worker had a difficult relationship might also be excluded. Identifying an appropriate informal carer may also not be without its problems, as was found in relation to one younger client where the identified 'carer' proved not to be the person caring foT tin-client in the sense of providing physical and personal care. This loss of control over the selection process was, though, balanced by the preservation of the privacy and confidentiality of those users and carers who did not wish to be approached, A total o( 52 users were interviewed, 31 (60%) of whom were aged over 65 years. Of these, over three-quarters were women. Interviews were undertaken with 36 informal carers, 19 of whom were supporting someone aged over 65 years. Among the carers of older people, four were male and 13 female, the remaining two J carers' were in fact married couples. In three catU 7 Was Given Options Not Choices' 10? the carer was the husband of the service user, one was the son and one was a sister. The largest group were daughters caring for a parent, comprising 12 of the sample of carers of older people-In 10 cases the carer only was interviewed because the older person was felt to be unable to participate. In 21 cases the user only was interviewed, and in 9 cases both user and carer were interviewed. Where carers were interviewed it was to obtain their views as carers, not as proxies speaking on behalf of the user. Where an interview took place with a user and/or a carer, three quarters of the older service users were living in the community, the remainder were in residential care. Involving users and carers Terms like 'involvement', 'participation', 'choice' can mean different things to different people. A worker's idea of involving a user may, from the user's point of view, amount to being informed of a decision made elsewhere. In order to conceptualise 'involvement' a number of commentators have drawn the analogy of a ladder (Arnstein 1969, Taylor et al. 1992). Although the descriptions of the different intermediary stepson the'ladder' may vary, essentially they describe the same process of movement from a low level of participation in which decisions are imposed on an individual with little or no discussion of whether, how, where and when support will be made available, through to a high point of service user autonomy in decision-ma king nml resource allocation. In the context of assessment and care planning, what is at issue is tin- degree of power or control the user and carer have over the process ■ltd its outcomes Focusing specifically on access to assessment, infor-nintion sharing and decision making, the aim here is to begin to explore Mil i i< vive of control and autonomy this sample of older service users ■nil their informal carers appear to be able to exercise over the process Tin* findings, at this intermediate stage of the project can only be ttntolivc rather than conclusive: raising questions rather than provid- ' . i<■.M■■ into r.v system Wf\ nil Ihe service users specifically sought help themselves, or knew Hm" hud made the referral. Of the 31 service users interviewed only H^B liAd referred themselves to the social work department. Of the W2 Developing Services for Older People and their FamiHcs nder, fourteen were unsure who had initially made the referral on their behalf Carers, on the other hand, appeared to be more proactive with eight of the 19 referring themselves and only two nut being aware of the source of the referral. What is perhaps more important is their understanding of why the worker contacted them. Among the sample of users most saw the worker's role in terms of seeing what help they needed. Many identified a change in their own circumstances as triggering the worker's involvement: a substantial number of the users had had falls which had landed them in hospital. But other users cited a gradual deterioration in their ability to cope, or a change in their home circumstances. In several cases these older users were themselves 'carers', and as a result ot their own ill-health were less able to provide care, There were also users who recognised that the reasons for the worker's involvement stemmed from their informal carer's inability to continue caring One, for example, described how the workeT came to see her about her going into a home because; 'My daughter did not want me in her home...she works most days.. .(she's] unable to cope with me and her family problems.' Finally, there were among the service users a few who remained bemused about the worker's involvement. For example, one user who was in a long stay hospital at the time of the interview could not recall the worker being involved at all, and denied that she needed any help. Another service user was unsure who had involved the worker and the reason for the visit: 'I was alright, don't know why she came f think it was just for a chat.' The carer in this instance referred to her mother's gradual deterioration and the fact that'you had to go through social work before there would k" iiny pkiO'inen^ 1m care'. As this example suggests, some carers had very specific ideas as to why a worker became involved, referring to what they perceived as tin-user's need for residential or nursing home care. Others cited specilii types of help they felt they required to assist them to carry on caring. One carer, for example, who made the referral herself, was looking fot respite from caring horn a demanding parent. Another needed care In be provided while she went into hospital to have an operation. In .1 '] Was Given Options Not Choices' 103 number of cases the request for assistance amounted almost to a cri de cot'tir, where a carer felt they could no longer cope with caring A recent study describes how much fear can be a motivating force for users and carers (Department of Health 1994), while Meethan and Thomson (1993) describe the relief felt by users and carers on entering into the Scarcroft project. What perhaps should not be overlooked is the possibility that a process which is often set in train at a point of crisis, or when a user or carer is feeling at the end of their tether, or 'like a useless article', may in itself underrrune people's sense of their own autonomy, or control over their own destiny. Exdumgirtg information Given th.il users and carers are often, as the seekers of assistance, placed in a dependent position, the onus is much more on the worker to redress this imbalance, both through listening and responding to users' and carers' expressed needs and by providing information. In Allen el tti.'s study (1992), just over one halí of the older people felt they had had enough discussion about what support and services would be most helpful to them. In the current study users, in general, felt that the worker was listening to them and gave them as much rime as they needed, as one remarked: 'He let me know he had plenty of time to listen, .he was very easy to talk to...I think I discussed all my needs and fears ..he's a good listener.' It could be argued that the apparently high level of satisfaction with workers as people willing to spend time and listen, reflects what Wilson (1993) describes as the public account or socially accepted version. Which may be at odds with the private account. However, the responses wrie not just what Wilson would perhaps describe as 'neutral' polite fcttments such as 'he's very nice', but quite fulsome praise One user, fltr example, described the worker as: 'Very kind and helpful, I call her a friend.. .she has been a brilliant hel |i to me.. 1 think very highly of her.' ......11. I he 1 i-spondents, critical comments tended to come not from WKK* Inn from carers, and tended to be rases where the carer was 1 ■ 1 !!>>■. 11 1 -iTTi,ii or nursing home care. In several cases they felt that ■< ■ 1 I ad listened to them and been prepared to spend time with 104 Developing Services fur Older People and their Families them, but appeared to be slow to get things moving. In other instances the carers iclt the workers involved were too slow to understand the pressure that they, as carer?, were under. A number of carers felt constrained Írom expressing their concerns because the service user was present when the worker came to do the assessment. What this illustrates is the potential tension between users and carers, and their conflicting perceptions of whose needs the worker .should be addressing. This emerged most poignantly in one case where the user wanted to stay living with her daughter but the daughter was seeking a residential placement for her mother. In this case tl*e user felt the worker understood the situation between her and her daughter, but nonetheless 'tried to get me to go to a home. I do not want to go there'. The daughter, for her part, felt that the worker 'would have liked my mother to stay here and have...some day care' In instances such as these, the worker's role may be that of an arbitrator seeking a compromise solution, rather than the desired solution of either party. Although the users interviewed indicated that they felt that the worker listened to what they had to say, the comments of the workers suggest that not all users were given a voice. This was found in relation to people with dementia who, although able to express an opinion, were not felt able to make an informed judgement. One worker remarked: 'With dementia they don't know what they want and they don't know what's best for them.' In cases such as these the voice of the carer may not only serve to speak for the user, but also be the loudest in the derision-making process. This it. despite, as some workers recognised, the possibility that carers have their own 'agendas'. For users without informal carers the decisionmaking responsibdity may rest solely with the professional. As r'isher (1990) comments, for people deemed unable to make reasoned decisions, 'concepts of choice and participation are nearly meaningless'. The other side of the coin to being listened to is being Informed Allen et af. (1992) found that substantia] numbers of both users and carers felt ill-informed about the range of services available. Worker, in the current study certainly recognised the importance of enabling people to make informed choices Nonetheless, the comments of 11 »■ -users and carers interviewed suggests that there is a fine line between being 'informed' and being told. In other words, the redistribution ol 7 Was Given Options Not Ounces' 105 knowledge which would enable the user and/or carer to make these informed choices, mav only be partial One carer, for example, remarked: 'I was given options, not choices I was told what was available/ while a user explained: 'She lold me what 1 was going to get and 1 told her what 1 didn't want' Given that knowledge is power, this dependence on the worker can mean that at the point of decision making users and carers are again unequal partners in the negotiation process. Decision nuking Users and carers may feel that they are listened to, but when it comes to having what they say acted upon where does the derision making power lie? Which voice carries the greatest weight and what are the decisions to be made? The responses suggest that the degree of influence over decisions, if not the power to make them, mav be unevenly distributed between users, carers and others. In some cases a medical decision to admit someone to hospital effectively removes the choice of social can options (at least in the short term). Second, as suggested above, there were Instances cited by the workers interviewed where the expressed views of the user might be nvcmdden because they were not believed to be I based on an informed judgement. In cases where a user continued to recalcitrant', several workers suggested they might consider I Invoking the law to ensure compliance. Third, there were cases, evident Btnoiig the sample of users interviewed, where residential care was Btlng proposed but the users themselves felt the decision was efiec-^^■Ly out of their hands. One user, for example, felt that she had no The doctor in the hospital told me I would not manage at home 11 had no choice other than to come into this home.' Hirlh, in cases where user and carer disagree, the importance, to a urker, of supporting the carer to continue in their caring role may ill 11 ii' balance of power toward the carers preferences, particulars In rv is a potential or actual threat of withdrawal of care. 106 Dewluping Services fur Older People and Star Families Certainly, several users interviewed felt under pressure to accept residential care because of their informal carer's needs. The comments of some of the carers, however, suggest that they did not always feel thai they had any influence. One carer who expected the worker would be instrumental in arranging for her mother to be admitted to residential care- appeared resigned to her mother's resistance: As my mother is not that far gone it is up to her to make her own choice as to what she wants. I agreed. In the end it is nothing to do with me ' Fifth, of course, is the influence of the worker themselves, Workers are not only advocates and advisers, but also gatekeepers to resources. If a user's or carer's expressed need docs not meet local eligibility criteria or agree with the professional's assessment, then professional definitions may prevail. For example, one user interviewed described how he had wanted to move to sheltered housing, but 'the social worker said I was better off where I was'. Different participants to the process may, therefore, have different degrees of influence over the outcome. But what of the decisions themselves' Users and carers may feel they are a given a good hearing by the worker, but while receptivity to users' and carers' accounts is a necessary pre-condition to consumeT involvement, it is not sufficient of itself. Arguably, the touchstone of 'involvement' is the scope which users and carers have to make choices in terms of the needs to be met and the means for meeting those needs. Allen et al (1992) concluded that most of the users and carers in their study had no choices either about what, if anything, went into their package, or about who provided this service and in what way In so far as consumer choice was exercised it was through refusal or by choosing to discontinue a service. The scarcity of resources was seen by workers, users and carCTs ad putting limits on user/carer decision making powers. Allen et tii. concluded that 'positive choice among consumers was not really encouraged, and in some cases, was treated as undesirable' From the current study, too, it became apparent that, at the point nl service provision, foT users and carers there can be a number of diifeivi il levels of decision-making power: • no opportunity to choose: users and carers are advised what they can have, with only the negative power of refusal (if deemed , il ill to give informed consent); 7 Was Given Options Not Choices' 107 • opportunity to choose from a limited range of available or pre-de-termined options; • opportunity to develop their own package, with the worker acting as broker, or user and carer having delegated authority to make decisions and access to resources. Levels one and two seem to characterise the experiences of the users and Carers interviewed in our study. Where the decision is between a residential or non-residential care plan, this may ultimately be made by the professional gatekeepers who determine eligibility. One carer, for example, described how the final decision on residential care was 'dependent on a panel vote' Among those who had leapt thishurdfe, it was clear that even where users were emphatic that they alone had made the decision, it was not necessarily a choice between alternatives. This was either because no alternative was offered, or because of the perceived shortcomings of the only alternatives believed to be available. One service user illustrated this very clearly: "The choice was mine. 1 chose the home m preference to having the upset of home helps changing... 1 didn't like the disruption caused when they were changed...sometimes they would be allocated half my usual time What can they do in half an hour?" Users and carers did, however, refer to having a choice of homes. Bui even this could turn out to be more apparent than real, dependent on the availability of places One user, for example, described how she had been waiting tor a place in one home but; 'It was made clear to me 1 would not get a room within (this) home, .ind Ifell I just had to accept this because there was nothing anyone could do.' Ulother constraint on choice' may be the costs involved both for the l»rrs and for the local authority. These interviews with users and carers ^^Knot explore charging or their attitudes towards paying for services. ^Btni' issues are being explored in the follow-up interviews Workers, BDwi'vcr. expressed their concern that people would refuse a service | v»\ tin- basis ol cost not lack of need. Thomas (1994) gives some ^^Htancc to this anxiety in her review of charging policies. But it is not ^Hp Ihv cost to the client which may impede choice. Workers were ■Wmi' that the options available to people being funded by the local 108 Dcivioping Services for Older People and their Families authority were constrained by the costs of different resources. One practitioner, referring to residential placements, commented: The family can look around at the homes. They still have the right of choice provided they are within the financial limits we give them.' In respect of domiciliary care, too, users and carers would not necessarily experience the process as one of 'choosing', as one remarked: ' I didn't choose., you got what was available/ For some there was some scope for trying out different things, albeit from a limited range. For example, one service user tried meals-on-wheels but did not enjoy the food The arrangement was changed to a home help coming in daily to prepare and cook meals. Overall, however, the notion that users and carers can pick and choose is undermined by the experience of one carer given the names of five homes for respite care: 'Some were far too expensive, some had stopped taking respite, and some were fully booked up.' There was also little evidence to suggest that users and carers felt able lo determine the timing and extent of the service, One service user, for example, remarked: 'It would be nice if I could have a longer time of home help. I cannot stretch or bend The home helps have the inclination, but not the time.' Nor did their accounts suggest they had much influence over the way the service was provided. One service user was happy to have a home help every day. but would have preferred to have a regular person who would 'know your routine and you would know them-. Another lor whom, after some delay, a social carer service became available, com mented: '1 didn't feel entitled to ask for a type of person who had the sain*' interests as myself.' The picture which emerges from the comments is of a process where! , the service users and carers agree with what is offered from a f.iiih 'J Was Given Options Not Choices' 109 standard list of home help, daycare, respite and residential care. As summarised by one service user: 'It was decided 1 would get an extra eight hours home help, 1 was agreeable to this.' In general, the respondents did not appear to be encouraged to explore different ways of meeting their needs, nor of being given much scope to choose between means. Their experiences would seem to echo those described by Meethan and Thomson (1993), as decision making between given services, rather than greater choice between possible services. While carers seeking residential care for the person they cared for appeared to be more active in asking for what they wanted, on the whole both users and carers appeared to be at a disadvantage in knowing what was available, or possible, or what they were entitled to. As such they were inevitably dependent upon the worker. Furthermore, expectations were limited. Only one user interviewed ques-[ honed the level of service she was receiving. Referring to the one and half hour's home help she received each week she remarked, 'But I would have thought 1 was entitled to more'. Conclusions In the context of the assessment, the responses of the users and carers interviewed suggest that they felt they were given a chance by the [ Worker to express their needs, and were listened to. In responding lo iliexpressed needs, however, the comments of the workers as well 1m of the users and carers imply that different voices carry different , weights. The loudest voice may prove to be that of the other profes-[ llonals and agencies determining need and eligibility. What also emerges from the responses is the degree of dependence |f tliers and carers on the assessing professional: for support at a time B crisis, for information and for access to resources. It has been argued ikii for older service users, the ceding of power to a professional may pelf be a positive choice. Stevenson and Parsloe (1993), for example, IHit'it that the concept of 'empowerment' needs to be specifically led In the different material needs of very elderly people, and may |d to encompass the older person seeking to hand over tasks which 110 Developing Services for Older People and their Families worry them Along similar lines, Robertson (1993) found lhat, in recognition of their own powcrlessness, older people sought a care manager: "Who had status, who wasabletocope with bureaucracy, had good contacts, was shrewd and assertive (with service providers) and could generally ensure the prompt and consistent delivery of the required care.' (p.16) This approach does pre-suppose that the workers themselves are unfettered by competing demands, but as has been demonstrated (see, for example, Ellis 1993) workers are not only advocates but allocators of scarce resources, using the assessment as a means for rationing demand. In effect, workers too may bring with (hem other 'agendas'. As a result of the tension between the competing imperatives of consumer empowerment and mariagemcnt control, people may feel they are listened to and consulted, but, that at the point of decision making, find that the exercise of power is severely constrained. For older service users and the people who support them, there may still be a long way to go on the ladder of participation Acknowledgements The paper draws on data collected as part of a Scottish Office funded study of the Efficiency and Effectiveness in the Delivery of Community Care. The views expressed, however, are those of the authors, and do not reflect those of the funding agency The authors would like to thank all those who contributed to the study whether as service users, informal carers or workers. References Allen, I, Hogg, D. and Peace, S. (1992) Elderly People: Choice. Participation and Satisfaction. London: PSL Amstein, 5 (1969) 'A ladder of citizen participation' Journal of the American Institute of Planners 35,214-24. Calduck, K. (1994) 'Policy arid practice: fundamental considerations in the conceptualization of community care for elderly people.' Health and Social Cars 2,133-144. Department of Health (1989) Canngfor People. Community Care in the Next Decode and Beyond' Cm R49. London: HMSO. 7 Was Given Options Not Choices' 112 Department of Health (1994) Vw F Futlor: Reasons Why Some Older People Chuoas Residential Curs, Department of Health. Ellis, K. (1993) Squaring tlw Circle- User and Carer Participation in Needs Awmm t University of Bhminghanv Community Carey Joseph Rowntree Foundation Fisher, M (1990) 'Defining the practice content of care management' Social Work and Social Services Review 2,3,204-ZW Lloyd, P (1991) 'The empowerment of elderly people ' Journal af Aging Studies S, 2,125-135. MarDonaid. C. and Myers, F. (1995) Assessment and Care Management: Vie Practitioner Speaks. Community Care in Scotland Discussion Paper No 5, Social Work Research Centre, University of Stirling. Mecthun, K. and Thompson, C. (1993) In Their Own Homes: Incorporating Carers'and Users' Views in Care Management University of York: SPRU. North, N. (1993) 'Empowerment in welfare markets.' Health and Social Caw 1,3,129-137. Robertson, S. (1993) Fed and Watered: The Views of Older People on Needs Assessment and Care Management. Edinburgh: Age Concern Scotland. Social Service* Inspectorate/Social Work Services Croup (1991) Care Management and As