BALDWIN, M.: Care management and Community Care. Social work discretion and the construction of policy. Ashgate, Aldershot-Burlington-Singapore-Sydney 2000
26 Care Management and Community Care
\
\ P^ffsy'LsfjnfiSniRS 's an irnportant part of social work practice.  It is a '. fundamental tenet of good social work practice that social workejrs_slipuld ' ensure that they have understood what service users mean in describing ; their perspective ontheircqiididon. There are times when social workers ! have tojmrjgsetiie.ir views on unwilling service users, hut, more often than ; not, they are trying to understand and respect other people's sense of . meaning. What follows is not exclusively about the social work practice of understanding meaning, although, in one sense, that is exactly what assessment practice is all about.   It does, however, acknowledge that varying meanings exist. This argument is expanded upon in detail in Chapter Four.
In order to contain this book within the enormity of a subject like community care, the area that will be focussed upon is the assessment task within care management. Following the publication of the White Paper 'Caring for People' (D of H 1989) and the enactment of the NHS and ■1/ Community Care Act 1990, Local Authority Social Services Departments 3 have been required to introduce new structures for organising the delivery of services to adults in the care sector. This has resulted in the universal introduction of systems of    .'p„aJS.^managements
.departments. In order to assist the process of introducing care management into departments, the government, through the_ Social
» Services Inspectorate, produced manuals of guidance for both jttajctitigners
i and managers, the beparimenFo'f"Health and the Social Services inspectorate also commissioned the National Institute of Social Work to produce £ practice guide. These three documents have been influential in
' social services departments, most of which have produced their own documents of guidance.
" ~~ Prior to carrying out the first phase of fieldwork for this research, therefore, I had an idea of what the government's intentions were in relation to care management. The White Paper and the Policy Guidance (D of H 1990) that went with it provide die major policy dirust of government intentions, introducing the key concepts of the community care 'revolution'. The fundamental changes were concerned with introducing an internal 'quasi-market* (LeGrand and Bartlett 1993) into the adult services arena of social welfare, following a similar introduction into die National Health Service. This internal market was believed by the government, informed by a market economy agenda, to provide the best
Policy Implementation and Community Care 27
way of introducing choice of high quality services targeted on those who are in greatest need.
In order to ensure that there is no contamination of the market ideal, those rcs^nsjbje for the purchase of services on service users' ■S^,shQUidbe.^B^^from tfibse"withinlociaT^Mvlces Departments 2*°. a.re.' rS^^i^§^-4^V:idjlng^§erj^s. Hence, as in the NHS, EH^as^rs 9f s?rvices.(tnose carrying out assessments and putting togedier care packages) should be hi g. separate part^ofjhe organisation from the providers. Indeed, there is a strong incentive for'social services departments to relinquish their traditional role as service providers and to develop a mixed egonorny_Qf_care through the encouragement of the" inde^en^ejitgector (private and voluntary).
^Sjaa^fiement, along with ^sesjrnent? has been presented, by the Department of Health as the key form of practice for introducing these changes into the provision of adult services.  The definitive versions of care management can be found in the guidance documentation (SSI 1991a and 1991b).   The Practitioners' Guide and Managers' Guide have been heavily influential on social services departments in preparing their own guidance documents for care managers.   That there are problems of consistejicy, especially in the area of role definition in these versions "of care management requires greater analysis, and this can be found in Chapter Four.   Having read the government documentation as well as having studied 28 social services department care management guidance documents, I was keen to establish the extent to which the knowledge embodied in the documents was being used by practitioners to inform their practice. This was die fundamental purpose of the fieldwork described in the next chapter.
The Department of Health through the Social. Services Inspectorate? hj^praduced^ajh^^ 1991a) which is
analysed" in considerable detail in Chapter Four. For now, a. description of this process is required as it is important as an influential part of the context for community care. Having read 28 of them, it is clear that this document has provided the model for most of the care management guideljnedocuments produced for their care managers by local authority Social Services Departments. Very few of the guidelines..1.have^studied deviate from the SSI docurneijk in any~way~at all They habitually define care "management as a cyclical process, following the model in Fig. 2. Thus providing information in accessible forms to potential service users,
ir™l s—|^ r^l jt—| <i—j «—1 s—| k—] £—j £—[ k—|   r~j <—| r—| <—j c—} i—j   r—f r~j
_i ■  'Ú_I    g__J    'i_I    ü_I
2 8 Care Management and Community Care
and a system for determining the level of assessment tD be offered following referral are the p re-requisites to the cyclical process suggested. A number of local authorities have decided not to follow pie option of having leyetsof assessment, choosing instead to offer a^b I anjcet assessment to all who are referred. There is evidence, however (Baldwin 1995) that there is confusion amongst care managers as to whether their authority^ is sanctioning "levels" of assessment or not, The third stage, of assessing needl is the keyjstage according to the glance.. The summary of practice guidance urges care managers to look at 'strengths and as^iratians1 (SSI 1991a: p.l 1) as well as neer]s, calling on care managers to bring together
j contributions from other agencies and specialists as appropriate. Needs are to be assessed 'in the context of local policies and priorities1 (SSI 1991a: p.l 1) which are part of the information to be published in stage one. The care pjanning stage number four requires care managers to present appropriate resources available from both statutory and independent sectors to enable the potential service user to make a choice of services which would then constitute a "care plan". In stage five the care pjan is implemented through negotiation by the care manager with appropriate
'agencies^'inbluding their own. It is also the stage at which financial negotiations are instituted so that responsibility for payment for the package of care can be confirmed. The final two stages, which feed back into the assessment process, involve monitoring the care plan and then regularly.reviewing its effectiveness, in the context of service user's and carer's unfolding needs over time. The monitoring would be continuous and is likely ta_jnyolve service providers keeping the care manager
Jnformepljif.prQgrgss. Reviews will occur at spéctfíeT'intervals'anä' would involve care manager, service providers as well as users and carers. These stages would have a general quality assurance function in thejcontinuing quest for improvement' (SSI 1991a: p. 11) in the merits of the services provided as parts of the package of care. This structure is the normative approach to care management in community care. As suggested above, there will be further analysis of this model, both in theory, in chapter five, but also in practice in chapter four.
Figure 2
Policy Implementation and Community Cnj-e 29 The Care Management Cycle
1. Publishing Information
2. Determining the level of assessment
3. Assessing need
7. Reviewing
4. Care Planning
6. Monitoring
5. Implementing the Care Plan
The importance of role clarity within a task as complex as assessment has not prevented it from becoming a_contested arena in its own right. What the research that informs this book lias sought to do is seek out the variety of rneaningsand the forms of knowledge that inform I the pracliee" 6T assessment within care management. We can then draw \ Tentative conclusions about the range an'd "degree of   influence that different types of knowledge exert on practice, and their affect on the implementation of policy.    If there is no congruence between the < knowledge and values that inform" the policy implemented through local authority departments and that which informs the practice., of frontline practitioners, then it is likely that there will be a gap between intention and practice leading to 'implementation deficit'.
This is a central"''line of argument within contemporary social welfare. The tension be^sgO,.-.pr^essipnal3_po
approaches to service delivery can perhaps be better understood within this context?The voice of users and potential users of welfare services can also then start to find a space within which it can be heard in its many guises. If assessment, as many Learning Difficulties (Souza 1997 in Ramcharan et
3 4 Care Management and Community Care
do when carrying out a sophisticated task such as assessment? Were there other, as yet unidentified, forms of knowledge that they were using? The farms of knowledge that care managers were drawing upon would provide evidence of the degree to which they were implementing policy as intended, although, as has already been stated and will be established in even greater detail in chapter four, policy intentions are not altogether clear in the most significant literature.
Research Methodology
Choice of Authorities
%tween_Apri[ and September of 1994 interviews were carried out with steff in two local authority social services departments. Originally it had been intended to carry out interviews in three local authority social services departments which conformed to notional points on a continuum °f adherence to central government intentions with regard to the '^traduction of an internal market in social welfare. I was looking for an authority that had pursued the intentions explicitly at one end of tiie cautinuum, another that had resisted the intentions and complied with the Minimum of statutory requirements at the other, with another authority at the midpoint on the continuum. Unfortunately the authority chosen for the .'Midpoint pulled out gf co-operation at ji iate^stage, and after letters of hitroduclion had been sent out. It was too late to renegotiate another similar authority and I chose to continue with only two, which did, at least, afford a direct contrast and comparison.
One of these authorities was a London borough (identified hereafter as Borough) and the other a shire county (to be known as Shire). §llire_had pj^sued the government agenda from an early stage, making an Organisational divide between. purchase and provision earlier than most °ther Social Services Departments. This meant that tiie staff in the authority should have already gained considerable experience of the kind °f organisation and practice changes that care managers in other authorities, like Borough, had only been used to for one year. Borough, on the other hand, were recommended to me as an agency who were following government guidance ajijy^Q^faL^ requirejmejits^ MjsistecLA comparative study between these two agencies was chosen on the grounds that there was sufficient differentiation between the two
Care Management and the Subversion of Policy 35 departments  to  provide  useful  comparison and  establish  a degree of
validity in the findings.
After the interviews, I studied the care management guidelines from Shire in order to establish what level of congruence there might be between the intentions of that document and practice in the department. Borough did not have a similar.-guidance dqcjnnent^but relied on the Social Services Inspectorate^ guidance (SSI 1991a; 1991b) on care management as the reference point for practice. My principle focus was on the actions of care, managers in their role in the assessmentjor potential, 'service^users' jieeds. inevitably, However, I needed to have some I^awledge of the whole care management cycle within which assessment sits, as it is perceived of as a whole within the literature (SSI 1991b) rather than a fragmented part. This cycle was described in Chapter Two (p. 65ff) and is further explored in Chapter Four.
The Participants
Interviews were carried out with care managers and first line managers in both social services departments. In addition two middle managers in Sjiirej and one senior manQfier in Borough were interviewed to obtain the view of staff with budgetary control and strategic responsibility within the jagericies. In^orougji, interviews were carried out witli 8_jtaff doing assessments within aduit services. Three of these, as well as carrying out assessments themselves, also had first line managerial responsibility for other staff carrying out assessments. Of these 8, 3 were qualified social workers, one an occupational therapist, and the others had no formal qualification but with training and experience appropriate to the task. I also interviewed three other first line managers in Borough, who had responsibility far the management of teams of workers. Two of these were qualified social workers and one an occupational therapist. Finally, in Borough, I also interviewed a senior manager in one 'area5 who had budgetary accountability, responsibility for managing first line managers, and strategic responsibility within the area and the whole borough.
In Shire I interviewed 9 care managers carrying out assessments. Two ofthese were child care workers, the rest worked in disability teams. All w^e_gu^Ijfie4.socjaJjvorkers who was an occupational
therapist and another who had the diploma in domiciliary care management. I also interviewed 6 first line managers in Shire who were responsible for budgets and managing care managers.   One of these
managed a child care team, the rest were managers of disability teams. All were qualified, one as an occupational therapist, and the rest as social workers. The two middle managers in Shire that I interviewed'were both qualified occupational therapists. They had staff management, budgetary and local strategic planning responsibilities. The gander of participants was mixed in both Authorities, and in each grouping of workers. Ethnicity was variedjn Borough, but all die interviewees in SJiiVeweje white. [ noted the ethnicity of interviewees as I felt the possibility of black perspectives on care management might reveal a different approach to the task from their white colleagues.
The Method
The interview schedule was semi-structured, comprising a list of questions that everyone was asked, buT^lTTn^option of follow up questions, in order to seek clarification where necessary.  I maintained a checklist of potential responses that I could prompt interviewees with, should they have problems in answering questions. I was very aware of the problems, in using interview schedules, of misunderstanding.   Foddy (1993) from a symbolic interactionist perspective casts doubt upon the usefulness of responses because the 'relationships between what respondents say they do and what they actually do is not always very strong' (Foddy 1993; p. 1). It is very important then, to ensure that the questions are understood in the way intended by the researcher and the answers,  conversely, are understood as intended by the respondent. There were important isgues^of meaning and intention that I was aware of, and determined to avoid the pitfalls of misunderstanding.    Other writers on qualitative research methodology (Silverman 1993; Lindlof 1995) urge the importance of interpretation and the need for piloting before and checking out during interviews to avoid the worst excesses of a 'scientism' (Silverman 1993 p.2) and 'abstracted empiricism' (Silverman 1993; p.27). I concurred with Silverman, and did not believe that bias could be 'techniqued out1 of an interview schedule (Silverman 1993; p.2&),   rather seeking To "remain vigilant, questioning and flexible in order to proceed with as few assumptions as possible. Prior to the research interviews in Shire and Borough I piloted the interview schedule in a team from a nearby local authority.
When I started the interviews in Shire and Borough the flexibility I was seeking proved invaluable as it rapidly became apparent that
Care Management and the Subversion of p0iicy 3 7
individual workers were fulfilling more or less subtly different roles in different settings, sometimes with the same job title. This was particularly the case in Borough, where decentralisation had created structures within different 'areas' which were very particular to that patch. The fundamental purpose of the interviews, to get at the actiial practice of individuals, and
Jo be dojng, made the avoidance of assumption a basic value" of the research interviews. In a similar vein, it was important that individuals were able to speak freely and in confidence about their work, and the organisational context, again, so that the degree of congruence between the 'ought' and the Ms1 could be gauged. Confidentiality and anonymity were 'de rigeur'.
Meaning Revealed
The interviews were all tape-recorded and have been transcribed. The transcripts have been studied in detail, and keXl!}6"}65 nave ^een extracted through content analysis. In what follows all qujota^ons in double inverted commas (" ") are direct quotations from participants. In order to avoid being guided purely by my 'hypothesis', that there are limitations to policy implementation as a result of the activities of key implementers, I have looked widely for issues that have arisen, and group them under three different headings:
• Role of the Care Manager
• Use of Procedures and Resource Management
• Implementation of the Principles of Community Care
It should be noted that I had no access to the outcomes of individual's practice in this research, onjy^ what they said about what they did. I have used care managers' own words where that is illustrative, but the intej^retafiqn. is.rn.jne.
1. Role of the Care Manager
Under this section we can look at the influences on their practice that interviewees listed. How do care managers see their role? What are the knowledge, skills and values that they believe inform what theydo? What
3 8  Care Management and Community Care
might the difference be between professional backgrounds, or between those with a qualification and those without?
Influences on Practice
I started by asking a general question 'what influenc^_yQUT_practicB7'. A substantial range of responses was revealed, and I felt that these 'volunteered' responses were at least as significant as those made to prompts about specific influences on practice.       The most frequently /mentioned pre-checklist   responses were   factors like "instinct^, "gut I feelings", "the personalities  involved",  and l^tr^iejicej". Agency 1 procedures - filling in the forms - was also a frequent response, but ' training, either in-service or professional was less often stated as an influence on practice, prior to respondents being given a specific opportunity to comment on this.     Even when training and theory were offered as prompts, many respondents found the question difficult. Only very few quoted specific theoretical models that they use to inform their practice or by which they evaluate what they have done.  One or two of these   answers   were  very   impressive,   the   rest   seemed somewhat embarrassed by their inability to dredge up_t^ories^_tfiexJiaOganit on training programmes, often some years before.  Some practitioners were able to articulate models of practice even though they could not put a name to them.
As far as comparisons between Shire and Borough, qualified and unqualified, social worker and occupational therapist are concerned, there was not a significant difference when the initial question was put. Qualified workers, when given the opportunity to speak of theory were generally belter able to do so. There were some notable exceptions, mainly where unqualified staff had made excellent use of prior learning, or in-service training to inform their practice, and were able to cite particular theories or models that they used to inform their actions.
The question of the relevance of training to the task of care management is an interesting one. There were some responses mat indicated a feeling that social work training was not relevant to care management, but most did not make a judgement on this. A senior manager in Borough felt that the current teaching on diploma in social work courses was inadequate for the role, but still the best available.
¥9^.as^essme^^ This was particularly the case with occupational therapists.  Again, there was
f~**i   f™***   .-rwi   r™™!   -r^ I—i   r"~i t—i
Care Management and the Subversion of Policy 3 9
very little difference between Shire and Borough in this analysis. It is important to add that the unqualified workers practice in this regard was at least as well informed as the qualified social workers. Some unqualified staff spoke most eloquently about the practice skills involved in needs-led and user orientated assessments.
'Resources3 were given as an influence on practice in two different ways. Lack of resources influenced practice in general, but so did knowledge of available resources. This left me with some concerns about the degree to which assessment outcomes were being determined by what ca^rganagers believed were the resources available to meet_any apparent need. We shall return to this point later.
One of the clearest differences between the two authorities concerned the degree to which 'values \ 'attitudes1, equal opportunities or anti-discrimination were volunteered as influences on practice. In Shire, Inese were seldom"' mentioned before the prompt. Even after Shire care managers were prompted with the question about values as a potential influence on their assessment work, many still volunteered little in the way of response that indicated a widespread understanding of a need to be influenced by, for instance, concerns that some service users may be disadvantaged in particular ways. There were some notable exceptions to this from care managers qualified for some time as social workers.
InBoroujih^ on the other hand, there was almost universal volunteering of the need for ethnic sensitivity, taking cultural difference into consideration and other similar.practjfie^^lyWs™" This'was primarily the case in relation tajrace' as a potential area of disadvantage. This sensitivity was perhaps not surprising given that in one of the Borough 'areas' the black population was set at 60% by one care manager. Borough care managers were also more likely to think ofequality of opportunity in relation to age, gender, disability, sexual orientation and poverty than their counterparts in Shire. I felt that this level of difference was likely to have an effect on practice. Care__management guidance documents from government and local authorities urge consideration of such factors so failure to do so would indicate divergence from policy intention, as well as a less effective assessment outcome.
Several qualified social workers in both Shire and Borough seemed uncomfortable about their difficulty in articulating values in relation to assessment practice - "I realise I haven't really thought about values for ages, it's terrible". There were, as before, exceptions to this point, with some impressive articulation of values by some individuals
1       J-1       1-------1       J--1       I-------1       i(       |       I       I       r—■       T-    ■ r-—m
40 Cars Management and Community Care
(qualified social workers from both agencies and unqualified care managers from Borough). In addition, some teams had welj^ defined[and shared values in relation to their practice, the most impressive example of this being in Shire - "as a team we have a stated document which list our aims and values ... an absolute commitment to equal opportunities ... working towards anti-discriminatory practice ... recognising that we do discriminate". The sort of values that were referred to in these cases are in the form of a set of principles to which social workers - in this case as care managers - are committed and which inform them of how they should behave (Banks 1995). The Central Council for Education and Training in Social Work (CCETSW) is the body that validates and provides regulations for professional social work courses. CCETSW's current statement of value requirements (CCETSW 1995) includes such phrases as respect for diversity, building upon strengths, promoting rights to choice, confidentiality and protection, countering discrimination and assisting people in increasing control over and improving the quality of their lives. This area of values is returned to in Chapter Seven when social work theory is looked at in detail.
In conclusion it was apparent that of the many influences on -practice in assessment, not all relate either specifically or even incidentally ;to policy guidelines. There was evidence of unconsidered reliance on intuitive approaches to practice - "a lot of gut feeling, a lot of intuition, you've just jolly well got the vibes". The apparent failure to reflect on the origins of this knowledge, added to some resistance to formal sources of knowledge and values - "I don't think I consciously draw on anything, I just think that I do things"; "I've forgotten all these things (theories and models) they all go out of your mind"; "I'm certainly not comfortable talking in the value thing - we're almost getting into mission statements" -makes congruence between policy and practice less likely.
Assessment - Knowledge Skills and Values
Assessment was focused upon in this research because it is argued as a key area in the care management cycle (Social Services Inspectorate 1991b). We have already looked at some of the influences on practice. There are other issues of practice and role. Care _ managers., almosl Jnyariabiy indicated the ng^ for a^esamenteto be neefer1ei and for ^ejnfluddual to be the fq^^^sessjnent. There was revealed, however, a very widely held belief that servicT'user^
Care Management and the Subversion of Policy 4 \
be^ia^as^rance that they .willrece^jj^service. that .will meet their 32ids- Thrs was justified IVough sentiments^such as""I think TtoTof service users don't understand". Time constraints on involvement were also revealed - "It really does take time, I mean time and effort to involve people"; "the reality is that you can't sit around and do it with them". This apparent failure of involyejnent has resulted in care managers adopting a role which shifts away from maintaining the service user at the centre of the assessment exercise. The likely result is an assessment based more on their professional opinion t|ian„on an assessment formed through prartaership. Using this evidence we can question die extent to which care managers allow their role to be defined by what they beljeve users want as opposed to what community care policy, procedure and ethos suggests is good practice. User involvement requires the education of service users into greater expectations, as much as it requires the education of staff into new ways of thinking and practice. This was clear evidence of a gap between the intentions of community care policy and the practice of care managers. It is interesting to note that the values of service user myolvement are contemporary social work values (CCETSW 1995) as well as policy intentions.
Care Management - Procedure versus Practice
My questioning found some debate amongst first line managers in both agencies about ^o^r^ejs^^car^managem Most care managers seemed less interested in defining a new role and more with protecting those parts of their current practice which they hold dear - "I'm actually doing very much the same thing as I always was". The two models were referred to as the "procedural" and the "jaissez faire". Also referred to at | one point was the "exchange" model' from the NISW book which is described in detail in the following chapter (Smale et al 1993) and which takes us close to the good practice intentions of CCETSW requirements. The_rjracedural_madel was perceived as mechanistic, following agency' ^rea^ratic^'guj^delines, and involved little active reflection on die nature of the relationship between worker and user. The other model is based more on traditional social worlc.as. a practice, and invliTveslhe fqrming^of rdatipnshjr^ajid the useof this Jor^exgloration and problem solving! * In the NISW book there is a similar mode! of assessment, referred to as the "questioning" model. This model also holds with a basic assumption that
42 Cars Management and Community Care
it is the care manager's role to make the judgement, based on their professional expertise.
Although care managers did not talk directly about these models, they are a helpful way of differentiating the forms of practice to which care managers appeared to hold allegiance when they described their aims in carrying out assessments during interviews. Some care managers clearly wanted^ta^.>cpiitin.u6^ an approach to assessment built on the^.use, .of ^SkiiOflshiBi as they felt they had always dqngt, and resisted the h^oduction of bureaucratic te9hnifllies^a^cQri§ejiuejnse - "I believe these forms ^abarner. hetween-a person and an assessor"; "if you present those (forms) to someone, the walls are up straight away". These tended to be care managers who had been qualified as social workers for some time. It is my view that this practice was closer to the questioning rngdej, which involves a more traditional application of professional knowledge, than the ^SilSHSSJES^gL wh'ph defines assessment and care management practice Within ajMrticipative context. There were few care managers .from.both Shire and Borough..who seemed to be using anything resernbjing the exchange model. Those who did were the same care managers who were clearest about their role, and seemed to be practising nearest to agency requirements in the Shire Guidance document. Other care managers seemed happier with aj^ocedural model, indicating that they would like the^as^essiTi5nt.Jnstruments-.t"D ..fee more prescriptive: "The forms are just blank pieces of paper", complained one respondent.
I found tliis debate to be evidence of confusion of role in both agencies. It may be that there is room for different kinds of care manager in a department, but the difference in perceived role does have an effect on practice, particularly in relation to user involvement in the assessment process. The perception of role confusion by care managers in both authorities has a detrimental affect on confidence and results in care managers sticking to what they know and feel assured of rather than moving on into a new and uncertain practice about which many have both
concerns and suspicion.
Some first line managers suggested that recently qualified workers were more likely to adopt a mechanistic approach to assessment - "what I find with more recently qualified staff and with student social workers is that they are looking at assessments in a much more rnephanical, administrative, bureaucratic Way"- This was a good critique of contemporary diploma in social work teaching, and there was some limited evidence for the assertion. On (he other hand, there were also examples of
Care Management and the Subversion of Policy 43
exchange practice from newly qualified staff, and, generally, it was hard to associate the approaches to any one group - social workers, occupational therapists, or unqualified workers.   One manager made the interesting point that she believed procedural  models were "undermining the traditional instincts" of care managers.  She was referring to the use of, relationship by social workers. There was also a^irect_cpntrast revealed" between^rjrrjfessional and procedural models of assessment, with the) interviewee  being  cleariyHn~favour  of the   former  -  "ability to; communicate, relate and set up a relationship will be a factor which is noil a very measurable factor". This resulted in resistance to the procedures to\ demonstrate that favour in practice - "there are some people who will try\ and get round the procedures because they feel they ore working against; the best interests of the client".  This was actively encouraged by some j managers - "so I said to her (an anxious social worker) forget the forms, \ just remember how you make a relationship with an old person ... it (use of j the forms) totally deskills some of the most experienced workers in the team".
In both Shire and Borough there was astrong defence of procedure from two care managers who were^nmrejish/^ (the Shire care manager was social work qualified, the Borough one was unqualified). Both of them, interestingly, ^hjlst^advocating a user focused, and neerJs-bdasji^^ that b^re^cjatic^roce^urep
introduced an element of eflujty.,into practice that had been very patchy in the past - "you've got the same set of forms and everyone gets the same ... and you look at the needs"; "I personally feel about social work that it needs to be accountable ... and that's from my past history in (another authority) where I just saw a mish mash response". This_approach was JnJ£°il££L^iLt£Sm jnanagers in both authorities - "it draws more people into that process, more people can participate in the care management process"; "it would contribute'to equity". This seemed to me to be a 1 justification for a hybrid between the two roles, with the procedure serving the purpose of the exchange rather than the other way round. It will be very difficult for agencies to introduce this sort of model for care management, however, against the resistance of care .managers who are suspiciousjgf influences such as_ bureaucracy - "it's certainly a barrier (form^fiUing) between this relationship thing" - resource control - "in budgetary control terms what label do we put on the relationship? You can't cost it" - and other techniques of managerialism - "(targets) as a management tool, wonderful ... but in terms of dealing with clients as
t 1
1 I
-i a—i   b_/   i_j
t-J   í—J   g_f   t_j   í_í   l^J   e_j   i_^j   í......i í^J.
i-í    i_I i_J
L,
44 Care Management and Community Care
people it's not all that helpful ... it gives connotations of measurement ... and it doesn't matter what the quaiity of the work is".
Discretion versus Prescription
There were many examples of rej^tancejo_ departmental pjp^sjjures, with care managers using the phrase "we should do" this or "we ought to do" that. The shoulds and oughts revealed either an unwillingness, which, when challenged produced a grudging acknowledgement that they did, indeed, do it as intended, or, more interestingly, the revelation of a continued adherence to J., metbodjfjf work jflg .which, was, olde^fid. more familiar - 'Tfyoifask my team manager I'm not supposed to have that role butTdo it anyway"; "I'm actually doing very much the same thing as I always was". There was one example of workers in a team running two systems side by side - the old and the new - because they found the new system inimical to their preferred method of practice - "this is not policy, tins is x's (team manager) own system".
This is evidence again of role confiision, but it also reveals the strength of adherence to traditional professional practices, as well as the degree of discretion ..Qa/e_nianagers__hold, despite the bureaucratic procedures. Care managers have the scope to resist policy intentions, and are doing so successfully, on this evidence. It was not confined to one agency, or to one profession. The corollary of this behaviour is that the baby of good practice is indiscriminately thrown out with the bath water of
the new procedures.
OneJShirejnanager spoke eloquently of the need for education in an academic sense, rather than training. Care managers, he believed, needed to have a deeper understanding of the changes of care management over traditional professional practice, so that they could really understand the advantages. This required a more academic approach to learning in his view, and suggested that going away to college was more likely to assist the process of reflection and adult learning than in-service training. We will return to this theme of diejn^ortance of reflecfon in the development of practice in later cha^rTTwaTa central" moment of learning and understanding for me.
Care A'lnnngcmcntand t/ic Subversion ofFoIicy 45
Individual Care versus Community Care yi -
Whether community care involves a process.l3y..whiQh,individuals receive / ftwrjarcngefo, or is about Ae^anagjm^
"gyn.gpfiyejasis, takes us to -flioTiSirt of the. enterpn^7~'ft articulates "the! differences between care in the community versus cojnmmn^care, raised Jk in an earlier chapter of the book.   My over all conclusion from both Borough and Shire is that this is another issue which adds to the confusion about the role of care manager.   Most are involved on ajjurely individual ^, k^^assjssingjta^
^^J^ma^fiMej^'tisT __We will return to resource deficit recording later, but the resistance to this was most revealing. Most care managers cannot see the priority for such activity, have yttl^ate^^ir^sjateg/c
^laim-fflgan general, and yet are very irritated by the lack of development .of resources in.some areas. The senior manager'Tn~Borough' despaired of this lack of understanding and intere^y^ajr^ on service
^delivery.
Care managers generally indicated that their prime responsibility is to the individual - "It's the individual we work with". Where^tfiVre was a
1 iwY
difference was in the way that care managers saw their clients within the broader community.  There was good practice in networking and multi-f/" discn5l£jrxX settings.    It was
particularly noticeable in Borough, with some goad examples of people using networks, both formal and informal, to, provide^ support ..for ÚldJYJduaJs. This was no surprise, perhaps, as these Borough workers were operating insmall, patches, where they had opportunities to get to know their communities and people within the community could get to know them. I was also impressed with the level of commitment, in Borough, to the importance of understandhig_tiie mix of culture, within the^patch. This was especially noticeable from the three black workers,, all or whom mentioned the importance of ethnic monitoring, and all of whom noted the need for increased training in ejhmcally sensitive practice. There were 1 white workers who expressed similar views "irf Borough, so this may be more an indication J)f^^fiy^thos^at work rather than" individual' . perspective. Two white interviewees commented on how helpful it was to have colleagues from different ethnic backgrounds because their perspective was a dynamic force for the deve/apment of practice more generally within their team.
I \ ví l.
4 6 Care Management and Community Care Acute versus Preventative Work
There was almost universal disappointment at the degree to which assessment practice involved patching up situations that had reached breakdown point before referral. Targeting those in greatest need was described as propping up the failures of informal care, and not good prioritisation - "if you dc^t^the^eyein^ve_wprk, you're doing knee-jerk crisis work which is twicejis„esp^n^we_and ]ial_f as_ effective". Putting resources jnj.p_ preventim _was_f^
ttierVwas little opportunity for this. One Shire care manager mentioned a figlire~of"T8D/o" put aside for preventative work, but this was a vague allusion that ccjuld not be elaborated upon, and which did not crop up again. Such a policy certainly seemed to be undermined by the degree to which only the highest priority cases were being seen for assessment. Targeting those most in need is Government policy. The view of professional workers is that it is not a helpful way of achieving the over all aims of maintaining people in their own homes. Ironically, it was proving more difficult to resist this policy initiative than some of the others which might have a more beneficial affect on service users' lives.
Resource Constraints
Resource constraint was routinely quoted as the major stumbling block to the meeting of needs, although there was variation in this. Some respWdentrffbm'bmh'irutliorities said that the problem was not resources in terms of money, but of the availability of specialist service. When care managers were "quizzed about this resource constraint issue, however, almost all of them owned that it was not- a problem that they had encountered. They put this down to luck in their area, and predicted that things were likely to be much tougher next year. With continuing fiscal crisis, they may be so, although the evidence I collected suggests that the ( practice of most care managers, in .taUg£mg„gssessm^ | of available resources may be more influential. Most admitted to this in ' Go1fi"liu1£^ justifying this by an'unwillingness to set__up_
expectations with service users that they knew they could not deliver - "All my judgement is not to ^courage, people to hope for things which are not in the end going to" be there"; "I have to say that if you do know that there are no respite places available to save your client distress and having raised hopes and then smashing them down, you don't recommend it".
Care Management and the Subversion of Policy 47
This kind of pragmatism is understandable for staff who have to negotiate the complexity of relationships with vulnerable, needy and sometimes hostile people. The result undermines the practice of needs-led assessment. Assessment and CM^^^gii^ in'numy of "the "cases '"that I heard about was,dn™^yj^ understanding.of resource
Care: managers, in addition, see very little worth in recording deficit - "there is'a service deficit form we're supposed to fill in ... I don't, I haven't got time ... if it's something everybody knows I can't be bothered". These two practices combined, the resource lead to assessment and failure to record service deficit, result in central planks of policy for community care being eroded by care managers' practice. This is clear evidence of the distortion of policy intentions by street-level implemented.
When managers were asked about the likelihood of this occurring, those in Borough denied that it could happen and that all care managers understood the need to assess without considering resource availability - "I think I can confidently say that they are not influenced by the availability or unavailability of resources". In Shire some first line managers acknowledged what was happening and constantly reminded staff of the requirement that assessments should be needs-led. In Borough, care managers with first line management responsibility told of giving assessments back to workers to repeat because they were so evidently resource-led. Without a shift in attitude by care managers, possibly through the provjsjon.pf.^on^pi^nities-tp, reflect .,upon-the,.cQnsequences tp£,thejr _actions_and non-actions, this degree of exhortation is perhaps the only way to alter practice.
2. Use of Procedures and Resource Management Allocation
All respondents were able to describe the system of allocation operating in their team coherently. Whilst systems were variable, there was a problem with the basis on which decisions were made.   We will return to the variable use of agency priority systems below, but there was much evidence of the use of systems, designed to establish eligibility for service \ post-assessment^being employedl_to make.decisions about allocation. This ■ incongruence between procedure and practice was most apparent in Shire. The result was a danger of judgements about need being made prior to' assessment. Such practice wou!3"uriHermine policy intentions. One middle;
'—' '—' I—'    5—I *—J i—J    i_i    i_i    I_i i
48 Care Management and Community Care
manager in Shire expressed concern about the sophistication of decisionmaking in allocation. The. procedure was believed to be too reliant on subjective judgements, and" the hope waTthai" mo7e..anaIytical" methods', based on tiiejanoritymajr^.. system could be developed - "people do need to learn a bit more about probabilities, making what are subjective, human emotional decisions but in ajnp_re analytical way". This desire for greater consistency is understandable. It needs to avoid prejudging priority of service delivery.
The Instruments of Assessment
These bureaucratic instruments were almost universally despised. The designers of these forms must be very thick-skinned individuals to cope with some of the venom directed their way from both care managers and first line managers. The accusation against those who design such forms was that they "only talk to computers", so perhaps they do not hear the complaints. I have already spoken of a few care managers, in both authorities, who found the prescription comforting, and others who felt that they combine flexibility with a consistency that is more likely to ensure equality of opportunity. When care managers were challenged on their negative attitudes to the forms many retracted their initial hostility as they found it hard to substantiate it beyond bare prejudice against bureaucratic procedures.
Some concerns remain, however, and many of them were offered by first line managers rather than their staff. The feeling that the forms, were "computer-driven" and more useful far the quantification of assessment procedure was widespread - "it is computer-led and statistic and data-led, rather than practice-led"... Consequently first line managers readily admitted that they 'were "of more help to them than their staff - "they do give me the answers I want if they are followed through". Even then, the kind of information available from the collected data was considered to , be disappointing by most managers in both authorities. Managers felt that 'the, quantitative data was crudejind. uphejrjful, giving^some weight to demands for more resources,.-but saying little akrout^guality, of work. Less assessments, they argued, may mean more effective assessments, and, therefore, less 'return' of service users, either as complainants, or in what is referred to in the health service as the 'revolving door'.
There was some articulation from managers and care managers in both agencies that the forms "get in the way of the primary task of.
_i     i_1 l_t    i__1     i_[    i_1    t_i t-J
Care Management and the Subversion of Policy 49
3|sjs^rru^^whicji_]s the fannation of a relationship. One social work manager in Borough managed a team who felt de-skilled by the forms. She had instructed her staff not to think about the forms until after the assessment visit The formscoiild then be_ filled m on .their returnjo the office.. This is another area in which policy seems to be unclear, because there was some belief amongst care managers in both authorities that they should complete the forms in the presence of the service user. This practice would maximisV'ttie likelihood of service user involvement in the process of assessment.
There would seem to be widespread belief, in conclusion, that the.1 forms are there to serve thejjureaucratic ajiajj-esource control function of the agency. Even though this function is seen as valid, respondents felt that the forms should primarily serve practice, needs as these are the ones most likely to affect the quality of service. As one manager said "a good assessment is not going to be a form-filling exercise". Dissatisfaction with the system leads to practice which undermines the good intentions of procedures, such as equality of opportunity, noted above.
Levels and Priorities
This is an area of some confusion, even where, as in Shire, there is a highly rational system of priority formulation, that has a substantial profile in the agency. Neither authority has a system of 'levels1 of assessment, j apparently. Some care managers said they did, but I understood this to be a confusion with the priority system. There was also confusion surrounding the use of a priority^system in allocation as opposed to a priority system. fgr^etermi^ing service .eligibility post-assessment. As far \ as levels Df assessment are concerned, where the concept was understood, it was generally felt to be unhelpful. Once referred, all got "the complete works" as one manager put it. Indeed, there was much evidence-of jid hoc arrangements for brief assessments, which did not mean that time resources were spent ann%w"priority assessments". I understood this to be against the policy of both authorities, but such was the diversity of views that it became impossible to be certain.
In Shire, as indicated, there is a'high tech' system of priority formulation. It wprks.very variably, according totFie responses I received. It is used in a number of teams as a method of prioritising allocations, with priority .scores being adapted after assessme.ntj depending on die result. HowTF'is used to establish eligibility is also variable. I understood that
I
5 0 Care Management and Community Care
different areas should not have had different policies about which bandings will or will not receive a service, and under which circumstances, but, nevertheless, the practice varied both within and between areas. Even given the attempt at rationality in prioritisation in Shire, rn^na^ers admitted that.it js a "fairly subjective score". Thejresultant scoring which can lead tp., service (or not) was._5een^a4_&J's.ta^
manager put it "the Committee have said this is what Social Services will do, will offer assessment to^anygne (with the right score), but obviously to make a score you have Jo dojan j^ssessmpnt, so we are in a bit of a Catcji 22". "ATsec^ond Shire manager said "I think we are being advised to give everything that comes through the door a score". In recognising the "cart before the horse" nature of this advice, he went on to say that "a lot of the practices in the Department are quite idiosyncratic", with many people, in j!is_vj£wj. havinjj^^^ Another manager
■. admitted that they write to some referred people refusing an assessment because mey_do..nof meet_th.ecrjteria. This seems to be against agency policy as weM as inequitable in the context of an ethos of needs-led assessment. Both ethos and policy would suggest that no judgement should be made prior to an assessment
One middle manager in Shire admitted that the latest policy on the system was unclear in her mind. Another was much more positive aboutv .;
JHhe system^ in I'
that they could deflect complaints "pii to^genc^_policy andjiway from ^ Lfp^"orja]^ecislon-malting In order to do this care managers must be clear arjolirwtaT^^ policy is. In addition, the latest policy needs to be
readily available to potential service users. In Borough, the system is far less prescriptive, so that the result is more flexibility, more imaginative use of resources, but the danger of less consistency, decisions being open to judicial review (only in Borough did I hear concern about diis eventuality), and care managers feeling unsupported and open to complaints being directed at them.
Procedures and Equal Opportunities
There was quite a deal of evidence of care managers routinely and V (v. deliberately omijfagjo^
. \ service usgrs Six care managers, between both authorities, stated that they □"o'not routinely complete this task that some admitted was supposed to be mandatory. The reagpnsgiven were to.do with user disinterest, or inability
\W
■ J 3>\
Cars Management and the Subversion of Policy 51
tQ.understend^due. to dementia or learning difficulty. One manager from Shire even claimed it was because users wanted fr^snyjR th* JTSSS." As implied above, itjna£wejl__be^^ low expectations have
resulted in a widespread display of apparent disinterest," Other care managers were clear about the need to give people their care plans and assessments, as of right, and felt that the onus was on them to explain why this was important.
My conclusion, on this evidence, is that there is probably a widespread, belief amongst care managers that service users are not really interested jn being involved in the process beyond giving information and receiving a service. The dangers of this leading to a practice that denies service users access to information that would be of use to them in making informed choices is worrying. It is another example of the opportunities practitioners have of using their discretion to undermine policy intentions.
3. Implementation of the Principles of Community Care
There are aijx areas, most already mentioned, that define the princjnjgs^of mmmmiitycare policy. To what extent are these principles being undermined? "
Service User Involvement
I have already said much about the widespread assumption that users are generally nfiUntgreated jn anything afiaiyrgjnuJge$^ their needs. If this assumption continues, the intentions of a user-focus to assessment will not be realised and policy intentions will be undermined. It was interesting to go through the interview transcripts and note the_ replies to the question of who was involved in^decjsion-making_ following aji.as^essi"nerit Qlily ten out_of the \1 care_managers_ sajcj the user or the carer should be. That does not mean that they are not, of course. The point isTthat when asked who should be involved in an assessment, user and carer did not immediately come to mind for a substantial proportion of careraanagers. TJe^sme'^in^can be made jbr the general provision_pf information in relation to assessment and care .packaging. The practice of providing information is very patchy in both authorities. Information provision is a key aspect of the care management cycle (Social Services Inspectorate 1991a, 1991b) and service users are less likely to be involved or enabled to make choices unless they are well informed.
52 Care Management and Community Care
The difficulties of being user-centred were honestly admitted by care managers in both authorities. It is much easier, when working with a user who has poor, memory or severe^ learning disability to take over, particularly when they have no carer willing or able to assist - "you shouldn't do it (make assumptions about service user needs) but I think sometimes we do". Time constraints on care managers are considerable -"the reality is that you can't sit around and dp it with them". Committed care managers admitted to being unable to sustain their and-discriminatory practice under considerable time constraints, - "we're not very good_at' sending the forms back_ fgr themto sign, i|'§J:ime and pressure". The way this undermined morale and confidence was painful to see.
There was a comjnonjyjield belief that ady^^cy^^uld^be^jole for^arejnanagers. Acting on users' behalf in trying to gain access to scarce resources, educating ser^jc^jjggr^Jnto the best ways to_acsess services themselves,1iow t^]ieJ,Fjjjs^s.1^e.,.m/^^
interested in actual services, which may not meet needs for that individual were all believed to be important roles for care managers. Such was the level of role confusion, however, that many care managers were notjure whether agency policy allowed-them to do this work or not. This, again was undermining of confidence.
The Relationship with Carers
Involvement of carers was generally at a higlier level, t|ian„wjrti^eryice userg., One care manager was anxious about this aspect of her practice, recognising that it was time related but d is empowering of the user. There was evidence from occupational therapists and some other care managers of a greater emphasis on listening to carers and not users - "I usually am much more comfortable in involving carers particularly as a lot of my clients have got a degree of mental impairment". Despite this, there was some evidence 'of imaginati^gractice with users to try and include them to the best of their ability, and recognition from at least one manager of the sophistication of practice necessary in resolving, or managing differences of opinion between user and carer, often where there was a substantial power imbalance between the two.
/
J—■   .rtl .fcj II |J  ll-J ^iflll T ■ II
Care Management and the Subversion ofFolicy 53 Choice and the Mixed Economy
Many of those interviewed revealed hpstijity towards the independent ^5lQr which was described as ideological - "I don't think you can'trust the care of anybody, especially elderly people, to private concerns where they have to rpake a profit and they have to undercut". Others were dismissive of the quality of service offered - "they are so unsophisticated". There was also, however, concern expressed about the inflexibility of in-house Home Care Services. In this case independent sector agencies were seen as more responsive. There was little evidence of a burgeoning mixed economy of care services from these interviews. It was unclear, however, how sophisticated the information was that care managers were drawing upon. If such a knowledge base was not routinely developed, how can care managers know what is available within a mixed economy of care, across a formal and informal spectrum?
Community Care Plans and Sfrategic Planning
Community Care Plans were not mentioned as sources of knowledge for either practitioners, managers or service users, although they were intended by the legislation to be one of the forms of information provision that would improve services. Care managers are the eyes and ears of departments. Data collection for strategic decision-making will be much the poorer if care managers can not be persuaded that they have a part to play in this. Team managers in Shire and the senior manager in Borough felt that care managers need to be more actively involved. One manager said that failure to establish a clear role through a more academic approach to learning "makes it very difficult to get staff to_identify service deficits ...as we get more money-led we_need these deficits to show up and they are not". Care managers could be more involved by routinely being fed back information based on the collective data derived from their individual assessments. For this to happen they must be persuaded.of the importance of de^ci^recording, as well as balancing needsried assessment with unreal expectations. "In this sense the future of implementation is in the hands of these street level implementers, and the degree to which they are to be encouraged to participate in rather than resist agency activities will be a key to successful implementation.
54 Care Management and Community Care Financial Confrol and Service Deliveiy
Changes in accountability and flexible use of resources by people closest to users has been argued as a key way to provide needs-led services. Accountability and budgetary control has been largely decentralised in both agencies. Respondents enjoyed the opportunities to provide more imaginative and user-led services. This was, after all the negative versions mentioned above, an example of the existence of discretionary power which held the potential to develop policy according to intentions, rather than undermine it. Any loss of this discretion, it was believed, would result in a reduction, in quality of service, particularly in the waythat services responded to individual need.
Miilti-Disciplinaiy and Inter-Agency Work
Most care managers are operating in a multi-disciplinary setting and feel happy to be so. There was some evidence of unease, however, particularly from recently qualified and unqualified staff. This seemed to be to do with perceived status, although, I felt that there was some concern that lack of role, clarity left care managers vulnerable when working with^fonexample, health workers who were believed to have a clearer idea of their role. The senior manager in Borough expressed concern about the lack of confidence being displayed by care managers in this area of work. He believed that training was very important, and hoped that in-service training, as well as diploma in social work courses would address this area more. Occupational therapists in both authorities and care managers in Shire were less likely to reveal such concerns, and there was a fair deal of evidence, particularly amongst the more experienced practitioners that they felt comfortable and well-equipped to be practising within a multi-disciplinary setting.
Conclusions and Implications
The influences an care management practice in these two local authority social services departments are nothing like as clear as can be detected from reading guidance manuals and other local and central government documentation. When it comes to localised practice the tensJ_on^between discretionary_b_ehayigur and. prescrjrjfiye procedures finds care managers caught in'a.web of uncertainty. In these circumstances we find practices
Care Management and the Subversion of Policy 55
are inconsistent, roles.are_unc|ear, and opportunities For flexibility at its bes^nd confusion at its worst, are rife. There is a professional agenda expressed by many care managers, and tfilei? lnanag«ir"Tt^™not"'a consistent discourse, however, and there is evidence of more than one professional agenda. I had described to me a more tradhignaLpractice. wJiiclUsJndLY^ ft is an approach which
draws upon a medical model of disability, and is at odds with the more contemporary approach of user-centredness within the policy guidelines. There is also evidence of a very" proced_ural^ approach, which borrows heavily from managerial interpretatia ns~o£ care management. Lastly there is'"a"more contejnjw^^ practice which is informed by;
principles  of user JnyjDl verge nt,   needs-led  assessment,  choice andj empowerment. This practice is not exclusive to qualified social workers, | although it is congruent with contemporary social work values (Banks 1995; CCETSW 1995).
These interviews would suggest that the procedures outlined in the Shire guidance manual and the Social Services Inspectorate document which serve as the principle source of procedural guidance for care managers in both authorities are 'more honoured in the breach'. The procedures provide a knowledge base for practice which has not been accepted by many care managers who are using their scope for discretion to undermine policy intentions. I have read many social services department care management guidelines and the Shire document is one of the better ones for clarity of practice and intent. It isvery^nrocedurai, but does, as one Shire care manager said "describe good practice". Role confusion in care management.is partly to do with resjstapcejo what is, seenjis an alien culture by care managers. The definition of a client in the Shire Guidelines as 'someone on whom the Department is spending moneys is the kind of 'value in action' that care managers resist. As one put it very prettily - "It makes my gorge rise".
This fieldwork indicates that social workers can make the shift in role and yet retain the fundamental tenets of contemporary social work values. Values are a crucial area for a complex reflective practice such as care management. Social workers are better educated for this approach to working with uncertainty, but the evidence suggests that the values of anfi-discriminatory andanti-racist,^ close to care managers
thoughts when practising. Being, user focused,, being aware, of Ji^need: to balance competing, demand^ - and appreciating
tfip. .effeGts:-j}f ynrecogrijsed-^ are all crucial to. the
i?—!   s—i  m   r i   *  i   i:' \   a—i  f~i  *—i
r
J
5 6  Cans Management and Community Care
development of empowering practice, which most care managers expressed a commitment to. It is also a key aspect of community care policy.
There was little evidence of needs-led assessment. Resource ayai]a.biJily, in both~rype'"and quantity, are"'thejnafofinfluence^ on assessment practice. Care managers do not routinely record service (deficits they come across. Being resource led, there is none to record. By over-reliance on carers for information, by assuming users .are not interested in being, involved and by not passing on-documentationjo them, care managers also fail to routinely involve service users in decisions that crucially, effect theix liyes'."" These practices, if replicated in other social services departments, are undermining the intentions of government policy in community care.
The lack of interest and knowledge of agency and inter-agency procedures, especially in relation to service development and strategic planning, largely as a result of suspicion of senior management coupled with a focus on individualism in assessment and care planning, is also a great barrier to the success of the community care enterprise. This is again unfortunate, in thaTservice d eve fa pme^is^going to be a key element if service users are going to be able to have anything other than Hobson's choice with regard tD services. The result in relation to the particular needs of marginalised groups like black service users, will be very negative. Better communication between senior management and care managers through bureaucratic processes such as deficit recording and ethnic monitoring could hold the key to greater awareness and understanding, but only with a commitment to sharing information.
Targeting of resources on the most needy is not an efficient use of resources according to the evidence of diese interviews. Engaging in mending broken informal support networks is also an ineffective way of maintaining vulnerable people's quality of life. Resources going into prevention and_early identification would provide an effective role for care managers, increase morale, save money and provide services"f6Jninrove quality of life. This would seem1 to be one of the areas in which care managers' critique of policy strikes a chord.
It is important to recall that I carried out these interviews in 1994. It might be expected that, one year into community care policy implementation, care managers would inevitably be struggling with these issues - trying to work out how to marry up their skills and knowledge with the expectations upon them. Whilst this is a valid perspective upon the
Care Management and the Subversion ot'Poiicy SI
findings from these interviews, there are two points that need to be made. Firstly Shire had made most of the substantive changes in relation to organisation and practice two years before implementation on April 1st 1993. Care managers in that authority had experienced the expectations of change over a long period and yet what they were telling me and what their colleagues in Borough were relating (in both positive and negative senses) was broadly the same. The second point was one that I was not to know at the time of my original analysis of the research interviews in mis chapter. In the months after constructing this analysis, I presented these findings to gr9HR5.Pf.Mr? managers who were carrying put.very similar roles to those interviewed in Shire and Borough, at workshops in other local authorities. This occurred prior to the instigation of the co-operative inquiries described in chapter nine. There was admission from most of these participants that much of what I had iearnt was still the case two and three years, into implementation. With this explanation and hindsight, I am not
.cojjyinSSOJS^^ w(tli't'fiie' implementation of ajiew, policy.
I—, C^0n|y c(ajm tjiat this is my interpretation Df practice within
these two authorities. They all received a copy of the report I wrote for the agencies, upon which this chapter is based, but I received little validation of this despite asking participants for their views on my findings. A couple of first line managers replied that it was much as they expected, and the senior manager in Shire expressed irritation but not surprise by what I had learnt. The care _managers, however, were silent. The validity of my learning is, therefore, suspect Imd tins "was "an area for further exploration in itself.
The gap between expectations of practice from policy guidance and actual behaviour by care managers is, however, clear from my interpretation. I have documented the difficulties that care managers had in describing or analysing the origins of the knowledge that informs their practice. I have tried to convey some of the richness of their text in the way I have offered direct quotations. If that seems somewhat thin, then I believe that is a reflection of that struggle that many of them had in defining the knowledge base to their practice. Such reflection is not a routine activity for care managers even if it is considered widely in contemporary social work analysis to be fundamental to any notion of developmental social work (Gould and Taylor 1996). I was still left with not oniy the question of what knowledge base care managers do draw upon in analysing their practice, but also how they go about the process of