This paper overviews the emergence of a philosophy of “consumer-direction” in personal, home, and community care for the disabled elderly in North America and Europe. Consumer direction is associated with direct payment schemes and other mechanisms that support user choices in the purchase of care, user empowerment and independence. To illustrate the strengths and limitations of consumer direction in practice, the paper analyses interview data collected from users and providers of existing care arrangements where elders and families choose and/or hire, supervise, and manage their “own” homecare workers who are self-employed. Interviews conducted separately with care users and providers illustrate how structural and interpersonal power related to financial, social and geographic proximity affect the way independent care arrangements are established, and maintained. Power issues embedded in marketized arrangements suggest the need for caution against wholesale adoption of market principles in social provisions for serving elders.
