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Among the changes the Labour government has brought to health and social care, the idea of effective patient and service user involvement and choice is, or is likely to be, the greatest cultural shift of all. It attempts to turn us all from passive recipients into experts in our own conditions, with the right (or should that be responsibility?) to contribute towards our own well-being, both through our actions or through our participation in making decisions.

Although professionals in the field recognise how dramatic an effect these changes will eventually make, it is clear that many service users and carers are being left behind in their understanding of what their role is meant to be in the new vision.

For example, when we have been discussing health services in our service user groups, many people have struggled with the recent structural changes. Many service users regularly use primary care and acute services but still find it difficult to distinguish between the roles of acute and primary care trusts. Many people still expect to be told what to do by health professionals. They still see the NHS as a seamless, if monolithic, service provider.

In the same way, the re-organisation of social services provision is running the risk of involving service users and carers without ensuring either a full understanding of their roles, or a true commitment to the process of change. I don't believe that this is for any ulterior motive, but because there is a lack of understanding of the mentality of dependency which has been ingrained in service users, and a lack of an effective voice for carers, for such a long time.

Carers and service users may have complained long and loud about unresponsive service provision that doesn't meet their needs but for many a state of learned helplessness set in a long time ago. This means that they will find it difficult to engage effectively in shared decision-making, particularly if first efforts don't reap immediate rewards.

Has anyone put any thought into retraining service users and carers, as well as the professionals?