What is happening in local government at the moment is quietly revolutionary, for several reasons. Firstly, the way devolution is happening turns on its head the historic approach to local government reorganisation. The reorganisations of 1974 and 1997 were done in the usual way. Parliament passed an Act. A commission of the Great and the Good was formed. Rutland was abolished, then created again. People in Metropolitan Borough X and County Y fulminated that what was being done to them was terrible. Decisions were eventually taken (The 1974 reorganisation took three years, 1997 nearly five). And then pretty much everything went quiet and local government carried on much as before. 

This time, it’s different. This time, the Government has simply asked the question of localities; how do you want to organise yourselves?  So, devolution is for real, and it is happening now. And so is devolution’s closest partner, integration. As part of the CSR announcement, the Government has said that even those authorities who don’t want to take advantage of the powers in the Devolution Bill must come up with detailed plans on how they will integrate their health and social care systems to be implemented at the latest by 2020. 

Why does any of this matter? It matters because for the first time elected people (or person, in the case of a Mayor) will have under their direct control all the levers of power in one area. So, instead of the Cabinet member for Adult Social Care thinking, “I’d really like to do something about keeping people with learning disabilities in my area out of acute healthcare, but actually, as that cost is picked up by NHS, I have other priorities”, and instead of the CEO of the Local CCG thinking “I’d really like to do some preventative work to stop people ending up in my hospital, but I’m not actually allowed to spend any money on that”, we will instead have a proper overview. It becomes worthwhile for Manchester (say) to invest money in identifying and trying to work with all the people with learning disabilities in Manchester and to find ways to support them to live at home for as long as possible, because the long term benefits will come back to Manchester. 

All of which sounds very simple, but there are some obvious risks along the way. One of them is that this all makes us think hard about how we provide health and social care, and what it looks like. One of the things it looks like is (whisper it softly) fewer hospital beds. This carries real political risk. Not many politicians are willing to run on a “Don’t Save My Hospital” ticket. So integrating health and social care will take political courage. It will also mean bringing the public along. There is a real challenge to everybody involved to try and engage the public. The fact is that no health and social care system in the world will be able to cope with the demographic changes that are coming over the next generation without making radical reforms. The need to make sure that this is understood by the general public and that change is not simply imposed from above should be a top priority for all politicians and leaders in both health and social care.

There is one more risk which is with us right now. The Chancellor in the CSR announced a number of measures intended to support social care which is generally acknowledged to be facing a crisis. As ever, the devil is in the detail and there remain serious concerns that when the dust settles, social care may not survive in its current form long enough to see through the transformation that is to come. Pretty much everyone agrees that an integrated health and social care system is the right way to go and that the long term prize is great. The risk that we run right now is that the patient will die on the table.

Adam Penwarden is Project Director at Lifeways Group