Picture the scene:

A huge hospital ward; bare walls and floor; bright enough, but all windows above head height; a stale smell. 28 young men with severe learning disabilities gathered in one corner, some in wheelchairs, some in armchairs, some sitting, some lying on the floor.  Clothes with names on but not matching the occupant, and all poorly fitting; nappies hanging round knees and some men with nappies tied round their necks to catch dribbles and spills. Three staff sit at a table in the opposite corner – smoking and drinking tea. Tea arrives for the patients, milk and sugar all round, stirred into the urn. 

Where are we, and when? Possibly England in the early 1900s, or more recently in a Romanian orphanage under the Ceausescu regime? In fact this was a long stay hospital near London just 25 years ago. 

Following my social work training and early career in progressive London boroughs, I took a job as service manager close to home. It would fit with family commitments and would be something different, I thought. Well it was certainly different and shaped the next 10 years of my career, working as both hospital resettlement manager and then commissioner developing community-based schemes to enable people to move on, ultimately resulting in the closure of three long stay hospitals – the most challenging but most rewarding part of my 35 year career. 

Thankfully, the government at the time recognised the need for change and the resettlement  programme proceeded at pace, supported by capital funding, transitional funding for double running costs, and revenue initially to support people moving out, but leaving this in place for future generations.  

Progress has continued. We have shifted from ‘professional knows best' to greater partnership with people using services and their carers, support focussed on the needs of people, and more holistic approaches, with initiatives such as the Better Care Fund providing a catalyst to join up health and care. The choice of services is no longer restricted to day centre, care home or home help, and for many people, direct payments have given enormous opportunity for choice and control.  

Of course, all is still not perfect. The Transforming Care programme and CQC reports remind us that change is still needed, and simply moving services from hospital to community does not, on its own, prevent institutional practice. I have learned that the best way to integrate health and care is not via organisational change. In both my authorities we have unpicked section 75 arrangements and are now looking at outcome-based alliance approaches to deliver more integrated support in partnerships that extend beyond health and care, including housing and the voluntary sector. 

Many councils, like my own, have successfully transformed services so they are fit for the future and more efficient. Our work to bring the staff teams together across Richmond and Wandsworth will net a benefit of £20m.

Great progress, but we are now at a new crossroad. Growing numbers of adults with disabilities, many of us living long into our old age; increased expectations; a shrinking public purse. Some councils are already struggling with overspends. The precept and Improved Better Care Fund will help, but won't solve the problem long-term. Integration of services and a strong focus on prevention are the ‘right thing to do,' but these approaches won't deliver the savings required. Councils and practitioners will continue to innovate, and find ways to make things work on the ground, but a more radical national shift is needed.  

The current system is too complex, even those of us working in the field find the system impenetrable as we try to access care and support for relatives. 

What might a changed system look like? Perhaps there is a future role for local government in leading integrated community services? This could be part of a national approach to the delivery and funding of a joined up system of health and social care. 

All are agreed, things need to change, and councils up and down the land, along with the Association of Directors of Adult Social Services and other partners will continue to make the case, with continuing optimism, that the nettle will be grasped before the system falls over. 

Cathy Kerr is director of adult social services at Richmond upon Thames RLBC, Wandsworth LBC and a trustee of the Association of Directors of Adult Social Services (ADASS)