The latest round table – ‘Social care at a crossroads’ – run by David Brindle was published yesterday (The Guardian 10/08/2011) . Brindle was joined by a very distinguished cast (including the minister, Paul Burstow, and the health select committee chair, Stephen Dorrell) to discuss the recommendations of the Dilnot report, with its call for ‘better integration of health and social care’. I wonder if I’m alone in thinking that these exercises at ‘The Guardian’ have run their course. Plenty of good points get made, but I’m struck by how little the content of the debate seems to have changed in twenty years. The language has changed but we were just as preoccupied with silo-thinking, and integrating services, in 1991 as these high flying commentators are now. Conventionally, this is taken to be inertia, exposing a lack of will and conviction. But is it time to reflect on why it hasn’t happened rather than carry on insisting with ever greater hyperbole and systemic flights of fancy that it must? Perhaps formally integrating services doesn’t work very well. Perhaps the purportedly seamless movement of ideas and products in consumer markets is a poor metaphor for the exchanges that underpin good care. Perhaps an uprooted, interactive, professionalism just isn’t for the most part liveable, its exemplars important but atypical. Instead we might consider the importance for individual services of their being well-led at local level and their having an identification with place. We might let go of the rhetoric of choice and aspiration and try to root services in how people actually live from day to day (as examined in Denise Tanner’s recent penetrating studies). We should relentlessly expose the paralysis that follows from poorly administered top-down changes (at Subco Trust, whose work was prominently identified during the discussion, the staff are currently on half-pay, and with no sense of how long their jobs will last). And we should stop trying to enshrine systemic proposals in legislation – how much more effective it might have been to pass Lord Ashley’s Independent Living Bill and give those who want it the right to personalise their services, than pursue the Independent Living Strategy, with its assumption that everyone and every need can be co-opted within the same grand aspirational design.