The NHS is not what it used to be.

In the early days, an ambulance driver was asked to report for work with a jacket and tie. They were given a hat to wear and the keys to the ambulance. It was the days of scoop and run. If they looked like lasting at the job it was suggested they should take a course in first aid. In their own time, if they were interested.

Now, paramedics arrive at the scene with more skills and equipment than were found in the early Casualty departments.

We know that the growing number of elderly people is a pressure on the NHS. As is the growing number of people with chronic (long term) conditions. We are getting better at keeping ourselves alive for much longer.

We also know that the bulk of our health care is given by GPs and community nurses. They provide 90% of our contact time with the NHS but using only 10% of the budget. Many hospitals are underused and expensive to run. Planned day surgery is now very efficient, but many older hospitals continue to exist with huge estates, heating bills, and wards which are little different to nursing homes – but free.

But any politician worth their salt knows that they must be very careful if they say that hospital X needs to change, and to never say it needs to close. Even government ministers will defend every hospital in their constituency, even against their own collective policy. Why would you give up any part of the hospital, especially if any savings go back to the Department of Health, never to be seen again.

So, devolving budgets on NHS spending to local areas in England is the latest attempt to square this circle. The promise is, if you go through the political pain of changing hospitals, you will be allowed to keep the money saved to spend on other parts of the NHS, especially in community health and social care.

In Greater Manchester we can already see this emerging, for example with the proposal to change Wythenshawe Hospital to only do planned surgery and no more emergency care, which is concentrated at Manchester Royal Infirmary. If you believe that emergency care starts with the paramedics, and that travelling a few extra miles for expert care doesn’t matter because your care has already started, and that the money saved from an underused hospital will stay in the local NHS, then maybe you will support this decision, or at least not vote against the politician on the TV next time.

But if your children were born at that hospital, if your grandparents died there, if your sister survived her appendicitis there, then you might feel differently, even if you agree with the logic of spending more money on people and less on old boilers and heating systems.

If politics is the art of the possible, then devolved NHS budgets is an experiment in whether it is possibly to reconfigure health care with the support of local communities.

And a big factor will be the Department of Health itself. If devolution is just about “managed decline” in the provinces while the department happily gives new money to other places, usually the so-called elite hospitals in London, then the political setback will be for generations to come.

The big question in devolution, it seems, is not so much whether you trust the local politicians, but rather do you trust the national ministers and departments to not be devious?

And looking at the Northern Powerhouse idea and Network Rail’s “pausing” for maybe five years of major improvements across the north of England, the omens appear to be getting worse rather than better.

You could say that there is not exactly an abundant supply of good faith from government to local areas at the moment, and this risks undermining the idea of devolution if it just another way of making cuts. Transparent budgets and decision making at the national level is the missing key.