Not for the first time in its 60-year history, the British National Health Service (NHS) is going through difficult times, but what makes the present ‘crisis’ so significant is that it comes at a time of an unprecedented growth in funding. Moreover, since 1997 a Labour government, ostensibly the saviour of the NHS, has presided over it. Paradoxically, however, as this book puts it, ‘something has gone terribly wrong’ (p. 12). In the words of another policy analyst, it is a case of ‘doing better, feeling worse’. A lawyer by background who has worked in the field of disability, Michael Mandelstam is not an academic and this book is not a research-based critique of the new NHS. As the title implies, it is at times a passionate and angry polemic on what the author sees as the dismantling of the NHS by a government that in 1997 committed ‘to save it’. Grappling with this paradox lies at the heart of the book; the author does his best ‘to describe policies and decision-making in the NHS that seemed, on their face, to be harmful’ (p. 9). The perspective adopted is that of the informed member of the public struggling to comprehend the events of recent years in terms of their impact on local services amidst endless discussions of closures and service rationalisation. Mandelstam's savage critique takes a swipe at just about every one of the many government initiatives since 1997.

There are several recurrent themes, including the government's lack of transparency and adoption of policy by stealth and concealment. In particular, Mandelstam accuses the government of privatising the NHS in a way unimaginable and certainly never clearly spelled out in the Labour Party's 2005 election manifesto. Other themes which crop up regularly are the cynical and manipulative way in which the government and local NHS organisations seek to consult the public but in fact do so having already made up their minds as to their preferred course of action. Mandelstam quotes Orwell on the art of doublethink so endemic to NHS policy-making.

Much of the book, especially its later chapters, deals with the impact of the successive changes under New Labour on vulnerable groups such as older people and people with mental health problems. Especially-depressing are the presented case studies, which demonstrate how little has changed from decades ago when health services were being accused of ageist practices, and when there was clear evidence of a lack of joined up working between the NHS and local authority social services. It seems that whenever finances are squeezed and whatever urgent targets have to be met, it is the complex needs of vulnerable care groups that suffer. Instead, attention and resources are focused on the ‘worried well’ and on ensuring that waiting-list and access targets are met. What becomes clear is that while the government talks yet again about the need to shift from a focus on ill-health treated in hospital to improving health in primary-care and community settings, the consequence of the policies and changes it is putting in place are likely to be quite the opposite. Instead of improved partnership working and integrated care pathways across primary and secondary care, the likelihood is one of greater fragmentation, with vulnerable people falling between services. Competition rather than collaboration, and choice rather than ensuring good local services are in place, are the order of the day.

The book leaves the reader frustrated and angry at the lack of accountability for what is happening and for the cynical way in which managers twist the evidence and the facts to fit the political line emanating from the central Department of Health. The English Parliament feebly stands by and is quite unable to hold the government to account, despite the valiant efforts of the House of Commons Health Committee, to track and comment on events. Locally, there is virtually no accountability. Inevitably, perhaps, the book is at its strongest on what is wrong with the NHS and almost silent on what should happen to remedy its numerous flaws and failures, many of which, as noted, are far from new and cannot be laid wholly at the Labour government's door. But as Mandelstam rightly says, the issue is not that there was a golden age or that there should be no change. Change is needed and people would be supportive of it ‘if an effective, well evidenced, fair and comparable alternative is in place’ (p. 19). One cannot help thinking on closing the book that we are all culpable for the mess described in painstaking detail. We get the politicians we deserve and if we share Mandelstam's view that they are betraying the NHS, then we need urgently to change our politics. Ironically, this seems to be the one area of contemporary life where real choice is wholly lacking.