Is our NHS debate avoiding the key issue? The talk is of another reorganisation of the NHS and greater efficiencies enabling the NHS in England to face the future. But the overall challenge goes much deeper, and the politicians dare not address it. As well as the pressures of demography and inflation in health care costs, the health service faces what it has always faced - public expectation of ever better health care means an ever greater proportion of our national wealth has been spent on health. Now it is said that this must simply stop. But does this hope - one in a long history of so far unrealised hopes -simply obscure the more painful reality. One way or another, privately or publicly, our health care ambitions have to be paid for, and we are failing to decide how.

In 'Unhealthy Expectations' Michael Blastland looks at how this problem has loomed for years but never been faced - at least not in open political debate. He explores what the real choices are if constantly improved care is to be provided - and whether this must mean either much higher personal taxes or a population prepared to pay much directly for care. Or is there a realistic way of squaring the circle of rising demand within fixed budgets?