Some reading may be optional - but Richard Barker’s book 2030 - The Future of Medicine is essential. It is based on unusual joint experience - of the UK and the US systems and of health system with scientific research.

Healthcare, according to Barker, is heading for meltdown. “The warning signs are there, the crisis is already being predicted, but unlike the financial meltdown it will unfold over years, not weeks and months.”

The merchants of life are there with more genetic testing, more diagnostics and personalised medicine - and very little will reduce cost. Even if the unit costs of a procedure falls, volume will rise through greater convenience and lower risk, and with it total expenditure.

Demand growth from new empowered patients is there, but so even more prominently is our old friend SID: supplier induced demand.

Barker quotes one particularly poignant example of a young woman with chest pain who visited a clinic in the US and ended up with a bill for $4,000 dollars for her ECG, chest x-ray, blood count, blood chemistries and cardiac enzymes. The $4,000 came after she had refused a CT scan of the chest at $1,500 to rule out pulmonary embolisms.

None of it worked, so she went to a physician in her native Guatemala who gave her ibuprofen - “and of course she got better”.  

The predictions of Ivan Illich about rapid medicalisation are at last coming back to haunt us. A useful part of Barker is showing that this time the “growing dilemma”, a.k.a Robert Maxwell, won’t go away.   

The bill for healthcare would ideally need to rise at 6 to 9 per cent a year in real terms in order to cover the cost of ageing (rather conservatively estimated at 1 per cent), higher expectations of baby boomers at 1 to 2 per cent and the higher costs of new technology at 2 per cent. Add to this the cost momentum of the system - on past experience around 2.5 per cent - and we easily get to 6 per cent or more: where are the younger tax payers to pay for this?

The most novel section is on solutions, where Barker uses his deep experience of the US and the UK to make a detailed case for a medical middle way where the UK gain in universal access is delivered by managed care incentives which keep down cost.

He lists ten possible “levers for healthcare productivity” from the British and US systems. The ten levers used together could move towards integration. But can they hold back cost? Cochrane thought that the coming of evidence based medicine would be a brake; in fact it has been an F1 class accelerator.

The Barker levers need attention and set a new agenda which is spelled out not just for government, but for employers and patients. If we don’t make the levers work we may have to fall back on a cruder alternative - an axe or a hammer.