This important book makes for uncomfortable reading. The Private Eye column by M.D. recently commented that the National Health Service (NHS) ‘pools everyone's risk and money, and the rich pay for the poor. This provides a decent, often excellent but occasionally dreadful service’. ¹ However, the author of How We Treat the Sick Michael Mandelstam claims that neglect or abuse are, in fact, ‘a systemic, rather than sporadic and opportunistic, affliction within our health services’ (p. 34).

The reader is repeatedly led from individual cases of terrible failures of care to institutional reports and responses, from the specific to the systemic and back again. These parallel levels of description will sit relatively easily with most clinicians, familiar with the dual perspectives of epidemiology and evidence-based medicine on the one hand and anecdotal clinical experience on the other.

It is sometimes difficult to discern the book's thread in the litany of examples. However, as it progresses a pattern emerges. Various specific areas where care can fail – dignity, continence, hospital-acquired infections, eating and drinking, pressure sores, etc. – are described in successive chapters, as are some potential causes, such as understaffing or distracting ‘targets’. Since older adults make up two-thirds of users of the NHS, they rightly receive a chapter devoted to them, entitled ‘The Unwanted’. The backdrop to all of this is the thesis that local failures stem from a ‘systemic blight in the health service’ (p. 358).

The book's purpose is to give a coherent voice to those who have been failed. Until the final pages, it does not attempt to offer solutions, which is just what Mandelstam accuses central government of doing. Many groups will attempt to rebut his accusations with claims that things have indeed changed. Frustratingly, many of these reforms merely tackle superficialities and ignore the enormous strain caused by caring for sick and suffering people as described by Isabel Menzies Lyth in 1960. ^{Reference Menzies Lyth2} Caring for people is extremely challenging and expecting anyone to do so in adverse, under-staffed conditions, with little or no emotional support, is asking for trouble, as the people given a voice in this book bear witness.