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The NHS is Britain’s beating heart – don’t let it flatline

After 30 years of meddling with the NHS, are we now at risk of destroying our most precious public s

I have hazy memories of my parents getting their first telephone. It was the late 1960s, and telecommunications was a public service. There was a waiting list but, in time, we got to the head of the queue. An engineer from the General Post Office installed the necessary equipment and we were connected - or at least, connected any time our neighbours weren't using their phone: ours was a "party line". I don't recall any grumbles about the tortuousness of the process, nor about having to share with the people next door. The sense of wonder at what was now possible must have mitigated any frustration. It was marvellous to be able to speak to relatives and friends from the comfort of home, without having to trudge to the phone box.

The National Health Service was viewed in much the same way. My father developed cancer when I was two years old. He was swiftly cured but irrevocably damaged, and he struggled thereafter with chronic ill-health. His illnesses had knock-on effects on various members of our family, myself included. Between us we saw a lot of the NHS. At the centre of it (to my eyes) was our GP, a good-hearted man with half-moon glasses and a somewhat distant manner. When he needed expert assistance, a referral would be made. Waiting times were sometimes long but were accepted with stoicism: the professionals we eventually saw did their best. Looking back, I recognise the profound comfort in those experiences for my parents, who had grown up knowing what medical care could be like - and its financial implications - before the advent of the NHS. No matter how threatening or scary things got, no matter what time of day or night, this health service was there to help and asked nothing in return.

In the mid-1980s, I entered medical school in Nottingham. Like most aspiring doctors, I knew what I was going to be: a public servant, working extremely long and often antisocial hours, the whole arduous endeavour sustained by a powerful sense of doing something important and worthwhile. I would be joining an unquestionable force for good, grouped under the fluttering blue-and-white standard of the NHS.

But even as I embarked on my training, society was changing under the Thatcher government. The emerging citizen-consumer was increasingly exasperated by the inefficiency of state monopolies; no longer could we tolerate waiting months to have something as commonplace as a phone line installed or repaired. Margaret Thatcher's solution was privatisation and exposure to market forces. British Telecom was sold off in 1984, two years after a licence had been granted to its first competitor, Mercury Communications. British Gas and British Petroleum soon followed. It was only a matter of time before government attention turned to the biggest state monopoly of them all.

I was nearing qualification as a doctor when the then secretary of state for health, Kenneth Clarke, published his 1989 white paper, Working for Patients. The huge, sprawling, multicellular organism of the NHS would be cleaved in two, hospitals becoming providers, wooing and responding to the demands of purchasers in a so-called internal market. Competition, survival of the fittest, would deliver a patient-centred NHS, something even the new breed of health service managers, ushered in by the 1983 Griffiths report, was failing to achieve.

The white paper was greeted with consternation in Nottingham. The city had two general hospitals. Each had the full complement of acute care services and they shared the emergency work, alternating days "on take" for admissions. Specialised departments were located at one or the other site. Co-ordinated by the health authority, they supplied virtually all hospital care for the local population between them, with little unnecessary duplication. Now they were to become independent trusts, no longer co-operating, but competing for each other's business.

The central dilemma with the model was: who, in practice, would the purchasers be? In any normal market, they would be the consumers. But in an era when most people's access to medical information was limited to the family copy of Home Doctor, patients could not realistically make informed decisions. The That­cher government's response was to invite GPs to become purchasers, controlling budgets on behalf of their patients. Generous management allowances and the freedom to reinvest savings provided incentives for uptake. Wave after wave of practices signed up, until eventually about 50 per cent of GPs - covering 60 per cent of the population - were fund-holders.

The Labour opposition was incensed by the scheme, arguing that it was creating a two-tier service. By this stage, I was working as a junior hospital doctor in a surgical speciality and the evidence was stark. The admissions office had a card system along the length of one wall, with a slot for each patient on the waiting list. The nearer a card moved to the left, the closer the admission date. Patients from fund-holding practices were flagged with red stickers. When any were in danger of exceeding the eight-week treatment time specified in the fund-holding group contract, they were simply bumped along, displacing those from non-fundholding practices who had already been waiting longer.

Unfair advantage

There were other perversities. A fund-holding practice's budget was set according to its activity in the year before entering the scheme. GPs routinely maximised referrals and prescribing in the run-up to budget-setting to ensure a decent allocation. It was not hard to make savings that could be reinvested. I spent a year working at a fund-holding practice in Oxfordshire in the mid-1990s. A consultant orthopaedic surgeon was contracted to run a clinic at the health centre every fortnight; patients had in-house physiotherapy and counselling. A handsome meeting room had been built and computers upgraded. Other practices opened branch surgeries; elsewhere NHS osteopathy and acu­puncture were made available. Fund-holding GPs and their patients had never had it so convenient or so good. Non-fundholding surgeries, such as the Oxford city practice I went on to join, were being left behind.

The 1997 election result was a great relief. True to its reputation as the party of the NHS, New Labour soon scrapped fund-holding and the internal market. Budgets were returned to health authority control in the form of primary care trusts (PCTs). I remember listening to the closing flourish of Gordon Brown's first Budget speech when he pulled from his metaphorical hat £1.2bn extra funding for the health service. Labour backbenchers sent up a raucous cheer, their reaction to the announcement reflecting my own surge of elation. Here at last was a government prepared to back the NHS with proper resources. The rhetoric of Blair's first term was about ensuring excellent health care for all, regardless of where you lived or who your GP was. New Labour, it seemed, was a party that understood our public service values.

National Service Frameworks (NSFs) began to spew from the Department of Health, dictating to doctors every aspect of the care they must provide for common, important conditions. I took the lead in my practice for the heart disease NSF; we welcomed it as a template against which to assess our standard of care.

All too soon, however, the rigid, controlling instinct of the New Labour regime emerged. The National Institute for Health and Clinical Excellence (NICE) was founded, its remit to abolish postcode lotteries in NHS treatment and further to promulgate a centralised vision of health care. Targets for hospital waiting and for access to GP care were imposed, spawning unintended consequences that inconvenienced or adversely affected more patients than they helped. The NSFs became incorporated into the 2004 GP contract as the tick-box-obsessed Quality and Outcomes Framework (QOF), straitjacketing doctors' ability to tailor treatment according to patients' individual needs. More and more managers were employed to survey and to audit and to enforce compliance with these various initiatives.

My GP colleagues and I have become press-ganged into the role of pill-pushers, the tyranny of QOF subjecting patients to bewildering and sometimes injurious choices of drug, irrespective of circumstances. The only way to practise holistically is to "exception-code" patients, removing them from QOF. But exception-code too many, and the managerial thought-police are quickly on to you - you're incompetent, you're a maverick, or even worse you are setting out to defraud. The distrust and disempowerment of dedicated professionals have been a kind of poison, choking off the immense goodwill that was the lifeblood of the NHS.

To compound matters, at some point during Tony Blair's second term, the decision was taken to revisit the Thatcher experiment. The language had to be distinct, so commissioners rather than purchasers would call the shots. And there could be no return to a two-tier service; all GPs were expected to become involved in the new, practice-based commissioning. Audaciously, Blair went where Thatcher had never dared to tread. The provider market was no longer to be internal: it was opened up to the private sector, treatment reimbursed at fixed-tariff rates. To kick-start the process, New Labour guaranteed returns to a number of independent-sector treatment centres (ISTCs), whose staff are often brought in from overseas, with qualifications, training and experience that are unfamiliar to local practitioners.

ISTCs have proved popular with many patients, who appreciate the plush facilities and short waiting lists that overgenerous block contracts have endowed. But, for the local NHS, there is uncertainty over clinical quality. One of my patients was given an inappropriate orthopaedic operation two years ago. The pieces are still being picked up by an experienced consultant at the local district general hospital. Nor is this an isolated case. Several other patients had to have camera examinations of their bowels repeated as part of a review of 1,800 procedures carried out at our local ISTC, following allegations of failure to diagnose cancer.

Even where quality of care is good, patients who have investigations that detect significant pathology then have to be referred on to consultants at the district general hospital, fragmenting their care and generating additional stress and anxiety, because ISTCs are not contracted or able to manage the conditions they diagnose. ISTCs have destabilised the existing NHS hospitals they rely on for safety-netting, cherry-picking patients at lowest risk and leaving the old providers to deal with complex, high-risk patients whose care is, as a consequence, more expensive. Training the next generation of doctors has been rendered problematic by the skewing of case-mix (patient categories) in medical teaching centres.

Franchised out

Allegedly to disrupt vested interests, New Labour also opened up general practice to the private sector. PCTs were compelled to award an increasing proportion of primary care contracts to commercial organisations. Under Lord Darzi's NHS Next Stage Review, every PCT was forced to commission a new "8-till-8" health centre - funded at levels a conventional practice could only fantasise about - the thinly disguised agenda being to expose existing surgeries to the white heat of (unfair) competition. The fluttering blue-and-white flag of the NHS to which I had once rallied has become a mere franchise, something to be waved by any organisation granted entry into the health-care arena, no matter its motivation.

In spite of the resources New Labour squandered to open up the provider market, practice-based commissioning proved an abject failure. By the time the policy was launched, PCTs had become mature, self-sustaining bureaucracies. With a few notable exceptions - where enlightened PCTs granted GPs substantial freedom of commissioning, and where some impressive innovations and efficiencies were achieved as a result - practice-based commissioning barely drew breath, smothered by managers unwilling to relinquish control.

The relief I felt last May when Labour was finally evicted was every bit as strong as that I'd experienced in 1997. Andrew Lansley appeared to be offering us the opportunity to reinvent the NHS as a modern public service - GP commissioning consortiums collaborating with consultants and other stakeholders to deliver joined-up, efficient, patient-centred care pathways. We had seen our efforts bear fruit in the few places where practice-based commissioning was allowed to flourish and there was an appetite to restore the public-service ethos that New Labour had so wilfully destroyed.

At what price?

Yet, in the months since the white paper was announced, clinician enthusiasm has been ever declining. Recent polls find only a minority of GPs continuing to back Lansley's plans and there has been an extraordinary convergence of concern among virtually every body representing the NHS, from unions such as the BMA, Unite and Unison, to the royal colleges of every medical and nursing discipline, to the NHS Confederation and various independent think tanks such as the King's Fund. There is anxiety about the pace and scale of the reforms, and disquiet about shifting responsibility for rationing on to doctors whose time-honoured role is to do their best for each patient. The show-stopper, though, is the picture that has recently emerged of Lansley's version of the provider market.

This is to remain external, with "any willing provider" (AWP) allowed to pitch for business under the NHS franchise. We have had more than enough experience with New Labour to appreciate the downsides, but the profession could probably live with AWP, relying on the commissioning process to factor in holistic care, were it not for Lansley's completely unexpected determination - smuggled into a brief mention when the Health and Social Care Bill was published on 19 January - to permit providers to compete not just on quality (as now), but also on price. The NHS regulator, Monitor, will be tasked with compelling this price competition. Far from collaborating with providers to design holistic, patient-responsive care programmes, GP consortiums will be bound by competition law and could face legal challenges, should they seek to work organically with selected organisations.

This surprise emphasis on price competition might at first seem reasonable, given the pressures on public spending. But the evidence strongly suggests that price competition lowers quality of care. One need only consider the NHS's single, disastrous experiment with it. Under the terms of the 2004 GP contract, PCTs were handed responsibility for commissioning out-of-hours care for patients, with no national tariff to adhere to. In order to win contracts, many commercial organisations bid low - either as a loss-leader to eliminate local, GP-led competition before increasing contract costs, or in the sincere belief that they could provide adequate care at bargain-basement prices.

In my own area we are all thankful that the PCT has continued to commission out-of-hours services from a not-for-profit company run and staffed by local GPs, which recently achieved second place nationally in a survey of quality. Elsewhere in the country, cut-price out-of-hours providers - by definition often dealing with patients with acute or life-threatening conditions - frequently depend on non-medical staff working to inflexible protocols, or on agency doctors who have little knowledge of local services, and whose language and communication skills can be markedly deficient.

At best, these apparently cheaper services consume more resources as inappropriate admissions multiply. At worst, patients needlessly suffer and die. All these services looked good on paper when the tenders came in. It takes a long time, and a lot of harm to patients, before deficiencies of quality become apparent; and it can be legally difficult to break a contract even when the provider seems to be failing.

Crossed wires

My family moved house recently. BT royally loused up the redirections we had commissioned on our old phone numbers. Innumerable operatives in call centres around the globe were unable to rectify matters, some simply hanging up when the going proved too difficult. In the end, even the high-level complaints manager we were allocated admitted it was beyond her power to put things right.

Disgruntled and nonplussed by BT's failure to make amends, we investigated switching providers, only to find that our contracts render any move prohibitively expensive. We are stuck, at least for the next year. Never mind, it really doesn't matter - it's only phones. But what if it did matter? What if this was a matter of life and death, or of life-enhancing care? What price would we then put on a health service that was there for us - not for profit - no matter how threatening or scary things were, no matter the time of day or night, and which asked nothing of us in return?

Phil Whitaker is a novelist and GP working in the south-west of England

This article first appeared in the 28 February 2011 issue of the New Statesman, Toppling the tyrants

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When it comes to responding to Islamic State, there is no middle ground

If Britain has a declared interest in curtailing Islamic State and stabilising Syria, it is neither honourable nor viable to let others intervene on our behalf.

Even before the brutal terrorist attacks in Paris, British foreign policy was approaching a crossroads. Now it is time, in the words of Barack Obama, addressing his fellow leaders at the G20 Summit in Turkey on 16 November, “to step up with the resources that this fight demands”, or stand down.

The jihadist threat metastasises, and international order continues to unravel at an alarming rate. A Russian civilian charter plane is blown out of the sky over the Sinai Peninsula in Egypt, killing 224 people, most of them returning from holiday, and the various offshoots of Islamic State bare their teeth in a succession of brutal attacks in France, Lebanon, Tunisia, Turkey and further afield. Our enemies are emboldened and our friends want to know to what extent we stand with them. The UK can no longer afford to postpone decisions that it has evaded since the Commons vote of August 2013, in which the government was defeated over the question of joining US-led air strikes against President Bashar al-Assad’s regime following a chemical weapons attack on Syrian civilians. MPs’ continued introspection is on the verge of becoming both irresponsible and morally questionable. There is no fence left to sit on.

On Sunday night, two days after the Paris attacks, the French – with US support – launched a series of bombing raids against Islamic State targets in Raqqa. With much more to come, the choice facing this country may not be easier but it is certainly clearer. Britain must determine whether it wants to be a viable and genuine partner in the fight against Islamic State, and in the long-term efforts to bring an end to the assorted evils of the Syrian civil war; or whether we are content to sit on the sidelines and cheer on former team-mates without getting our knees dirty. We can join our two most important allies – France and the United States, at the head of a coalition involving a number of Arab and other European states – in confronting a threat that potentially is as grave to us as it is to France, and certainly more dangerous than it is to the US. Alternatively, we can gamble that others will do the work for us, keep our borders tighter than ever, double down on surveillance (because that will certainly be one of the prices to pay) and hope that the Channel and the security services keep us comparatively safe. There is no fantasy middle ground, where we can shirk our share of the burden on the security front while leading the rest of the world in some sort of diplomatic breakthrough in Syria; or win a reprieve from the jihadists for staying out of Syria (yet hit them in Iraq), through our benevolence in opening the door to tens of thousands of refugees, or by distancing ourselves from the ills of Western foreign policy.

That the international community – or what is left of it – has not got its act together on Syria over the past three years has afforded Britain some space to indulge its scruples. Nonetheless, even before the Paris attacks, the matter was coming to the boil again. A vote on the expansion of air operations against Islamic State has been mooted since the start of this year, but was put on the back burner because of the May general election. The government has treated parliament with caution since its much-discussed defeat in the House in summer 2013. The existing policy – of supporting coalition air strikes against Islamic State in Iraq but not Syria – is itself an outgrowth of an awkward compromise between David Cameron and Ed Miliband, an attempt to reverse some of the damage done by the 2013 vote in parliament.

The Conservatives have waited to see where the ground lies in a Jeremy Corbyn-led Labour Party before attempting to take the issue back before the Commons. Labour pleaded for more time when Corbyn was elected, but there is no sign that the Labour leader is willing to shift in his hostility to any form of intervention. More significantly, he has now ruled out Labour holding a free vote on the matter.

If anything, the coalition of Little Englanders, anti-interventionists and anti-Americans in the House of Commons seems to have dug its trenches deeper. This leaves the Prime Minister with few options. One is to use the Royal Prerogative to announce that an ally has been attacked, and that we will stand with her in joining attacks against Islamic State in Syria. The moment for this has probably already passed, though the prerogative might still be invoked if Isis scores a direct hit against the UK. Yet even then, there would be problems with this line. A striking aspect of the killing of 30 Britons in the June attacks in Sousse, Tunisia, is just how little domestic political impact it seems to have made.

Another option for Cameron is to try to make one final effort to win a parliamentary majority, but this is something that Tory whips are not confident of achieving. The most likely scenario is that he will be forced to accept a further loss of the UK’s leverage and its standing among allies. Co-operation will certainly come on the intelligence front but this is nothing new. Meanwhile, the government will be forced to dress up its position in as much grand diplomatic verbiage as possible, to obfuscate the reality of the UK’s diminishing influence.

Already, speaking at the G20 Summit, the Prime Minister emphasised the need to show MPs a “whole plan for the future of Syria, the future of the region, because it is perfectly right to say that a few extra bombs and missiles won’t transform the situation”. In principle, it is hard to argue with this. But no such plan will emerge in the short term. The insistence that Assad must go may be right but it is the equivalent of ordering the bill at a restaurant before you have taken your seat. In practice, it means subcontracting out British national security to allies (such as the US, France and Australia) who are growing tired of our inability to pull our weight, and false friends or enemies (such as Russia and Iran), who have their own interests in Syria which do not necessarily converge with our own.

One feature of the 2013 Syria vote was the government’s failure to do the required groundwork in building a parliamentary consensus. Whips have spent the summer scouting the ground but to no avail. “The Labour Party is a different organisation to that which we faced before the summer,” Philip Hammond, the Foreign Secretary, has said. It is ironic, then, that the Prime Minister has faced strongest criticism from the Labour benches. “Everyone wants to see nations planning for increased stability in the region beyond the military defeat of the extremists,” says John Woodcock, the chairman of the Parliamentary Labour Party defence committee, “but after two years of pussy-footing around, this just smacks of David Cameron playing for time when he should be showing leadership.”

The real story is not the distance between the two front benches but the divisions within both parties. There are as many as 30 Conservative MPs said to be willing to rebel if parliament is asked to vote for joining the coalition against Islamic State in Syria. It seems that the scale of the Paris attacks has not changed their position. A larger split in the Labour ranks also seems likely. Even before Paris, there were rumoured to be roughly 50 MPs ready to defy their leader on this question.


At first, in the wake of last week’s attacks, it seemed as if the Prime Minister might force the issue. To this end, he began the G20 in Turkey with a bilateral meeting with President Putin. His carefully chosen words before and after that discussion, in which he was much more emollient about Moscow’s role, showed the extent to which he was prepared to adapt to the changing situation. Cameron hoped that if he could show progress in building an international coalition on the diplomatic front, that might just give him enough to get over the line in a parliamentary vote.

This new approach has not had the desired effect. At the time of writing, the government believes it is too risky to call another vote in the short term. It calculates another defeat would hugely diminish Britain’s standing in the world. In truth, the government was already swimming upstream. On 29 October, the Conservative-
dominated Commons foreign affairs select committee, chaired by Crispin Blunt, released a report on the extension of British military operations into Syria, in anticipation of government bringing forward a parliamentary vote on the question. The report recommended that Britain should avoid further involvement unless a series of questions could be answered about exit strategy and long-term goals. The bar was set deliberately high, to guard against any further involvement (even the limited option of joining the existing coalition undertaking air strikes against IS in Syria).

The most flimsy of the five objections to further intervention in the report was that it will somehow diminish the UK’s leverage as an impartial arbiter and potential peacemaker. This is based on an absurd overestimation of the UK as some sort of soft-power saviour, valued by all parties for its impartiality in Middle Eastern affairs. Britain cannot hope to have any influence on policy if it is always last to sign up while others put their lives on the line. As so often in the past, what masquerades as tough-minded “realpolitik” is nothing of the sort. It is just another post-facto rationale for inaction.

Although it is sometimes said that Britain has yet to recover from the consequences of the invasion of Iraq, the committee report had a retro, 1990s feel. Many of the objections raised to burden-sharing in Syria were the same as those raised against humanitarian intervention in the Balkans two decades ago, when Blunt was working as special adviser to Michael Rifkind as defence and foreign secretary, and the UK was at the forefront of non-intervention. Likewise, two of the committee’s Labour members, Ann Clwyd and Mike Gapes, were veterans of the other side of that debate, and strong supporters of the Nato intervention in Kosovo in 1999. They expressed their dissent from the report’s conclusions but were voted down by their Conservative and SNP fellow committee members. “Non-intervention also has consequences,” said Gapes when he broke rank. “We should not be washing our hands and saying, ‘It’s too difficult.’”

Polling figures have shown majority public support for air strikes against IS since the spate of gruesome public executions that began last year, but nothing seems to change the calculus of the rump of anti-interventionist MPs.

All this promises an uncertain future for British foreign policy. On 6 November, the Defence Secretary, Michael Fallon, suggested that the UK’s existing position, of joining the coalition in Iraq but stopping at the borders of Syria, is “morally indefensible”. The killing of Mohammed Emwazi, aka “Jihadi John”, by a US predator drone on 12 November demonstrates what he meant. Emwazi was a Briton who was responsible for the beheading of British and American citizens, as well as countless Syrians. While the UK government was closely involved in that operation – and has previously used the justification of “self-defence” to “take out” targets in Syria – such are the restrictions placed upon it that we are forced to ask our allies to conduct potentially lethal operations (which are in our core national interests) on our behalf. The very act of “self-defence” is subcontracted out once again.

How long can this last when Islamic State poses a much greater threat to the UK than it does to the US? There is an issue of responsibility, too, with hundreds of British citizens fighting for and with Islamic State who clearly pose a grave danger to other states.


The very notion that Britain should play an expansive international role is under attack from a pincer movement from both the left and the right. There are two forms of “Little Englanderism” that have made a resurgence in recent years. On the left, this is apparent in the outgrowth of a world-view that sees no role for the military, and holds that the UK is more often than not on the wrong side in matters of international security, whether its opponent is Russia, Iran, the IRA or Islamic State. The second, and arguably just as influential, is the Little Englanderism of the right, which encompasses a rump of Tory backbenchers and Ukip. This is a form of neo-mercantilism, a foreign policy based on trade deals and the free movement of goods that regards multilateralism, international institutions and any foreign military intervention with great suspicion, as a costly distraction from the business of filling our pockets.

The time is ripe for long-term, hard-headed and unsentimental thinking about Britain’s global role. The country is not served well by the impression of British “decline” and “retreat” that has gained ground in recent times; and it is no safer for it, either. Given how quickly the security and foreign policy environment is changing, the publication of the Strategic Defence and Security Review in the coming week, alongside an update of the National Security Strategy, is likely to raise more questions than it answers. The officials responsible for its drafting do not have an easy brief, and news forecasting is a thankless task. Strategic vision and leadership must come from our elected politicians.

For all the talk of British decline, we are still one of the five wealthiest nations in the world. What we do matters, particularly at moments when our friends are under attack. However, until a new broad consensus emerges between the mainstream Labour and Conservative positions on foreign policy, the Little England coalition will continue to have the casting vote.

Syria continues to bleed profusely and the blood seeps deeper into different countries. There will be no political solution to the civil war there for the foreseeable future; to pretend that there is a hidden diplomatic solution is to wish to turn the clock back to 2011, when that might have been possible. Nor is the security situation any easier to deal with. A few hours before the attacks in Paris began, President Obama gave an interview in which he argued that he had successfully “contained” Islamic State. For the wider Middle East and Europe, that is simply not the case. Now, France will escalate its campaign, and the US will do more. Russia already has troops on the ground and will most likely send reinforcements.

The war in Syria is becoming more complicated and even more dangerous. The best that can be hoped for is that the Syrian ulcer can be cauterised. This will be achieved through the blunting of Islamic State, simultaneous pressure on Assad, and the creation of more safe places for Syrians. All roads are littered with difficulties and dangers. Yet, in the face of this ugly reality, is Britain to signal its intention to do less as every other major actor – friend and foe alike – does more? If we have a declared national interest in curtailing Islamic State and stabilising Syria – both because of the growing terrorist threat and because of the huge flow of refugees – then it is neither honourable nor viable to let others take care of it on our behalf.

John Bew is an NS contributing writer. His new book, “Realpolitik: a History”, is newly published by Oxford University Press

This article first appeared in the 19 November 2015 issue of the New Statesman, The age of terror