When Ken Clarke (KC) became Secretary of State he was concerned to try and make the service much more accountable to its patients, and to stop it being so borne down by bureaucracy and dominated by industrial relations problems. The idea of NHS Trusts was to give more autonomy to the local users of services so they could answer for their performances to their local public. KC states that before the purchaser/provider discussions nobody really knew what the NHS was spending its money on, and the idea that the money given might be linked to the outcomes was never contemplated. He found that the old ‘asylums’ were absolutely shocking places so it was perfectly sensible to introduce this policy of care in the community, provided it was integrated with hospital care by psychiatrists and others in a coherent way. Regrettably, the public believe that whenever there is extra money in the health service it ought to be spent on cancer patients or children, not on mental health, and populist Secretaries of State in populist governments accede to these requests, especially on cancer, a subject that terrifies the public so they feel if politicians spend more it might go away.