I’ve stayed out of the NHS debate. These days I spend lots of time in countries like Bangladesh, Kenya, and Guatemala, and viewed from those countries – where health workers and essential drugs are often missing – you wonder why the fuss over the NHS. Everybody has a doctor, primary care is strong, and access to specialist care is easy. What’s the problem?

Of course, there are problems—deep seated ones. But so much of the debate seems to be about superficial and highly emotive issues, not the deep ones that may overwhelm us. I thought this as I found myself last week in a discussion with three old warhorses of NHS policy and a group of bright young NHS managers. I was there in my performing monkey role (one I enjoy), but I was struck with the contrast between the discussion we had and the frantic one that goes on in public. I was reminded too of one judgement on why Hillary Clinton’s attempt at health reform failed: it was a technical solution to ethical problems. The same might be said of the current US reforms even though they are a “success” in that a bill was forced through Congress. And it’s surely true of the NHS reforms (and reforms of reforms) as well.

Our conversation in London began with whether we had too many acute hospitals. Of course we do, said the warhorses. Worse, they said, we have a system dominated by hospitals. People don’t seem to have noticed that health needs have changed dramatically. Healthcare is now mostly about caring for people, usually elderly, with multiple conditions. For many of these people social care is more important than healthcare, yet you must pay for social care but not healthcare. The traditional medical model of “diagnose, treat, cure” is almost finished, but we have a health system designed for patients with acute conditions dominated by hospitals, specialist doctors, death denial, and drugs.

Britain is not alone in this, and most policy makers recognise the need for fundamental change. For example, Scotland’s 2005 report Building a Health Service Fit for the Future recognised the need and has a table that compares the current system with what is needed: we must move from hospital to community, from doctors to teams, from reactive care to preventive care, from passive patients to active patients, from self care being rare to being common, from carers being undervalued to being true partners, and—this one surprises—from low tech to high tech. This last shift doesn’t mean more robots or scanners but rather sophisticated use of information technology, something common in many sectors but woefully underused in healthcare.

So the policy wonks know what needs to happen, but it doesn’t happen because of huge vested interest. Doctors unfortunately are the best paid and most influential part of that vested interest. Doctors are comfortable with hospitals, specialisation, disease, treatments, and drugs. Hospitals will fill up as surely as motorways and prisons, and it’s very hard to go backwards. In technical terms we have “supply driven healthcare,” but cutting supply is tough—and certainly beyond most primary care trusts.

Our next conversation was whether the NHS would be able to meet the “Nicholson challenge” of making efficiency savings of 4% compound a year for four years to save £20 billion.  No chance, agreed the warhorses. The NHS has never managed such savings and nor has any health system anywhere. And much more difficult is overcoming the “scissors of doom,” the upturn of an aging population with increasing demands and the downturn in a working population able to fund the care for the elderly. All developed countries are affected by the scissors and without fundamental change may go bankrupt one after another.

What then will happen if the Nicholson challenge cannot be met? This is where our conversation descended to the short term and the tactical, but we don’t seem to have even that conversation in public. The answer is probably as always that the NHS will “muddle through.” Some more money will be made available (possibly taken from sectors like housing, social services, the environment, or education that might do more for health than the health services), waiting lists might lengthen (although the prime minister insists not), some hospitals will close, and there will be lots of hidden, low grade rationing of services for the old, the mentally ill, and the marginalised. But in the long run it will not be enough.

We might have thought pretentiously that we were having the debate that mattered most, but we never once mentioned climate change and the huge carbon footprint of the NHS. That debate is even more important.