This book has provided evidence, derived from actual care processes, that commercial patterns, no matter how modified, are inappropriate for any health care system aiming to cover the whole lives of whole populations, at optimal efficiency. Health gain for whole populations cannot be produced efficiently as a by-product of investment for profit. Under present UK and EU company laws, wherever responsibility for service is contracted out to private sector providers, they are compelled to ignore such evidence, and subordinate the needs of society to commercial ambitions. The consequences are concealed by laws guarding commercial secrecy, and by politicians and media commentators apparently incapable of thinking outside a provider/consumer box or of imagining any cooperative rather than competitive society in practical terms.

Fully rational development and use of medical knowledge for all who need it requires a gift economy, congruent with the shape of continuing clinical decisions in continuing real lives. In such an economy, staff and patients could learn together, from their own successes and errors. They could learn to work in new ways, harnessing the reserves of motivation and goodwill that are now frustrated or wasted by confining patients and communities to consumer roles, magnifying wants and ignoring needs. Such an economy would depend on levels of personal trust which are unsustainable in commercial transactions. Its own cooperative processes could build that trust, instead of eroding it by pillorying staff for unexpected outcomes.

A gift economy in health care is justified not only because it could be happier, more imaginative and more human, but because it would probably be more efficient. It would probably promote sustained commitment by staff and intelligent participation by patients, thus expanding resources at little or no additional cost. Because it would support sceptical appraisal of claimed innovations, rather than credulous acceptance of promoted wants, it could expand at a sustainable pace, similar to that of experimentally proven advances in science. Because its processes would be open to public scrutiny, not cloaked by commercial secrecy or falsified by promotion, we could see the negative as well as positive consequences of our decisions, and learn from them.