What is wrong with the NHS?

I certainly don't, even though it is now more than 20 years since I first sat down to dissect the workings of what was then called a local health authority.

It ran hospitals, and oversaw most other aspects of local health care. It was the grassroots level of the service, but even so it took a while for me to master its complexities and write about it with confidence.

Then they changed the rules, splitting hospitals and GPs ("providers") from the people who decided what levels of health care the area needed ("purchasers").

They've been shifting the goalposts ever since. Every time I thought I'd got my head round what was already an infuriatingly complicated organisation, it was transformed again. I don't believe any of those changes have made matters clearer for the people who pay the bills. That's us, in case you're wondering.

Now, with most labyrinthine Government organisations, the natural reaction is: "Who cares? What do the inner workings of this bureaucratic beast matter to the man and woman in the street?"

But the NHS matters an awful lot. Its vast empire reaches into the lives of virtually every family in the land, in the most vital ways.

Several years ago, when I was health reporter for this newspaper, I tried to explain what creating primary care trusts (PCTs) would mean to people in York and North Yorkshire. It wasn't exactly gripping reading. But that was before the money got tight.

That made our local PCT headline news. First it ran up millions of pounds in debts; now it's effectively rationing whole areas of health care in a desperate bid to claw the cash back. The Press has led the way in exposing the very real human cost of this.

Of course, the NHS is still doing a great job for many people, but its future looks increasingly uncertain.

How did this happen? How could NHS organisations go from ploughing cash into the system to meet and beat Government targets, to suddenly being held to account for vast overspending?

Different people in the NHS give different answers. A GP may have a contrasting view to a hospital consultant, a Department of Health official is unlikely to concur publicly with someone from a public sector union, and goodness only knows what the Health Secretary, Patricia Hewitt, thinks about anything.

Could it be that there's some conspiracy behind the confusion? It's more difficult for outsiders to criticise if they can't cut through the bureaucratic tangle to establish what has gone wrong, and why. They're also unlikely to know who to blame.

True, there are occasionally changes at the top of hospitals and PCTs when things go wrong. But how often do the departed simply move to another NHS job? (I don't, incidentally, advocate the usual supposed cure for all NHS ills - getting rid of the managers. Most NHS managers I have encountered were doing their utmost to make the system work.) Recently a doctors' group said a free NHS was just a "political mirage". My growing fear is that delays and gaps in provision will push those with any spare cash at all to "go private", and the health service will deal only with those on benefits and emergency cases (if the latter are lucky enough to be near to a hospital which provides for emergencies, of course).

This could, of course, just be a paranoid fantasy.

Not all "NHS reform" is bad. At York Hospital a new members' council, local people who will oversee its activities, has just met for the first time, part of the change to foundation hospital status.

But the hospital trust board, which makes the decisions, will meet in private, and the papers it considers will be private, too.

Does that matter? It does if you want to know how the hospital is spending our cash, or how it's coping with waiting times or MRSA - issues plucked by The Press from the board papers in recent months.

I still don't know how the NHS works. But I have an idea when something is going wrong, and I reckon that's happening now.