opinion POLITICS

Published: 30/01/2003, Volume II3, No. 5840 Page 19

Whether or not you agree with Frank Dobson's angry outburst on GMTV's Sunday-when-We are-all-still-asleep programme, it is hard to disagree with the connection he made between foundation hospitals and Charles Clarke's new scheme for university top-up fees.

In the past few days I've heard several Cabinet ministers make the same link with varying degrees of enthusiasm - and Labour MPs with dismay.Opposition health spokesman Dr Liam Fox is set to publish a scheme to reimburse private hospital patients 60 per cent of the cost of what an operation would cost on the NHS.

'Hospital top-up fees', was how one of chancellor Gordon Brown's advisers described them.

Both Blairites and Brownites want to open up access to the best public services to the poorest.

Under the 'law of inverse care', they agree that those in greatest need often get the worst health and educational treatment. In his Camden speech - the one interrupted by anti-war hecklers - Mr Blair argued that Labour had confused universal services with uniformity of service.

The question is, how to do it.

'Dull uniformity or downmarket equality' results in the middle class buying its way out of the public sector.

'The result is elitism or worse on the basis of ability to pay.

That is the real two-tierism, ' the PM insisted. I am sure that health secretary Alan Milburn agrees. I do not think Gordon Brown does.

That is why Mr Milburn is groping towards a devolved, localised hospital and - more important, surely - primary care service. On Sunday morning television, old Dobbo, Mr Milburn's predecessor at Richmond House, also disagreed. You could probably make a case for top-up fees for the top 10 world-class research universities, but not for introducing market forces into the entire system at£3,000 a pop annually, plus maintainance.

'Universities are already foundation institutions, ' newish education secretary Charles Clarke reminded me the other day, legally independent and free to charge and borrow in many ways. 'There is one iron rule of market systems and that is the best-off get the best deal and the worst-off get the worst', plus debts of£15,000, Mr Dobson counters.

So far as I can tell, Mr Brown resisted the option of a graduate tax, partly because the money would take a long time to start flowing in, partly because it would count against public borrowing (loans will not). But he also wanted the extra cash to flow into the Treasury for him to dole out, not go direct to the universities to do as they see fit.

Sounds familiar? It parallels the NHS debate. Mr Dobson and Mr Brown are warier of markets; their position is more paternalistic, more statist - more socialist, you might say. Yet even they back public-private partnerships to rebuild our hospitals and rail networks. Inconsistent, surely, critics like University College London's Dr Allyson Pollock would argue.

My heart is with them, but my head is with Blair-Milburn and even the bearded Clarke.

'The proportion of working class kids going to university is no better than it was 40 years ago, ' snaps one Milburn ally. 'What put them off was lack of aspiration to become doctors or whatever; it obviously wasn't money since it was free.'

So new methods are being devised to pursue greater equality, but also efficiency: that is the Blair-Dobson divide.Dobbo says choice is a luxury when there is an excess of healthcare supply over demand, Blair and Milburn say it is a driver (modish word) of expanded supply.

Ditto college fees which may - in theory - be zero, not£3,000.

Which leads us to fears voiced by health unions that the supply of doctors and nurses will dry up if training costs so much.

Well, the Milburn-Clarke axis is working on that. The NHS already block-buys university training for nurses, though it cannot stop them going straight off to work for BUPA.

Doctor training is still in the hands of the higher education funding council - less responsive to demand too, Mr Milburn might add.

Either way, I suspect that extra funds that will flow in with these changes will be used in part to create 'golden handcuffs' to pay a nurse or doctor's way through college in return for serving the NHS a specified term.

The armed forces have been doing it for years.

My son's oldest friend studied physics courtesy of the RAF and now flies rescue helicopters off the Scottish coast.A fine woman she is, too.