Published: 20/03/2003, Volume II3, No. 5847 Page 19

I missed Dr Liam Fox's 'patient's passport' speech at the Tory spring conference in Harrogate, but for a very persuasive reason.

I was on a small volcanic island in the midAtlantic watching Tony Blair and George Bush make their high-profile final effort to cajole France into lifting its veto on military action against Iraq.

But Dr Fox's plans were in my mind. I had put the Conservatives' policy document, Setting the NHS Free, in my bag to read on the plane to the Azores.

Losing my notebook in the security mêlée which always surrounds US presidents these days, I used the policy document's blank pages to write down what Messrs Bush and Blair said at their press conference. Thanks Liam.

But on the way back I did peruse the text and next morning read the Fox speech on the internet while the diplomatic effort to avoid war ticked away in the background.The Tories have been persistently unlucky with publicity since Iain Duncan Smith took over in the very week of the 9/11 attacks.

Was Dr Fox unlucky or was the modest publicity (200 words in the Telegraph) a blessing in disguise? Last week's summary of the policy in HSJ highlighted its promise to 'dismantle target culture' and bureaucratised management culture by giving every hospital foundation status.

He wants to build up PCTs, a way of restoring GP fund-holding by other means.

NHS GPs are admired round the world, the text points out.

But HSJ also briskly noted that 'the bulk of the [Fox] document echoes and extends existing government policy'.

That sort of remark infuriates politicians who are prone to what Dr Freud once called 'the narcissism of small difference'. How dare you say my policy is like his! ? But high above the Bay of Biscay I had the same thought several times.

What Dr Fox seems to be trying to do is reject the centralised and 'collectivist' 1948 model of the NHS with its 'inefficient, monolithic' structure and lack of choice or incentives for better quality of care. 'Politicians, not clinicians, dictated decisions on the nature of care.'

Hence the Tory drive to restore what sounds like a golden age when kindly clinicians took decisions in the interests of their patients rather than (as occasionally must have happened) their prejudice or their golf swing. Labour's 'obsessive target culture' has undermined managerial as well as clinical freedom - managers please note - distorted priorities and undermined morale, he says.

Even Dr Fox has the grace to admit, mid-text, that the trend towards input-driven, waitinglist obsessions dates chiefly from 'the last 10 to 15 years' - ie the age of Ken Clarke and Virginia Bottomley at the Department of Health.

By the same token his 'one size fits all' jibe at health secretary Alan Milburn ignores Milburn's determined effort to decentralise, which may or may not succeed. Dr Fox's 'patient's passport' remedy depends on its failure.

It is a form of voucher, an idea that has been touted by free-market economists (rarely by elected politicians) since the '70s as a remedy for failing schools and hospitals and is regarded by critics as a way of allowing the better off - or the street-smart poor - to do better at the price of leaving the bottom third behind.

'Tory leader champions middle class, ' as the Telegraph's headline explicitly states. What it would mean is that if you needed a hip operation the NHS (actually your GP) would give you the 'passport' cost - say,£5,000 - to buy the op at any public or private hospital, but have to pay any extra yourself.

Dr Fox's motive is buried in his Harrogate speech. Whereas 85 per cent of UK health spending comes from the NHS and 4 per cent from private medical insurance, 11 per cent comes from self-funding - ie cash payments by patients. That is the sector which is growing at 20 per cent a year: 250,000 cases last year.

By encouraging people to spend more on healthcare he hopes to stimulate private investment, choice and funding of the NHS 'based on real activity, not block contracts', he argues.

Money will flow between NHS and private providers based on a 'national tariff system' of set costs.

Oddly enough, I think you may find that Mr Milburn is already busy in that very territory.