Published: 20/12/2001, Volume III, No.5786 Page 21

As MPs headed off to their constituencies (or anywhere but) for Christmas, Iain Duncan Smith made it clear that he will go into 2002 determined to take risks with Tory policy towards Britain's embattled healthcare system - in the hope that it will do him good in the long-term.

Long-term care, eh? We are all in favour of it in theory, though I predict that the devolved administration in Scotland will come under renewed pressure from Whitehall to rethink its generous promise - social as well as medical care for ailing elderly people - now that Gordon Brown's protégé, Henry McLeish, has stepped aside for Jack McConnell.

But back to Mr Duncan Smith and the Great NHS Debate. He used a BBC TV interview to revive that old chestnut, charging patients for a visit to the doctor, something his health spokesman, Liam Fox, ruled out as recently as the summer.

'It is a living lie that Labour tells, that says this [the NHS] is absolutely free.

Everybody who uses it knows that in certain categories you pay - The public already know they're paying.

The problem is they do not get the service that they feel they ought to, ' he said.

That is IDS-speak for more money and, as you know, he wants to raise that extra wonga via charges and top-up insurance for those, and their employers, who can afford it. You and I both know the case for and against such policies - probably so does IDS, even if he didn't a month ago. But if Messrs Blair and Milburn want a Great Debate, this must be part of it.

Mr Duncan Smith used end-ofterm question time to raise a more interesting point. If the prime minister says that 8 per cent of national income is the EU average spend on the NHS, and that 8 per cent would solve our problems, why is it that many health outcomes in Scotland, Wales and Ulster - where NHS spending is already 8 per cent - are among the worst in Europe?

Part of the answer is historic and cultural, the product of a brutalised industrial culture in which the industries may have faded away but not their unhealthy legacy - bad diet, poor education and housing.

But it is also a useful reminder that, as Lord - sorry, Mr - Derek Wanless noted in his report, the answer is not all money: genes and lifestyle matter. In his fascinating Sunday night BBC TV series, The Threads of Life, Robert Winston (he really is a Lord) made the same point. Scots can hold their booze for the same reason that 50 per cent of Chinese can't:

adapted genes.

I digress. Ministers want to persuade voters that the difference between Labour and Tory is that they want the NHS to be free at the point of use, even if BUPA is doing the operation.

Dr Fox and IDS contend that the 'great division is not between our parties, it is between members of the government' - mainly Gordon Brown vs the Rest.

There is, alas, some truth in this. Someone you and I both know looked me in the eye recently and said the chancellor had told his best friend in politics: 'I got married, We are having a baby, why are you still prime minister?' That tension is another theme for 2002.

Here may be another. I rang Labour's Andrew Mackinlay about a challenge he made to health minister John Hutton during exchanges on the excessive cost of hiring agency nurses -£6m per trust, according to the Lib Dems.

How are records of such nurses being improved, 'bearing in mind that recent police investigations have been hampered' by inadequate records, the fearless Mr Mackinlay asked.

Mr Hutton sounded a bit stumped, as he was when the Thurrock MP bearded him in the tea-room.

Mr Mackinlay was scarcely more forthcoming with me.

Suffice to say he is investigating the possible connection - only theoretical, he stresses - between a series of hospital deaths in different areas, and casually hired agency nurses who can't subsequently be traced. Far-fetched?

More so than charging a tenner to visit your GP?