It is the Hewitt-Blair vision of US-style competing hospitals which causes offence to activists in Wales

Two conversations at different ends of the M4 motorway highlight the yawning gap between the way the NHS's future is seen as it struggles to adapt and survive.

In an affluent suburb of Cardiff the other sunny evening I watched supporters of Wales's first minister, Rhodri Morgan, canvass for Labour votes in the 3 May assembly elections. By chance I discovered two NHS managers among them. They see health secretary Patricia Hewitt's talk of choice and contestability of services as less relevant than the harsh facts of life up the valley in Merthyr Tydfil, where some can expect to live eight fewer years than in the suburbs.

'It's all about diet, about giving up smoking, about the education of children and getting people into work. Waiting times and waiting lists are irrelevant for most people, most get treated within three months,' said one. From this perspective - not universally shared even in Wales 'where income does not equate with how you vote' - primary care and public health are much more important.

Welsh Labour has already introduced its smoking ban and this month added free prescriptions, which my new friends fiercely defend. Only one in three now pay them and the charge covers far fewer than one in three scrips, they add. 'People still ask the doctor 'which is the most important pill you want me to take?' because they can't afford them all,' says one.

As a visitor from the market culture of the South East, I ask if free scrips will gradually unleash unaffordable levels of demand. Isn't that part of the price mechanism, to dampen down demand? But no, it is the Hewitt-Blair vision of US-style competing hospitals which causes offence to activists here.

Inadequate healthcare is the number one campaign ('you'll see 'save our hospital' posters right across Wales,' Plaid Cymru's Adam Price told me) with Labour's rivals accusing it of planning to close hospitals, wards or services after 3 May if it retains power. The ambulance service doesn't even aspire to English performance levels, bemoans the Western Mail.

Back along the M4 in Whitehall the outlook is very different. Chatting to a government official as the quasi-Tory pressure group Reform tells Ms Hewitt that free healthcare has become a 'political mantra' that is no longer economically realistic, I mention Nuffield Hospitals group's withdrawal from the protracted negotiations to provide a new generation of mobile independent treatment centres in the West Midlands.

Is this a blow, I ask? Not necessarily, is the reply. Remember, the two big private health players in the UK are Nuffield and Bupa, and both have been found wanting as overseas bidders for NHS work have provided overdue competition - as has the NHS itself in reducing waiting times and lists.

The pro-market lobby would say at this point that the NHS near-monopoly since 1948 has squashed real competition in healthcare: all that is now changing, as former health secretaries Alan Milburn and John Reid and Mr Blair intended. How much chancellor Gordon Brown wants it is unclear. Even though Ms Hewitt is apparently working closely and well with him on pay policy and budgets (both tight), she does not know either.

You may have read that Bupa is planning to sell its hospital division. Who would buy it? Enter stage right Alliance Boots. My Whitehall chum is very keen on Boots, with whom the Department of Health has had an unsung 'brilliant' partnership promoting management of long-term conditions and self-care, including sexual health. Young people are happier taking a chlamydia test at Boots than at their family GP.

But Boots is currently being fought over, Godzilla-like, by private equity groups KKR and Terra Firma, whose boss, Guy Hands, would also snap up Bupa's hospitals as part of a global healthcare strategy. Scary stuff or part of the emerging pan-European health and pharmacy market?

Scary and challenging actually. It is not that Whitehall is right, Wales wrong, or vice versa. Small countries are 'wealthier and healthier', says Plaid Cymru's election manifesto. But they still need Boots. Just like the French elections, it's about getting the right mix. -

Michael White is assistant editor (politics) of The Guardian.