As the political parties mobilise for the conference season it is tempting to believe there is broad consensus about the future of the NHS. But three debates that go to its heart are raging.

As well as the impassioned row over the justice and wisdom of allowing top-up payments for drugs, health policy is being buffeted by a crucial decision on the extent to which the NHS can offer everyone equal health, as opposed to equal access to healthcare.

Meanwhile, in the wings - the right one, to be precise - think tank Reform is again raising the spectre of a two tier, insurance based health service.

Argument over the extent to which the NHS can overcome socially and economically driven differences in quality of health and length of life has moved from academia to the Department of Health’s secretive advisory committee on resource allocation. In practical terms it means: does the service continue the trend of increasing funding for deprived urban areas, or does it shift more money towards relatively affluent and rural areas with significantly older populations?

Other principles

As well as being an issue of principle, there is a financial management argument which cannot be avoided - areas with older populations tend to have more money problems.

The Reform report Making the NHS the Best Insurance Policy in the World entertains the fantasy that an insurance based scheme would “depoliticise healthcare”, an assertion which may surprise the public sector unions massed at the TUC conference this week. But it highlights the failure of the NHS to achieve equity in health. Despite its universal provision, the UK is ranked bottom in terms of social equity in a list of eight leading economies.

The NHS is doing much to tackle inequalities, from increasing GP cover to improving screening. But the service cannot hope to overcome the growing gap in life expectancy by pumping more and more health resources into deprived areas.

There is widespread acceptance that the biggest determinants of health inequalities are differences in income and socioeconomic status. The government is raising false hopes by giving the impression that these profound disparities can be overcome by some shrewd commissioning from the local primary care trust. It needs to be more honest about inequalities’ causes and cures.