Steve Richards: The abiding lesson of the NHS is that people still look to the state in their hour of need

Like an ageing rock star selling out stadiums around the world, the NHS continues to transcend the apparent fashion of our times. Long ago, the political and media establishment turned its back on most services that are publicly owned. Fearful ministers hand them over to anyone that wants them, from Richard Branson to anonymous members of non-elected quangos.

Most recently, remember the visible fears of Gordon Brown as he was dragged towards the state ownership of Northern Rock, and also how over-excited David Cameron and George Osborne were in their disapproval when Brown made his reluctant move.

Yet most voters looked to the Government for help in the Northern Rock crisis, as they do when they fall ill. There are some that yearn to break up the NHS, but it is too popular for them to articulate their dream in public. Political fashion is more complicated than it seems. Although the simplistic slogan "get the state off our backs" resonates for a few seconds, most people turn to the state for help and will do so even more amid the wild fluctuations of the global economy

Indeed it is one of the ironies of the current political situation that there is greater recognition now about the necessity of government intervention than there was in 1997 when a tentatively defensive Labour administration won a landslide. Then it was too scared to intervene even in the hopeless railways. Now everyone is arguing for more intervention in the once-mighty mortgage and banking industries.

Yesterday's launch of Lord Darzi's NHS review was preceded by a pamphlet published at the end of last week on the Government's broader approach to public services. At a time when Brown is being savaged from all directions, it is worth noting that the pamphlet is subtler and more sophisticated than equivalent policy statements issued by Tony Blair during his final years in power. Towards the end of his prime ministerial career, Blair tended to stay in his comfort zone, proclaiming what we had been hearing since the early 1980s, that choice, competition and private providers were the way forward. This was an easy message to convey, supported by virtually every newspaper and the Conservative Party.

That does not mean Blair was wholly wrong. He was right to seek ways in which to lift the public sector out of a conservative complacency that can lead to appalling inefficiencies and indifference to users.

But delivery of a public service free at the point of use is far more complex than Blair suggested. He never had the courage, or inclination, to put the case that government must inevitably play its part as well. Brown dares to do so. He is cautious in his boldness, fearing a single comment that suggests he is turning away from "reform". In the pamphlet, Brown dutifully stresses the importance of choice in public services, but makes clear that only an elected government with democratic legitimacy can ensure that fairness and social mobility are not undermined.

Democratic legitimacy is surely important in a supposed democracy, but the point is often lost. As patients or parents, we can get rid of a government. We cannot remove a private contractor so easily.

Later, the pamphlet again states the obvious, that without support from government some will be able to make more use of choice than others. It gives the example of education, where genuine choice for pupils can take place only when all schools have fair admissions policies. The document also outlines in detail the positive roles a government can play, as a protector of standards, a long- term investor and as a capacity builder. Again, this is a statement of the obvious, but if no one states the obvious the argument that governments can play a constructive role is lost. Much of the pamphlet focuses on Blairite/Cameron terrain, empowering the users and local providers. But it also makes clear that none of this works without the resources and direction that a government accountable to the voters provides – the missing argument since 1979.

Nowhere is this more obvious than in the policy area of health. One of Brown's successes was to persuade GPs to open their surgeries at weekends. This would not have happened without the political will at the centre and the increase in resources that accompanied it. GPs do not become more accessible by accident.

It is the reluctance of GPs to accept that we do not all fall ill between the hours of nine and midday four mornings a week that highlights a flaw in the Conservatives' approach. Responding to the anti-politics mood of our age, the Conservatives propose more sweepingly to devolve decision-making to the practitioners.

Yet on the basis of their recent protestations, the first decisions the practitioners would make would be to work less and earn more. The Conservatives' approach to the NHS was framed when the party was behind in the polls. Their current position should give them the confidence to think again. As matters stand, if they win the next election they will take the flak for raising the cash for the NHS through taxes. Then they would hand it over to some of the more conservative forces in the public sector to decide how it would be spent.

Imagine in government George Osborne explaining to his activists that although he is spending a fortune on the NHS, and therefore cannot cut taxes, he has no control over how the cash is spent.

In the Government's NHS review there are similar tensions over the balance between the centre and the local, reflected in the desire to end the post-code lottery and to allow a thousand local flowers to bloom. It is a conundrum without obvious resolution. The Government raises the cash and is accountable for how it is spent, yet local providers need more freedom to respond to the needs of individual patients.

The review does not address the other great dilemma, how to meet the unconstrained demand for health care when public spending is limited. As Charles Clarke has argued, the introduction of co-payments is a possible way forward. The review also fails, or does not dare to learn, the lessons of the smoking ban, that direct government action can lead to increased personal responsibility. Again, at some point soon some patients will have to pay for treatments brought about by their own behaviour. The threat of financial penalties will reduce the level of obesity as quickly as the smoking ban has cut the amount of cigarettes being lit.

Still within the familiar political and economic constraints, the Health Minister Lord Darzi makes strides by focusing relentlessly on the need to raise the quality of care, navigating deftly between the justified demands of patients and his extensive consultations with those that work in the NHS. As the CBI noted yesterday, if these reforms are introduced there is a chance that Britain will get the world-class health service it is paying for. A year ago Brown knew that the Government had to change tack subtly. Amid the growing storms on this at least, he follows a steady course.

s.richards@independent.co.uk

Interesting? Click here to explore further