An heroically ambitious document that gives the NHS hope

Comment: Donald Macintyre

Aneurin Bevan, it is safe to assume, would have wholeheartedly approved. He would no doubt be bewildered at first by some of the details in the NHS plan unveiled by Tony Blair and Alan Milburn yesterday - such as the expansion of NHS Direct and the rebuilding of the service's wobbly IT system.

Aneurin Bevan, it is safe to assume, would have wholeheartedly approved. He would no doubt be bewildered at first by some of the details in the NHS plan unveiled by Tony Blair and Alan Milburn yesterday - such as the expansion of NHS Direct and the rebuilding of the service's wobbly IT system.

But he would surely have been delighted by the breakdown of ancient demarcations, which will give rapidly expanding numbers of nurses greater clinical responsibility. He would admire its consum-erism. He would be especially pleased by the emphasis on reversing health inequalities that allow markedly higher rates of morbidity in deprived areas; he would have welcomed the emphasis on disease prevention. But, above all, he would have approved the central thrust of the report - that Labour still regards a tax-funded NHS as the best means of delivering universal health care.

For one of the most interesting chapters in the plan is the one that seeks to demolish the other methods of financing healthcare, from charging, to employer-based private schemes to private insurance. Whatever else, the plan gives the lie to the idea that there is no difference between the parties on health care. True, it envisages greater use of private sector facilities by the NHS where appropriate. But this remains NHS care free at the point of service.

The difference between that and William Hague's clear wish to see an expansion of private health insurance may look narrow - but it is very deep. And part of Mr Blair's great gamble is that this will appeal as much to Middle Britain, by relieving it from the costs of private care, as it should to Labour's heartlands.

In theory, the Government might have produced its plan and then made the additional funding conditional on its implementation - instead of producing the funding first and the plan second. But this is probably the right way to go about it for several reasons.

First, to attempt this wholesale reform without the funding - amounting to a one-third increase in real terms over the next five years - would have meant that lack of money would have been cited again and again as the reason the service could not be improved.

Second, while the Government has largely dismantled the competitive system of the internal market bequeathed by its predecessors, it has replaced it with one of incentives, which will mean that the more a hospital trust or primary healthcare group reforms and performs, the more it will enjoy "earned autonomy" about the way it deploys its resources.

It's that which provides the answer to the criticism that Mr Blair and Mr Milburn are trying to micro-manage the NHS from the centre. Only the under-performing centres of health care will feel the heavy hand of command and control in how they spend their money. Last, for all its deep faults, the NHS is a "high trust" organisation with a degree of staff commitment that is almost unrivalled. For all these reasons, the gamble that the service will not simply pocket the money and run is a shrewd one.There will be political difficulties. The separate decision on long-term care, to spend £900m on rehabilitating elderly patients at the expense of universal free personal care for those in residential homes, provoked an expected backlash from the Tories.

And in the NHS one of the most important pieces of business left unfinished by Aneurin Bevan in 1948 was a consultants' contract which would not only replace the cosy system of merit awards by consultants to each other with a bonus system directly related to productivity and quality of work for the NHS, but would stipulate that they will not be able to take private work for the first seven years after qualifying. This will take some negotiating with an uneasy BMA, though ministers remain confident that it will be achieved.

For all the sensible qualifications in the plan about the length of time it will take to turn round the health service, this is an ambitious document. But that doesn't mean it cannot be fulfilled.

The Prime Minister is said to have two reasons for confidence. The first is that the willingness of the NHS's leading professionals to sign up - literally - to the welcoming preface to the report means the service is as committed to its principles as the Government is. The second is that almost every innovation proposed in the report is already happening somewhere. While it makes a persuasive case for a genuinely patient-driven NHS, a hard-headed and sceptical public will judge its success by results and not rhetoric.

By putting himself at the centre of the struggle to save the NHS, Mr Blair has taken a personal gamble as well as a party one. But most of Britain will surely be willing him to win.