No-one doubts that the NHS will be a key battle-ground at the next general election. If New Labour were to lose 70 seats because the public thought there had been too little improvement, we would then see a dramatic shift on what politicians dare to think.

Why wait for the electoral expression of public frustration and disappointment? Why not initiate a serious public debate now about what we know works everywhere else? We do not need to look abroad. We can learn, notably, from the UK example of direct payments to the disabled and for those who now buy social services with direct payment. And from the UK revolution in optical services in every High Street. These work. They give patients control of individual funds. They have dramatically improved services. Why not generalise the concept?

Most attention recently has been focused on provision - on Foundation Hospitals. But it is from buying power effectively organised that change will more likely come. It is purchasing power that will generate effective reform - for higher quality services which patients prefer, for more sensitive provision, and for enhanced capacity. Individual responsibility, which is a key to better health, can be directly linked to this approach. Without it we continue to put ambulances at the bottom of cliffs.

The electorate are, instead, offered two possible ways forward. Neither seems likely to be as powerful as purchasing with individual economic empowerment.

First, there is Gordon Brown's policy of spending your way to security. Inevitably this approach will generate some service improvements. But the fundamentals - notably the denial of individual choice and responsibility, and its substitution by "expert" planners - remain. Without direct incentives, choice, and the discipline of pluralist competition we shall never attain European levels of quality care.

Mr Brown is spending huge extra funds. But so far there is little or no gain in productivity or quality. We have a frantic policy of more money, more management, more targets, more inspecting, more regulating, more re-organising - but, it seems, no increases in patient satisfaction and little increase in productivity, or in measurable quality. Morale remains low. More doctors are retiring early. And new research by the Joseph Rowntree Foundation (in its "Shaping Our Lives" project) shows that service users do not believe that existing government policies on user involvement will make anything better.

Nor do the Conservative or Liberal Democrat parties yet offer any credible empowerment for the individual patient. And health treatment outcomes remain significantly poorer in most specialisms than in Europe.

Second, there is the consensus amongst all three parties for "decentralisation". But this offers no patient power over money. Meanwhile the poor do least well from the NHS, as they always have. Conservative policy turns on decentralisation and on the proposed "health passport". However this does not ensure that we are all one people in one market for one service. It would seem to help the middle-class, whilst doing nothing to empower the poor. Decentralisation, which the Lib Dems also favour, will not by itself change the position of the patient, who will still have no power over where money is spent and on what. "Experts" will decide.

Why is healthcare to remain exempted from direct incentive, and consumer empowerment? The argument has been that social solidarity will be undermined. However UK experience of direct payments and of tax transfers to the poor show that (like social insurance systems) we can achieve social solidarity, fairness, equality of access, higher quality, greater capacity, improved professional pay and morale, and enhanced funding with individual insurance "top-ups". In such systems the poor are empowered by cash transferred from taxes. They are supported by the middleclass and the rich in routinely accessing good quality care.

One key political challenge is to show that it is the exclusion from markets, which has helped deny the poor and the weak the full benefits of modern healthcare which they otherwise enjoy in Europe, from social-insurance systems. There we see at work personal responsibility, incentive, choice, competition, and the disciplines of pluralist and informed markets. Individual economic empowerment is the pivot.

This spotlights the vital distinction between seeking to discipline a system by political action (occasional voting and consultation - having "a say", or having "a greater say") and being able to secure a necessary, personal, intimate, separable and timely health service when and where you want it by purchasing power.

My proposed structure offers a new approach to a legally-guaranteed core package of care for all. This turns on the essential economic empowerment of the individual.

We know in every other areas of our life that money talks, and preference walks. Why do we exempt health care? This is the royal road to social solidarity, and to better care for all.

Professor John Spiers is the author of Patients, Power and Responsibility (Radcliffe Medical Press and IEA) £27.95