David Cameron's speech this week on the NHS reforms is much more significant than it seems. On one level the words were predictably expedient, an attempt to reassure that the NHS is safe in his hands and that it is he who is leading the review of the changes, not the Liberal Democrats seeking fresh, more vocal distinctiveness. His words were also evasive enough almost to please supporters and opponents of the original reforms. The precise details are still to come. Details are always more testing than speeches previewing the defining announcement.

The obvious expediency is deceptive. Cameron's speech was the most important he has made since he became leader of his party in 2005 and has implications well beyond the game of chess being played in relation to the NHS. It signals the end of a particular dream envisaged by the political romantics in his entourage.

To his credit, and in spite of his instinctive pragmatism, Cameron is surrounded by a surprisingly large number of Tory romantics. They include his senior advisers, Steve Hilton and Rohan Silva, and influential ministers such as Oliver Letwin. I do not describe them as romantic to be disparaging. On the contrary politics desperately need more like them on the left and the right, original thinkers driven by ideas, vision and with the courageous guile to follow through with policy implementation. Several senior Labour figures tell me they lack the equivalent now. In the case of this trio, and a few others, they transformed traditional Tory values and placed them in a modern setting. They did so much more effectively than New Labour on the centre left, where some values went missing in its modernisation project.

In order to explain why their dream died during a speech triggered by short term pragmatic calculations, it is necessary to go back briefly to the period before the last election. Under the auspices of Hilton and Letwin the Tory Shadow Cabinet took part in a series of seminars to explore their public service reforms in what they called a post-bureaucratic age. One element was a radical redistribution of power. Another was what several speakers described as a revolution in the political culture of Britain, one in which ministers would argue that they were not directly responsible for the delivery of local services. I have notes from an address from Letwin in which he said explicitly: "If a service fails, an interview at ten past eight on the Today programme should be with the direct local provider of the service and not the Cabinet minister in Whitehall." He acknowledged, as did other aspiring ministers, how tough this would be in a centralised media culture. Cameron was in the audience modestly taking notes but ended the meetings by insisting that this was part of the Conservatives' big idea.

In fairness to the Health Secretary, Andrew Lansley, his original reforms are entirely in line with the envisaged revolution. If they had gone ahead I can hear him telling John Humphrys in the midst of some crisis or other: "This is not a matter for me, but for Monitor or the GP consortium. I hope the disgruntled patient moves to another consortium, but this is not an issue for a minister in Whitehall."

Not surprisingly the romantics around Cameron have been fighting behind the scenes in No 10 to retain as much of the original Bill as possible, on several grounds but partly recognising their wider dream is threatened. At one point two weeks ago it seemed possible that virtually the entire Bill would be scrapped but Hilton and others fought back in the intricate current negotiations.

Indeed Cameron looks and sounds remarkably bouncy as he navigates around the conflicting concerns of the Treasury about the wisdom of the original proposals, the Liberal Democrats, the right of his party, the romantics within No 10 and the many detailed points raised within the NHS – some of which go well beyond self-interest.

His speech on Tuesday suggests that while some precise controversial elements of the Bill might still remain in place the vision that shaped it has gone. Indeed Cameron stressed the precise opposite from the cultural revolution emphasised in the pre-election seminars. Personally he guaranteed as Prime Minister that the waiting-list target defined by the centre would stay; there would be a level playing field with the private sector, including the costly obligation to train staff; an increase in spending in real terms; and an NHS that remained integrated and national, one that would be accountable to the centre and one that he would be held directly responsible for. Lansley or his successor will emphatically not be appearing at ten past eight on Today and arguing that a health crisis in Carlisle has little directly to do with him.

There is much to admire in the Tory romantics and Labour would benefit by having a few more on their side. In relation to the cultural revolution they are not only idealistic but to some extent have evidence already on their side. When a prisoner escapes it is absurd to blame the Home Secretary. Now that trains are privatised a minister cannot be directly responsible for the reliability of the 8.45 service run by Virgin, although they are rightly held to account for the overall costs and quality of the erratic network.

But the romantics' concept was always going to struggle. Partly this is down to our media culture that is driven by inconsistency. Most of the time newspapers scream for the Government to get off our backs, in line with the romantics' instincts, until anything goes wrong when they ask what the Government is doing about it.

More importantly there was always a fundamental problem with the vision. I recall discussing this with the romantics at the time. When the Government is responsible for raising the money for a service it is unavoidably accountable for how it is spent. It is no surprise that George Osborne is the main advocate for taming the NHS reforms. As a Chancellor imposing cuts he has good cause to be uneasy about a reform that costs money in the short term, and which would leave the Treasury with no control as to how the cash was spent. As long as the finance is raised centrally, services delivered free at the point of use and the NHS remains "national" the Today programme has every right to call on the Health Secretary at ten past eight. It was the point that the chair of the Health Committee, Stephen Dorrell, grasped immediately and argued recently on BBC's Question Time: if the Government raises the money it must be accountable in a way that is formally recognised. Dorrell is a long-serving Cabinet minister. On the whole romantics have limited experience of ministerial life in a department.