The Social Market Foundation may have some difficulty now with its title, and certainly the first volume shows that even its contributors scarcely echo Spiers' bold assertion of the 'successful and growing private sector' in the UK today.

Wylie seems to be more signed up to the market doctrine than others, but his belief in the power of patients to make their own decisions regarding their care once they have been given all the facts doesn't take us beyond the well-worn and largely inadequate right-wing libertarian stance which lets the government off the hook but leaves so many needful patients dangling unsupported.

Dawkins explores evidence-based medicine but asks whether it aims to improve quality, save resources or empower patients. Perhaps the change in culture that it induces is its most important feature.

Freeman and Roberts' chapter thoughtfully suggests that it is not the state that offers an NHS insurance policy but commissioning health authorities and some GPs. But this is likely to lead to a steady reduction in insurance cover.

This book has been overtaken by The New NHS white paper, but the chapter by Richards and Shaw, based on experience of locality commissioning in and around Southampton, is an interesting gloss on the viability of primary care groups. Their radical suggestion is the introduction of 'total healthcare' where secondary care clinicians are contracted to practise their skills where needed. This is similar to the US's health maintenance organisation solution, except here the insurer would be the state. Trusts would then become facilities managers. But would this exacerbate the commercial culture which many feel has done so much damage already?

A chapter by Trevor Turner - whose biography is missing from the preface - rehearses the problems of mental health but offers little new thinking. Griffiths and McWilliam are more positive in their belief that, 'the advantages of retaining a large state sector input on the care of the elderly is overwhelming'. But how can we be sure that it is adequate and appropriate?

This is where the second volume is useful, reviewing health policy in a succinct if arguable manner, and then reporting the findings of a survey of public opinion on the NHS. MORI conducted the survey of 2,012 adults over the age of 15 in July/August 1997. The majority believed the NHS underfunded and thought rationing, however unwelcome, was inevitable.

So what do Bosanquet and Pollard suggest? Readers should be warned of the authors' bias in their statement that '...the NHS appears now to be grounded in a distant reflection of British society, with the rise of individualism and consumerism reflected in a private sector that barely touches the NHS'.

They largely rubbish the survey's finding that the majority of people would favour an increase in taxes, on the grounds that the past five elections tell a different story. Their answer? GP charges followed by a more fundamental review to agree to limiting the NHS to core services (but see New Zealand, which has tried it). Then bring in means testing (already there for the elderly), and third, encourage private provision and its concomitant insurance for what is excluded, as in the dental service.

That these solutions appear to be no solutions at all just puts the dilemma right back where we started. Maybe muddling through isn't such a bad approach.

ANDREW WALL

Visiting senior fellow at Birmingham University's health services management centre.