Opinion about how to set priorities in the NHS is diverging. 'Explicit rationers' preach that, where resources are limited, so too must be services. This book's more considered view condemns the stereotyped thinking which relies on the macho approach.
Nevertheless, the developed world is concerned about how best to make choices in healthcare .
Rationing and priority-setting are not the same. Rationing, a more emotive term, suggests denial, only one of the well-known aspects of controlling demand.
The assumption that rationing is inevitable distorts reality. Only some aspects of care can be rationed.
No-one suggests that the 'rule of rescue', whereby patients in extremis are treated without concern for cost, should be abandoned.
If some patients are exempt from rationing, others may be discriminated against just because their care can be limited or postponed. Here, as elsewhere in the debate, ethical considerations loom.
But priorities have to be determined. How is this best done?
The traditional way was to leave decisions to the experts.
Increasingly, the public is drawn into decision- making.
Why? Is it because citizens have a right to know what is decided on their behalf, or can they actually help determine what is to be done?
The former view claims democratic legitimacy, the latter assumes that decisions will somehow be better if they are more widely debated. The authors review both propositions with commendable clarity.
Involving the public unleashes many difficulties. In what way will the decisions be improved and how can public involvement best be achieved?
A very useful chapter reviews the pros and cons of methods of engaging the public.
The authors conclude that there is no best way. 'Ultimately, ' they say, 'which method is most appropriate in any given circumstance will depend on the objectives of the exercise.'
There is no such thing as an 'innocent' view.
The most challenging chapter reviews the various attempts that can be made to elicit values.
Having read it, no-one will undertake a survey of public opinion lightly.
This book provides a staging post in the debate on priority setting.
This will, hopefully, leave behind the cliches used by the explicit rationers.
The authors' formidable knowledge of the relevant literature and their balanced and well-argued text makes this book obligatory reading.
Andrew Wall Visiting senior fellow, Birmingham University's health services management centre.