Rationing will become more explicit because of the cash limits on primary care groups, according to an Institute of Health Services Management discussion paper.

The authors, Professor Alan Maynard and researcher Karen Bloor, both from York University, say elected politicians should provide more explicit direction on rationing issues.

They are worried that the pace of development set by the government may hinder 'the formation of effective PCGs' and are also concerned at the lack of attention paid to the management capacity and capability needed to run them.

The paper says the experience of total purchasing pilot schemes demonstrates 'that management is good investment' and that management costs of PCGs 'may be insufficient'.

It also expresses worries about equity of access to healthcare which, 'if taken seriously by policy makers', may require 'revolutionary policy initiatives' such as changes to the GP contract and a substantial increase in the number of salaried GPs.

The role of the chief executive will also be crucial to the development of health improvement plans and clinical governance. But the paper says inadequate attention has been given to the dual leadership of chief executives and PCG chairs.

Primary Care in the UK: evolution or revolution? IHSM Publications Department, 7-10 Chandos Street, London W1 9DE.£10/£7.50 IHSM members.