The global challenge of health care rationing Edited by Angela Coulter and Chris Ham Open University 288 pages £19.99

Although this is a policy text, there is useful analysis here that w il l help pr imary care groups, primary care trusts and health authorities in taking the tough choices confronting them when designing systems.

The book views rationing as synonymous with priority- setting and assumes these are inevitable parts of healthcare.Chapter one moves directly to a very useful summary of the lessons that can be drawn from international experience and shows this is a messy problem not amenable to simple technical fixes.

It also raises some important ethical questions about how health systems are held to account. In a sparkling exchange, Rudolf Klein argues that we need to get our inadequate institutions right to set priorities effectively, while Alan Williams wants more and better information and measures.

Although they give two sides to a debate, it is clear that both are correct, and this re-enforces the view that we are a long way from a solution.

Part two looks at the experience of governments in the Nordic countries, Israel and the US.The papers are punchy and chart the journey from establishing a technical process to a realisation of the complexity of the task.

Part three looks at developing countries and highlights the importance of the sectors that compete with healthcare for resources.Part four examines the ethical dimensions of some real situations and includes key guidance on how decision-makers should test the process they are using.

Attention is focused on techniques for making decisions, involving the public and the practical experience of rationing.

The conclusion of the book pulls these themes together and shows that the current debate on rationing is really work in progress.The institutions, information, techniques and intellectual framework we have are still inadequate.The editors rightly argue there should be more openness between doctors, patients, politicians and the public, and an extension of the debate.Two themes of particular relevance emerge for the UK.First, the need to understand the tension between central and local decision-making and the risks associated with a bias towards either.Second, the importance of clinicians as the agents of change and the people responsible for some tough choices.What is clear from this book is that their work and decisions need to be set in a very clear and quite exacting accountability framework.

Nigel Edwards Policy director, NHS Confederation.