Desperately seeking solutions Rationing health care By David Hunter Longman 224 pages £14.99

The debate continues. To date, the rational rationers have largely held the field. David Hunter's criticism of their views is that they are 'fundamentally misguided and politically naive'.

And that's on page 1. Can he live up to this lively start? Undoubtedly he can. This book has long been needed to question the apparently unstoppable moves towards more and more explicit rationing of healthcare.

Professor Hunter is anxious not to be seen as an old paternalist supporting doctors who make covert decisions without any sense of accountability to the population beyond the patient lying on the couch. He defines himself as a 'realist' and he believes there is a third way which he calls 'muddling through elegantly'.

Rationing is the product of two major changes in the NHS: general management and the introduction of the internal market.

Before then people talked of priority setting. But those changes emphasised some of the paradoxes in the NHS: conflicts between the rights of consumers and the need to pursue the common good;

developing national standards while encouraging consumer induced local variations; and holding managers accountable for clinical decisions.

The new public management doesn't believe what it can't count - evidence is all. This in a service that is based on the trusting relationship of clinician and patient.

Professor Hunter reviews the technocratic support for rational rationing and finds it riddled with value judgements and, in the case of QALYs, dubious ethics.

Similarly, many of the ways of involving the public pander to the more influential groups in society.

But given that it is easy to do a demolition job - including an assessment of attempts at rationing in other countries - does Professor Hunter come up with anything helpful?

He maintains that there are five levels of rationing. The first is at national level, sorting out the relative priorities for government spending. Certainly this requires explicit debate. Level two is determining how to split resources between care groups.

The third level decides priorities within specialties and the fourth and fifth decide which patient, and what is to be done for them.

But if all but level one are implicit, how can we be sure people are being dealt with fairly?

Professor Hunter supports a charter of rights: the right to be heard, to have consistency of decision-making, to benefit from unbiased decisions, to be given reasons, to be able to appeal. This acknowledges the patient and clinician as 'co-equal partners'.

His main concern about explicitness is that it fosters suspicion and conflict, between patient and doctor, between doctor and manager and between health professions and government. So the casualties of explicitness may well be some patients, many doctors and most managers.

So where does this leave the government? Ministers, of course, have never acknowledged rationing, but their proposals for clinical governance will need careful and tactful handling to avoid the pitfalls of explicitness that Professor Hunter has so ably clarified in this timely and important book.

Andrew Wall Visiting senior fellow, Birmingham University's health services management centre.