Contested decisions Priority setting in the NHS By Chris Ham and Shirley McIver King's Fund 85 pages £10.99

Using the child B case as their starting point, Professor Chris Ham and Shirley McIver examine the ethical questions and conflicts of interest that can arise when clinicians make decisions about whether to offer a patient treatment.

With the creation of primary care groups and primary care trusts, the book is timely, as these structures have the potential to create conflicts for GPs, who may struggle trying to balance their perceived traditional role of advocate for their patient with their new commissioning role.

This changing role of GPs must be set alongside a changing culture among patients whereby they and their families are increasingly willing to challenge decisions and invoke legal action if they are still dissatisfied with the response - highlighted by the authors with case studies.

Decision-making is viewed at three levels: macro (national), meso (health authority and now PCG/PCT) and the micro (individual clinicians).

PCGs and PCTs, of course, bring the GPs into the meso level and It is the relationship between this level and the micro level that the authors concentrate on.

Through five case studies they examine in detail the process by which decisions were made, retrospectively interviewing the key players about the way they made the decisions and the factors they considered.

Worryingly (but perhaps not surprising given the emphasis on decisions being taken at a local level) the authors find that 'the NHS lacks a clear and consistent process for making priority-setting decisions', with practice varying between HAs.

They argue that while improving the evidence of the effectiveness of treatments is important, there is at least an equal need to develop the decision-making process.

With an unprecedented growth of information about new drugs and treatments, and a lay public more ready to challenge the professions, we will inevitably see a continuing rise in contested decisions.

This book should prove a valuable pointer to the ethical and policy issues for all those involved in the process.

It may, however, find lessons drawn from its studies needing revision: the role of patient advocates is not explored and it will be interesting to see what effect such developments such as the patient advocacy and liaison services (if established) will have on contested decisions.