Education & Debate

The doctor and the patient enter the examining room and the door is closed. For even the most jaded doctor and the most cynical patient the click of the door catch creates a special and privileged space. In that space trust can develop, needed disclosures can occur, tears can flow, lifelong burdens can be lifted and explored, and information of the most delicate and significant character can flow from one attentive human being to another. Doctor, patient, and society have conspired to create that space because, in the end, we all need it. But no door bolts tightly enough to exclude the realities that have come to besiege modern medicine. Doctor and patient can ask for-and have a right toprivacy, but they will not be assured insulation from the times. Real life enters the consulting room through seams and pores. Care costs too much in America, and payers are asking why. They are studying the practice of medicine and manipulating the rules of payment. Studies show levels of variation in clinical practice that offend logic.' Patients, made wary by newspaper accounts of malpractice and by their own experience of rushed, insensitive systems, approach formerly trusted doctors with increasing confusion and uncertainty. Doctors, experiencing the unexpected burden of scrutiny and accountability, become unhappy in their work, defensive, and perhaps even emotionally less available to the patients who need them. To be sure some of these trends have been far more pronounced in the United States and in several western European countries than in the United Kingdom. In the United Kingdom the NHS as a structure has tended to diffuse the anger and anxiety that has come to characterise medical care in the United States. In addition, the cost of health care-the most important single source of pressure on the American system of care -has been maintained in the United Kingdom at a remarkably low level (as a percentage of the gross national product). Health care absorbed 11 8% of the United States gross domestic product in 1989, but only 5 8% in the United Kingdom. Though it has taken its share of criticism for its queues and rationing choices and for the development of a privileged private care market, the NHS remains overall a system that compares favourably to the American system in its commitments to equity of access and cost control. But the seams of the NHS are worn thin. Expenditures, though rising more slowly than elsewhere, are a matter of increasing political controversy. There are widespread concerns that care is too often delayed, that access to technology is too severely rationed, and that NHS resources have failed to keep pace with needs. Complaints ofdeficiencies in service levels have become commonplace. It seems unlikely that increases in spending alone can cure this. Moreover, the full potential of truly community based care that the regional and district structure offers has never been fully realised. As in other countries trying to absorb the wonders of high tech medicine, health care in the United Kingdom has become fragmented in its relationships among general medicine; public health medicine; and hospital based acute, largely technical care. A system that would best operate as a seamless whole works instead in functional compartments that leave many patients unhappy and providers of care frustrated. For some even the quality of care provided in the NHS is now seriously in doubt.'