ABSTRACT
The broad cultural context is set by controvertible questions both about the life of the imagination and about social organisation. Cultural – and thus structural – change is of the essence to achieve the prevailing objectives of justice in access, and a new balance between the individual and the state. The cultural message of the health savings account is that we need to think differently about the relations between surface and substance, aesthetics and value, the patients’ experience of services, and what they think of them. The ‘public service’ (and the elite professional culture) is being challenged by the new information society, by interactive technologies, and by generational change and shifting expectations of many kinds from a more demanding but less deferential public. Culture changes most indelibly locally – in the actions, attitudes and behaviours of individuals. It changes the senior clinician and physician.
