The "malpractice crisis" in the United States cannot be understood in isolation. Litigation is precipitated by features of the American health care and social security systems. Relative to the United Kingdom, there are fewer barriers of access to the courts, although the role of contingency fees has probably been exaggerated. Given the great institutional differences between the UK and the USA, the crisis seems unlikely to be replicated here unless there are further moves towards privatising both the costs of providing health care and the costs of its failures. It is concluded that a marginal change in the frequency or average cost of claims could have a serious impact on National Health Service resources, the medical defence societies, recruitment to specialties, and clinical practice. Debate over possible reforms is compromised by the dearth of good empirical data. Any changes, however, must address both the deterrence of bad practice and the compensation of injured patients.