Through a study of diabetes care in post-war Britain, this book is the first historical monograph to explore the emergence of managed medicine within the National Health Service. Much of the extant literature has cast the development of systems for structuring and reviewing clinical care as either a political imposition in pursuit of cost control or a professional reaction to state pressure. By contrast, Managing Diabetes, Managing Medicine argues that managerial medicine was a co-constructed venture between profession and state. Despite possessing diverse motives – and though clearly influenced by post-war Britain’s rapid political, technological, economic, and cultural changes – general practitioners (GPs), hospital specialists, national professional and patient bodies, a range of British government agencies, and influential international organisations were all integral to the creation of managerial systems in Britain. By focusing on changes within the management of a single disease at the forefront of broader developments, this book ties together innovations across varied sites at different scales of change, from the very local programmes of single towns to the debates of specialists and professional leaders in international fora. Drawing on a broad range of archival materials, published journals, and medical textbooks, as well as newspapers and oral histories, Managing Diabetes, Managing Medicine not only develops fresh insights into the history of managed healthcare, but also contributes to histories of the NHS, medical professionalism, and post-war government more broadly.
community–hospital divide. Through these and similar measures, managedmedicine became central, not just to diabetes care, but also to the NHS.
Looking closely at the measures introduced for diabetes care, we can see how the reforms of the early 1990s consolidated a post-war transformation in British medicine. Across the twentieth century, doctors considered diabetes an incurable condition, one characterised by a chronic state of raised blood sugar and subject to lifelong management to abate symptoms and correct disturbed metabolic functions
paid to the agencies involved in guideline production. The lead taken by professional bodies, international organisations, and the BDA not only highlighted the prominence of professionals themselves in the reformulation of managedmedicine. It also marked a shift in the organisation of British medicine, with elite agencies laiming to more formally regulate the activity of local practitioners.
The emergence of guidelines in diabetes care: facilities, staffing, and nomenclature
As Chapter 1 outlined, the first official
guidance could be offered to health authorities on the most effective means for dividing professional labour. Research would create guidance to manage healthcare activity, resulting in improved health and cost savings.
The way in which DECs were discussed, and SMD funding granted, was informed by previous changes in the relationship between diabetes, clinical medicine, and prevention between the 1960s and early 1980s. It was also indicative of the way in which organisations like the BDA and Royal Colleges were thinking about diabetes more broadly
, patient-centred care, and managing temporality
As discussed in previous chapters, specialists after the 1960s increasingly emphasised the importance of close surveillance in diabetes management. Shifts in discussions of preventive medicine – triggered by new treatments, NHS reform, and epistemological and evidential change – made oversight more important for all practitioners.
These drives to surveillance found further support from renewed emphases on patient self-management. The 1970s and 1980s saw a marked increase in
, that managed – patient and practitioner from within a pre-existing culture of bureaucratised care, propelled by (and fostering) anxieties over clinical standards. In fact, it was by combining new therapeutics and ways of working that many conditions were made chronic, and similarities between diverse patterns of symptoms were constructed. 35 Finally, although this routinised disease management invited external regulation and provided an ideal vehicle for testing local and national systems of managedmedicine, this work has demonstrated how a series of competing
and 1950s. Underpinning such efforts were shifting ideas of chronicity, growing clinic workloads, and novel views on how the new NHS should manage such problems.
Remaking chronicity: the chronic sick, social medicine, and chronic disease
During the 1940s, medical and public health discussions of chronicity centred on a very different set of patients from those in similar discussions later in the century. At this time, the most common use of the term ‘chronic’ was in reference to ‘the chronic sick’, a rather loose term
became an object of political interest.
Managing British medicine before 1979
The 1980s and early 1990s were a period of radical innovation in British health policy. 3 During these years, Conservative administrations significantly altered the institutional configuration and dynamics of British healthcare, transforming the role of health authorities and central government in delivering health services. Neoliberal analyses of professionals, bureaucracy, state, and economy provided a broad underpinning for much reform. However
practice the control of diabetes should not be undertaken by one of the partners in the way that maternity work is sometimes undertaken.’ 35 In addition to managing already diagnosed patients, Pike also envisioned a greater role in case-finding and preventive medicine. Drawing on the Birmingham detection survey, he ruled out mass screening on grounds of expense. Instead, ‘greater results will be obtained with less effort’ if practitioners focused on those considered ‘at-risk’. 36 In this case, vigilance would be applied to individuals who had relatives with diabetes
Indeed the social background and academic
qualifications of many Colonial Medical Service employees were often
modest compared to those of their contemporaries in the Colonial
Administrative Service. See Crozier, Practising Colonial
Medicine , p. 106
The Foreign Office managed the African