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, managed medicine 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
management in modern medicine.
Diabetes and chronic disease in the twentieth century
In the five decades after the Second World War, health systems in Europe and North America gradually adjusted their approaches to the challenges of long-term disease. 2 Through its focus on diabetes, this work has traced the actors, politics, and technologies central to such adjustments in a leading chronic condition. Two questions remain, however: to what extent did the developments in diabetes draw from, and feed into, broader changes in
diabetes and service guidance. Reflecting their historic concerns with service organisation, and engaging with mounting critiques of medicine made from within and without the profession, various professional bodies, international organisations, and the BDA became increasingly concerned about standards of diabetes care over the last quarter of the twentieth century. The Royal Colleges and BDA, for instance, collaborated in drawing up guidance on service organisation in 1977, and audited the staffing and facilities available for NHS diabetes management in 1984. Into the
reasons, by the 1980s professional bodies like the RCGP had connected diabetes management to professional projects. The promotion of diabetes management formed part of efforts to enhance GP responsibility for preventive medicine, with understandings of secondary and tertiary prevention recasting GP diabetes care as an innovative form of risk management.
The re-spatialisation of care, together with a growing emphasis on surveillance and blood glucose control, raised questions for clinicians and GPs involved in diabetes management. The first was how
social welfare spending. As well as being a clinical and moral issue, management of retinopathy aligned with new political imperatives of retrenchment and national competition. It was this focus on preventive medicine and potential savings that attracted ministerial attention to organisational trials. Funding had been in doubt as late as 1983, but fresh political interest in the economic possibilities of prevention set retinopathy in a new light.
In examining these developments, this chapter does more than tell a story of policy networks. 4
By the 1990s, a consensus was emerging in British medicine about the need for new instruments of professional management and clinical regulation. In the four decades after the 1950s, professional, political, and public anxieties about standards of medical practice had grown inexorably. Critiques of variations and evidence in medical care had joined with concerns about cost and professional accountability to produce a ‘crisis’ over quality. Locally, some practitioners responded by intensifying projects for structured care, creating more
cases, it is very difficult for an athlete or
coach to determine the exact state of the actor-network inside the
This problem is generally solved by enrolling sports
scientists and medical professionals into the sporting arena. Indeed,
experts in sports science and medicine are now assumed to make up a
significant part of a competitive athlete’s actor-network. These
experts have a range of technological tools at their disposal that are
able to reveal the inner workings of the body and suggest solutions
4 Middle-class medicine
It is well known that Englishmen are in the main
opposed to any and every new system with which they are not familiar.
Probably to this influence is due the fact, that, with a few exceptions,
pay wards are as unknown in this country as the pay hospitals
Sir Henry Burdett
2 Medicine and charity in Bristol
Before the NHS, British healthcare had no
national system. 1 While policies
could be agreed and pursued by the Ministry of Health, the British Medical
Association (BMA), the Institute of Hospital Almoners or any other national
body, decision-making was distinctly local. For public hospitals this meant
either the poor law union or the municipal authority. In the voluntary hospital