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.
This book examines the payment systems operating in British hospitals before the National Health Service (NHS). An overview of the British situation is given, locating the hospitals within both the domestic social and political context, before taking a wider international view. The book sets up the city of Bristol as a case study to explore the operation and meaning of hospital payments on the ground. The foundation of Bristol's historic wealth, and consequent philanthropic dynamism, was trade. The historic prominence of philanthropic associations in Bristol was acknowledged in a Ministry of Health report on the city in the 1930s. The distinctions in payment served to reinforce the differential class relations at the core of philanthropy. The act of payment heightens and diminishes the significance of 1948 as a watershed in the history of British healthcare. The book places the hospitals firmly within the local networks of care, charity and public services, shaped by the economics and politics of a wealthy southern city. It reflects the distinction drawn between and separation of working-class and middle-class patients as a defining characteristic of the system that emerged over the early twentieth century. The rhetorical and political strategies adopted by advocates of private provision were based on the premise that middle-class patients needed to be brought in to a revised notion of the sick poor. The book examines why the voluntary sector and wider mixed economies of healthcare, welfare and public services should be so well developed in Bristol.
➤ The basic principles of the NationalHealthService
➤ The origins of modern problems in health policy
➤ Review of Conservative policies on health in the 1980s and 1990s
➤ Review of Labour policies after 1997
➤ Critique of these policies
➤ Analysis of the enduring problems in making health policy
The NationalHealthService came into existence in 1948 after a prolonged
period of negotiation between the reforming Labour government of the day
and various sections of the medical profession. It was an idea with great
popular support, but which also
category is the boy whose illness constitutes a central thread in
the story; compared with most of the stage-schooly child actors of
the time, Brand Inglis is notably fresh and affecting. The instructional mode . Basil Radford plays a confused
gentleman who is just back from abroad and doesn’t understand
the workings of the new NationalHealthService. The porter
hospital in the decades preceding the inception of the NHS.
The road to 1948?
The establishment of a nationalhealthservice was a key plank of Labour's postwar social reforms. At the end of the
Second World War, business as usual was restored to British politics in a
startlingly prompt manner. Only two weeks after the Allied victory in Europe,
Churchill's national coalition partners withdrew their support and forced the
The Third Way and the case of the Private Finance Initiative
HealthService (Private Finance) Act, which empowered NHS trusts to
enter into PFI agreements and guarantee financial payments over the
life of the contract, irrespective of public expenditure
totals . 45
The Financial Times (17 July 1997) noted that
future cash outflows under
PFI/PPP contracts are
The voluntary hospitals underwent a great many changes during the interwar years. The pre-National Health Service (NHS) hospital did not become a site for generating profit. Yet payment did find a place, even as the hospital remained essentially a philanthropic institution. The idea that the working classes should pay in to the system, the various schemes that facilitated this in the community and the almoner who policed it in the hospital, and the idea of opening up the hospital to middle-class patients, were all inventions of the nineteenth century. Yet it was not until the interwar years that any of them became the norm, or even commonplace. In both principle and practice, the change brought about was more complex than a simple switch from medical charity to private healthcare, a reformulation rather than a rejection of philanthropy.
NationalHealthService in 1946, however, the state guaranteed to provide
The Welfare State
health care for all, on demand and according to need. At the same time
everybody in work was required to contribute through National Insurance
payments. The NHS was both universal and compulsorily funded. A small
private health sector remained for those whom preferred to pay for care.
We could apply a similar analysis to other services such as housing, education
and social security, to illustrate the difference between the Welfare State as
such and what had gone before. For
Chapter 3 .
6 I. Loudon and M. Drury, ‘Some aspects of clinical care in general practice’, in I. Loudon, J. Horder, and C. Webster (eds.), General Practice under the NationalHealthService, 1948–1997 (Oxford: Oxford University Press, 1998), pp. 103–4.
7 A. Digby, The Evolution of British General Practice, 1850–1948 (Oxford: Oxford University Press, 1999), pp. 332–7.
8 Loudon and Drury, ‘Some aspects of clinical care’, pp. 106–8.
9 D. G. French, ‘Advances in general
In 1948 an animated public information film called Your
Very Good Health explained the benefits of Britain's soon-to-be-introduced
NationalHealthService (NHS). 1 It
portrayed two different categories of hospital patient. The central character,
Charley, says he is ‘on the panel’ as he cycles through an optimistic
impression of a new town. 2 The narrator
asks him to imagine that he fell off his bike: ‘You'd be carted off