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.
issued in 1963, one consultant physician from Caerphilly summarised a situation common across Britain: ‘on the whole, G.P.'s [sic] prefer to leave the care of diabetics to the clinic and none has expressed special interest [in patients with the condition]’. 1
Despite such trends, within ten years of this assessment a host of systems and research programmes emerged around generalpractice and shared care in diabetes. Into the 1980s, many hospital practitioners remained sceptical about the abilities of GPs, and evaluations of new organisational
become realms of predictability. Under them, long-term investments in intellectual formation and the means of production also make sense for persons far from
the centres of power. The lack of a monopoly of violence produces (under competitive conditions) spaces open to violence – violence ﬁelds. In these violence
ﬁelds, people invest individually in the social and physical conditions of security
in much higher proportions. Development, growth or productive innovation are
not their preoccupations.
The generalpractice of state policy towards violence ﬁelds organised by
return in three or six months, but before the 1970s providers were seemingly unmotivated or unable to chase patients proactively.
As the frequency and content of patient oversight gained ever greater value, doctors and care teams designed tools to facilitate better tracking of patients. In generalpractice, the earliest efforts to regulate patient attendance were based upon recall systems, generally in the form of card-index technologies. A Bristol GP, J. M. Wilks, described such a system in a 1973 article for the Journal of the Royal College of
disease, diabetes, and other chronic disorders’ were ‘becoming widespread in generalpractice’. 23 Diabetes may have provided inspiration for some practitioners considering how to integrate specialist and GP in managing long-term illness, but this was a problem common to the care of other chronic conditions. 24 Tackling this issue provided a foundation for practical debates about chronic disease management in the last quarter of the twentieth century.
As George Weisz has made clear, the meta-concept of chronic disease had less centrality in
expressed by public and political bodies. By the 1970s, certain sections of the medical profession had also questioned the capacity of certification, informal regulation, and discipline to effectively ensure quality care. During the mid-century, for instance, dissatisfied GPs, registrars, and consultants expressed numerous frustrations with the NHS, ranging from underinvestment and poor resource distribution to colleagues’ attitudes to patients and – particularly in generalpractice – the detrimental impact of professional isolation on care. 17 Quality practice was seen
managing such illnesses were believed to encounter psychological challenges, discrimination, and often painful long-term complications. For these problems, it was argued, early diagnosis and treatment by a multi-disciplinary team of medical, nursing, and technical staff offered the best solutions.
Unfortunately for visionaries like Reid, the tripartite division of the NHS into generalpractice, hospital, and local government provision made multi-disciplinary and cross-institutional disease management difficult to realise. Reid had, for instance
Kirsti Bohata, Alexandra Jones, Mike Mantin and Steven Thompson
records for colliery districts
indicate that their injuries, illnesses and ailments formed the bulk of the daily
work of doctors in these districts.43 In her study of generalpractice in the century
up to 1948, Anne Digby found that the vast majority of the cases that presented
in colliery surgeries in coalfield districts consisted of chronic chest complaints
and accident cases.44 Doctors suffered excessive workloads in industrial districts
and were not able to do much more than deal with the majority of cases in
a perfunctory manner, in the shortest time possible: case
performance-related pay was part of a number of changes designed to shift the focus of generalpractice towards preventative medicine and to make primary health care run more efficiently, while also reflecting the increased marketisation within the NHS. 17 The new general practitioner contract faced significant opposition from the BMA, but Health Secretary Kenneth Clarke forced it through in 1990. 18 This was linked to the economic and social imperatives of what might broadly be called the New Right or Thatcherism during the 1980s and early 1990s. 19 Managerialism and
The changing mix of public and private can also be seen in the
field of generalpractice. The 1911 National Insurance Act had introduced the
panel system, whereby compulsory insurance for workers in selected industries
would provide access to a doctor when taken ill. This system expanded over the
interwar period, when it came to cover the majority of the adult population,
alongside a parallel growth in the still more profitable