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
, preventive medicine, clinical care, chronic disease, and health service management saw state bodies become interested in the condition as an early testing ground for developing new approaches to managingmedicine.
Although not determinative of government direction, neoliberal critiques of welfare were particularly influential here. As noted above, reforms of the health service in the 1980s and 1990s were not implemented according to any blueprint. Nor were they purely ‘neoliberal’ according to any abstract criteria. However, characteristic of ‘New
, 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
secondary prevention of long-term sequelae ( Chapter 1 ). Unlike professionally designed schemes, however, the government contract attached financial incentives to practice-based disease management. In exchange for payment, GPs engaged in performance management relationships with FHSAs. Practitioners would develop protocols with fellow professionals, and the relevant FHSA would assess care against agreed criteria to determine financial recompense. The new arrangements, therefore, reflected the mix of projects supporting managedmedicine. One the one hand, cognisant of
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
This chapter analyses the emergence of clinical and public health concerns with non-infectious disease in Britain during the immediate post-war decades, and examines the implications for the expanding diabetes care team. It suggests that central government’s concern with chronicity during the 1950s and 1960s primarily related to the resource demands of the ‘chronic sick’ – a term used to refer to institutionalised populations of elderly and infirm patients. However, these decades also saw clinicians and public health practitioners begin to discuss chronic illness in new ways and with reference to different demographics. Spurred on by the creation of the NHS and the development of new investigatory techniques, public health doctors and service providers increasingly debated the social, economic, and medical challenges of chronic diseases in younger and middle-aged patients, and experimented with new forms of service organisation. In diabetes, clinics of the 1940s and 1950s responded to a renewed interest in the ‘social’ dimension of care by expanding educative roles for dietitians and nursing staff, and by attaching health visitors and district nurses to their teams. With expanded teams came greater emphasis on bureaucratic co-ordination within the hospital. Eventually, however, resource constraints and rising patient numbers encouraged more radical schemes of GP-based co-ordinated care into the 1960s and 1970s.
This chapter examines the development of new forms of general-practice-based diabetes management over the last quarter of the twentieth century. Although GPs had retained responsibility for ongoing patient care after 1948, the creation of the NHS consolidated the dominant role of the specialist clinic in post-war diabetes management. During the 1970s and 1980s, however, hospital clinicians and GPs began to devise more formal systems of structured and integrated diabetes care, with GPs assuming greater roles in disease management. For clinicians, deputing responsibilities to GPs offered a way to manage patient loads and increasing demands for surveillance in a context of constrained resources, and enabled consultants to refocus on challenging work. For GPs, new forms of care dovetailed with emerging professional projects connected with distinguishing GPs from hospital practitioners and moving GPs into team-based, proactive preventive health work. By the early 1990s, the Royal Colleges, the British Diabetic Association, the Department of Health, and international organisations all supported the increasing role of primary care practitioners in diabetes care. Medical politics, resource distribution, and epistemic change had once again combined to reshape approaches to diabetes management and reposition it as a form of long-term risk prevention.
This chapter explores the formal emergence of local systems of managed diabetes care, and situates them in relation to tools used to integrate hospital clinics and primary care into shared care arrangements. The respatialisation of care in the 1970s and 1980s, together with a growing emphasis on surveillance and blood glucose control, raised questions about how patient care could be effectively co-ordinated. In response, GPs and specialists drew upon a rich culture of regulatory bureaucracy within British medicine and mobilised a combination of tools – from recall systems and medical records to local care protocols – to regulate the timing, nature and content of medical engagements. These tools embodied an increasingly standard view of ‘good diabetes care’, and inherently ordered medical labour. The implicit politics of these instruments, however, became explicit within in a context of mounting political and professional concerns about professional competence, and in relation to concerns about the deputation of care to previously inexperienced practitioners. Especially once practitioners began to use standards to audit care, this ‘technology of quality’ subjected routine practice to a novel form of bureaucratic management and provided new forms of evidence for later national initiatives.
. (Cambridge: Cambridge University Press, 1950).
17 Martin D. Moore, Managing Diabetes, ManagingMedicine: Chronic Disease and Clinical Bureaucracy in Post-War Britain (Manchester: Manchester University Press, 2019).
18 Virginia Berridge, Marketing Health (Oxford: Oxford University Press, 2007).
19 Porter, Health Citizenship ; Huisman and Oosterhuis, ‘The politics of health and citizenship’.
20 See, for example, the history of health and safety and changing notions of “risk” for