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
, Managing Diabetes, ManagingMedicine: Chronic Disease and Clinical Bureaucracy in Post-War Britain (Manchester: Manchester University Press, 2019), pp. 50–1.
Ibid.; J. B. Walker, ‘Field work of a diabetic clinic’, Lancet , 262:6783 (1953), 445–7.
T. H. Marshall, Citizenship and Social Class and
. (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
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
Dietary advice and agency in North America and Britain
-War Britain, 1945–1985 (London: Pickering & Chatto, 2015), pp. 59–74.
D. Harvey, A Brief History of Neoliberalism (Oxford: Oxford University Press, 2007), p. 2. For a more in-depth historical analysis: D. Stedman Jones, Masters of the Universe: Hayek, Friedman, and the Birth of Neoliberal Politics (Princeton: Princeton University Press, 2014). See also: M. D. Moore, Managing Diabetes, ManagingMedicine
40 P. Farrington, M. Rush, E. Miller, S. Pugh, A. Colville, A. Flower, J. Nash and P. Morgan-Capner, ‘A new method for active surveillance of adverse events from diphtheria/tetanus/pertussis and measles/mumps/rubella vaccines’, The Lancet , 345:8949 (1995), 567–9.
41 See Chapter 1 . On the role of doctors as levers for change in 1980s and 1990s health reforms, see Martin D. Moore, Managing Diabetes, ManagingMedicine: Chronic Disease and Clinical Bureaucracy in Post-War Britain (Manchester: Manchester University Press, 2019
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