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.
The Epilogue sets the developments in diabetes management explored over the preceding six chapters against changes in chronic disease care more generally, and considers the story of British professional management in relation to international and present-day comparators. In so doing, it returns to themes and questions laid out in the Introduction, reflecting on diabetes’ historic position as a model chronic condition, considering the post-war changes in medical professionalism, and drawing out the connections between chronic disease and professional management in modern medicine. It concludes with a reflection on the relationship between historians and historical writing, and a consideration of future policy for diabetes care and health services management.
The Introduction sets the arguments of the book in historical and historiographical context. It argues that the predominant frameworks for assessing the emergence of managerial approaches to medicine, though insightful, have downplayed the central role of doctors and their organisations in co-constructing new systems and relationships in partnership with the central British state. Thus, whilst acknowledging that professional management was underpinned and driven by a broader set of technological, cultural, social, and political changes, the Introduction nonetheless suggests that the work of elite and academic practitioners was central to constructing managed medicine. Similarly, it proposes that, though possessing peculiarities, diabetes care’s historical status as a ‘model’ of healthcare management makes it a productive lens through which to reassess the history of managed medicine in Britain, and to explore the connections between chronic disease management and professional management. It concludes by outlining the power of a single-disease, single-country study for generating useful insights for future comparative work.
This chapter explores how managerial medicine emerged as government policy during the 1980s and early 1990s. Institutionally, it argues that a new consensus around guidelines and audit systems was founded upon post-war policy networks connecting senior British diabetologists, government bodies, and international organisations. Personnel continuities between committees ensured agreement across local, national, and international levels. Conceptually and politically, by contrast, it locates government interest in a growing influence of neoliberal political analyses on policy-making, and in attempts to control costs and make healthcare operate more like a market. Although professional and governmental projects were often politically misaligned, both parties saw benefits in co-operation and actively sought collaboration. Diabetes management – and chronic disease management more broadly – lay at the centre of new initiatives due to cost implications, cross-institutional reach, and the well-developed managerial and policy-making architectures that had been developed over the past three decades. Such conditions made long-term diseases like diabetes ideal constructs on which to pilot new forms of work.
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.
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 chapter outlines how diabetes re-emerged as a concern of central government during the late 1970s, setting the scene for the move of managed care from clinical settings to policy arenas. It does so by examining the tribulations of efforts to secure Department for Health and Social Security funding for retinopathy screening and photocoagulation treatment trials between 1977 and 1985. The trials were by no means the biggest intervention that central government made into diabetes care during the 1970s and 1980s. Examining their history, however, reveals the ways in which post-war policy networks developed in relation to diabetes, and the shifting ways in which they framed diabetes to garner government attention in a period of considerable economic and political change. Crucially, underpinning debates about the trials were new concepts of risk management, disease prevention, and standard-setting that became central to policy discussions of diabetes care and managed medicine at the end of the century.
This conclusion presents some closing thoughts on concepts discussed in the preceding chapters of this book. The book emphasises how the interconnectedness that has been at the heart of the voyages continued to matter far beyond the time that people spent at sea. It shows that medical knowledge and authority was never a given, and convicts and emigrants actively invested in and shaped the meanings and outcomes of voyages. On an individual level, these voyages were a stepping-stone through a career that might combine service in a British hospital, on a West African patrol, or in an Australian prison. Surgeons' ideas and actions reflected broader assumptions of class and gender, as well as an ethos of nineteenth-century naval medicine as it sought authority and status, particularly under the leadership of William Burnett at the Admiralty.
The history of quarantine stations is a history of what it meant to make the transition from emigrant to immigrant, and it is never just about disease. In a period that lasted 150 years, from 1832 to 1984, thirteen thousand people were quarantined at Sydney's North Head for diseases including typhus, smallpox, plague, cholera, and measles. Compared to diseases such as cholera, smallpox, and yellow fever, typhus has played a minor role in the history of modern quarantine. In a politicised and factious atmosphere, the significance of quarantined immigrants reverberated beyond the medical debates of the quarantine station. As news of the cholera outbreaks in Britain reached New South Wales, the colonial government passed its own quarantine legislation in 1832. As the colonial economy of New South Wales entered the depression of the 1840s, the British government suspended its schemes of emigrant assistance.
This chapter dwells in the tropics, where the experience of calms reinforced and extended preconceptions about the coast of West Africa across the space of the sea. It explores the ways in which passengers used an eclectic range of corporeal, scientific, cultural, medical, and colonial frameworks to evaluate their encounter with the maritime environment. The chapter shows that understandings of health were not just related to being at sea, but also to constant movement through the different regions, environments, and climates of the oceans. In order to understand how medical experience and knowledge evolved over the time and distance of the voyage, it is crucial to appreciate how constant movement through distinct regional maritime climates affected travellers' knowledge of health and illness. Of all these regions, the Atlantic tropics perhaps most define the environmental experience of voyaging to Australia.