By expanding the geographical scope of the history of violence and war, this volume challenges both Western and state-centric narratives of the decline of violence and its relationship to modernity. It highlights instead similarities across early modernity in terms of representations, legitimations, applications of, and motivations for violence. It seeks to integrate methodologies of the study of violence into the history of war, thereby extending the historical significance of both fields of research. Thirteen case studies outline the myriad ways in which large-scale violence was understood and used by states and non-state actors throughout the early modern period across Africa, Asia, the Americas, the Atlantic, and Europe, demonstrating that it was far more complex than would be suggested by simple narratives of conquest and resistance. Moreover, key features of imperial violence apply equally to large-scale violence within societies. As the authors argue, violence was a continuum, ranging from small-scale, local actions to full-blown war. The latter was privileged legally and increasingly associated with states during early modernity, but its legitimacy was frequently contested and many of its violent forms, such as raiding and destruction of buildings and crops, could be found in activities not officially classed as war.
The creation of the NSF for diabetes in the early 2000s marked the consolidation of managerial approaches to the disease and its professionals at a national level. The framework laid out clear standards for high-quality care and strategies for achieving them. The latter built upon the registers, recall systems, care protocols, guidelines, and practices of target-setting and audit – the technology of quality – through which professional bodies had sought to subject diabetes care to structure and review over the post-war period.1 Although it introduced subtle changes to the prevailing consensus on diabetes management – for instance, developing primary preventive strategies and bringing professional management closer to performance management – even these innovations were closely tied to developments discussed in the preceding pages.
In concluding a book of ‘contemporary history’, it is tempting to bring the narrative up to date. In an earlier draft, this Epilogue surveyed the changes in diabetes care since the early 2000s, tracing the evolution of the QOF since 2004 and the growth of the National Diabetes Audit after 2005. However, in the following pages I want to set the developments in diabetes management explored over the preceding six chapters against changes in chronic disease care more generally, and to consider the story of British professional management in relation to international and present-day comparators. In so doing, this Epilogue returns to themes and questions laid out in the Introduction, reflecting on diabetes’ historic position as a model chronic condition and drawing out the relationship between chronic disease and professional management in modern medicine.
Diabetes and chronic disease in the twentieth century
In the five decades after the Second World War, health systems in Europe and North America gradually adjusted their approaches to the challenges of long-term disease.2 Through its focus on diabetes, this work has traced the actors, politics, and technologies central to such adjustments in a leading chronic condition. Two questions remain, however: to what extent did the developments in diabetes draw from, and feed into, broader changes in relation to chronic disease? And how far can diabetes stand analytically as a model chronic condition for historians?
In Britain, the innovations in chronic disease care discussed in the present work initially cut across decades of national and local policy, with institutions at every level of the health services having sought to marginalise patients with long-term complaints since at least the late nineteenth century.3 Hospitals adopted exclusionary approaches despite chronic conditions having been widely diagnosed, discussed, and treated in earlier centuries.4 Certain lifelong complaints, such as consumption and gout, had even attained cultural and literary importance, and chronic illness formed the subject for innumerable medical handbooks and textbooks.5 As noted in Chapter 1, however, hospitals in the nineteenth and early twentieth centuries regularly sought to exclude chronic and incurable cases in order to stem the potential demand for care.6 At this time, emerging health systems were increasingly shaped by the demands of scientific medicine and institutional efficiency; after community-based consultation, only the most acute and medically challenging cases were supposed to be referred to the hospital. Once there, patients were to provide cases for clinical and scientific research, and to receive technologically oriented diagnostic and therapeutic interventions until either cured, stabilised, or dead.7 Within this framework, chronic patients were grouped with elderly and infirm persons, positioned as the responsibility of families, and considered drains on limited institutional resources.8 Nonetheless, whilst such policies were effective enough to influence the life course and experiences of ill persons, by the turn of the twentieth century chronic patients were accumulating within (often stigmatised) institutions. Different countries developed different approaches to the care of such individuals. However, in the absence of efficacious or active treatment, institutionalisation was a common fate of long-term patients, who might spend days, months, or even years between institutional walls.9
As argued in the first three chapters, it was in relation to the quotidian management of individual conditions that local systems made their first adjustments to previous policies. Certainly, some early care structures for longer-term problems fitted neatly within earlier organisational paradigms. For instance, treatments for cancer required specialist technologies and careful institutional management that were emerging from new relations between laboratories, hospitals, medical schools, universities, national funding councils, and industry.10 Indeed, as noted in Chapter 1, the early management of diabetes through scientific diet and insulin developed within this framework.11 Equally, across the post-war period, healthcare teams devised an array of practices to care for long-term diseases, often focusing heavily on acute and potentially terminal episodes.12 Several disease- and population-specific programmes even drew attention away from broader policy notions of ‘chronic disease’, underlining its position as a medical and political construct rather than a neutral category.13
As outlined within Chapters 2 and 3, however, healthcare teams treating many long-term conditions also devised ways of working that differed from traditional, acute disease-oriented approaches. Building on a series of technical and pharmacological innovations, after the 1920s clinicians and researchers devised long-term management programmes for a host of incurable conditions, from diabetes and hypertension to asthma, anaemia, and rheumatoid arthritis.14 Though many such conditions differed in course, symptomology, and the quotidian work required of patients, new systems of care were nonetheless based in similar practices of surveillance, education, long-term intervention, and, increasingly, proactive organisation.15 Moreover, though specialist clinics initially provided a valued site of care for most of these conditions, from the 1960s onwards management slowly extended into the community.16 Specialists and hospital clinics did not disappear, but multi-disciplinary teams increasingly operated across primary and secondary sites of care.17
Such migration was not solely dependent upon pharmaceutical innovation. Moves away from the hospital were also facilitated by experimentation with instruments of monitoring and with systems of organisation that integrated new spaces and combinations of labour.18 Crucially, medical and nursing practitioners involved in such developments did not produce materials and ways of working de novo, but often adapted existing tools and methods over time. It was through designing such programmes that more cohesive concepts of chronic disease emerged, providing a useful foundation for organising medical practice. Early innovations did not distinguish between whether a condition was considered to be communicable or not, or to be even a pathology at all.19 Hospital clinics for diabetes in Edinburgh, for instance, were initially based on those held for lupus; shared record cards in some sites were likewise adapted from those used in antenatal care.20 Over time, however, systems of treatment for diabetes provided an example for other long-term conditions, and vice versa. Insulin, for instance, provided a model of research and treatment for the use of methonium compounds in hypertension, and recommendations for primary care asthma clinics used equivalents in diabetes and hypertension as comparators.21 Similarly, appeals for GPs to become involved in chronic disease care more broadly were predicated on the potentially preventive powers of structured disease management, forms of which were widespread in hypertension and epilepsy, as well as diabetes.22 Indeed, the tools mobilised to structure diabetes management were being applied across long-term conditions. As one letter to the BMJ pointed out, by the mid-1980s the RCGP had ‘increasingly … defin[ed] protocols for the care of serious chronic disease’, and ‘clinics for the care of asthma, hypertension, chronic arthritic disease, diabetes, and other chronic disorders’ were ‘becoming widespread in general practice’.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 Britain than elsewhere in terms of national policy.25 The NHS's universal coverage, combined with its collectivisation of financial risk across a national population, certainly provided British clinicians with an effective foundation on which to innovate and share models of chronic disease care in practice.26 However, these same features also undermined the political cache of ‘chronic disease’ until later in the century.27 There were some movements in this direction before the 2000s, and diabetes once again provided an important component of such policy.28 As noted in Chapters 4-6, whilst single diseases and their complications had previously attracted policy attention, both the 1990 GP contract and the related programme The Health of the Nation (1994) aimed to address rising rates of chronic disease (and associated acute outcomes), albeit in different ways. The GP contract sought to prevent and better manage chronic disease in the practice surgery, bringing together developments in the primary care management of diabetes and other conditions within a single measure. Likewise, The Health of the Nation built upon decades of government-supported health education, emerging first in relation to smoking and lung cancer during the 1950s and 1960s and then spreading to other risk factors for multiple conditions, such as alcohol consumption and obesity.29 Although diabetes was excluded from The Health of the Nation, the government had signed up to international targets of diabetes prevention and management, and the risk-based, target-oriented approach could be seen reflected in the final shape of the NSF a few years later.
Chronic disease and the management of medical professionals
Shifts in diabetes management, therefore, formed part of a broader change in approach to chronic diseases, and often served as an exemplar in some respects. Although its history cannot serve as the history of all conditions discussed under the banner of ‘chronic disease’, the dynamics involved in its management may well prove illuminating to future research.
With regard to professionals, one subject that a growing historical literature on chronic disease has not discussed is the relationship between long-term disease management and managerial approaches to medicine.30 The contemporary connections between chronic disease management and professional management have occasionally been raised in sociological work. For instance, in a wide-ranging, though unfortunately brief, article published in 2005, the sociologist Carl May proposed that the NHS had experienced an ‘explosion’ of chronic illness since the 1960s. The growth of such conditions, May suggested, produced surveillance-oriented, routine, and ‘highly determinative patterns of professional labour’, ‘forms of professional work that are amenable to external regulation and governance’.31 In an even shorter response, David Armstrong questioned whether, rather than producing forms of regulatory work, chronic illness provided ‘the ideal construct on which these forms of social management can be practised’.32 Although this brief exchange was extremely productive, no more extensive investigation took place, and no historical work has assessed the potential relationships between chronic disease and managed medical labour to ask where and how possible connections were made.
The present work has taken up this challenge, tracing the emergence of new forms of managed care in relation to both disease profiles and broader patterns of political, professional, cultural, and technological change. In agreement with May, it has suggested that increasing consultations for chronic diseases were an important motivator for service innovation. However, it has also warned against explaining this increasing workload as the product of an ‘epidemiological transition’, the result of a process in which the epidemiological prominence of acute infectious disease gives way to an ‘explosion’ of chronic illness.33 As indicated above, long-term illness has been a common feature of disease experience since at least the eighteenth century, and a post-war increase in consultations for chronic diseases therefore needs to be viewed in relation to the control of common infections (increasing the visibility of other problems) and contextualised in the development of new methods of diagnosis, novel modes of community research, mutating disease boundaries and definitions, and the creation of new categories of illness following pharmaceutical innovation.34 Equally, it should be remembered that rising demand for treatment became problematic only within a system of limited means, characterised by ethical imperatives of life-extension and equitable treatment.
Even in such a situation, as Armstrong notes, the shape of disease management programmes was not inevitable. Rather than chronic illnesses generating new forms of working, that is, practitioners actively forged routines of disease management. They developed instruments that regulated, monitored, and integrated – in short, 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 managed medicine, this work has demonstrated how a series of competing political projects, financial pressures, and cultural concerns about professional accountability underpinned such developments. The roots of these developments can be traced throughout (and in some cases, before) the post-war period. Nonetheless, they came to a head during the 1980s and early 1990s, with Conservative governments – guided by neoliberal principles of statecraft – supporting the development of national instruments and policies of professional management. As the chronic condition with perhaps the longest history of quantification and bureaucratisation, diabetes provided a perfect testing ground for new managerial solutions, and was incorporated into early efforts to introduce performance-related pay and establish national standards of care.
Yet, despite the importance of a motivated central government in establishing managerial structures for medicine, medical professionals themselves drove the creation of managed medicine, using chronic diseases like diabetes as vehicles for such work. They developed the first systems of structured local care, introducing mechanisms for regulating and reviewing the temporality and content of clinical activity in order to integrate dispersed labour. Amid professional and popular anxiety about the quality of British medical practice, elite specialists and GPs also developed the first national guideline and audit systems, designed to inform local care and structure national provision. In doing so, these practitioners incorporated previously academic tools for research and healthcare assessment into routine care. Moreover, acting through statutory bodies associated with the NHS and the standard-setting bodies of the Royal Colleges, leading professionals also worked in concert with government agencies to devise policies and populate committees refining managerial mechanisms. Indeed, through well-connected patient organisations like the BDA, these specialists lobbied for diabetes to be at the forefront of new developments, and enrolled international organisations to enhance the power and legitimacy of managerial programmes.
The importance of professional activity to the development and character of managed medical care in Britain can be seen in a short comparison with developments internationally. Drives for protocol production and audit of care have been characteristic of modern medicine at least since the last quarter of the twentieth century, though with precursors in the nineteenth and early twentieth centuries.36 To some extent, that is, the move towards management emerged as a logical corollary of the rationality underpinning the scientific medicines of laboratory and clinic, a manifestation of standards and efficacy assessment writ large.37 Furthermore, international connections forged through philanthropic organisations, global health agencies (such as the WHO), and growing policy communities also help to explain similarities.38 Yet the character of management in different countries also reflects differences in the structures, politics, and cultures of medicine across nation-states.
In the USA, for instance, multiple groups contributed to concerns about costs of healthcare in general, and chronic disease in particular. Hospitals, organised medicine, politicians, and federal and state government bodies were not the only actors in US health policy. Post-war policy debates received considerable interest from lawyers, academics, pharmaceutical companies, insurance agencies, philanthropic and non-profit organisations, and consumer representatives.39 In response to concerns over costs and insurance coverage, these agents also drove the development of managerial technologies. Whereas US physicians had been able to shape medical institutions to their needs during the first half of the twentieth century, their influence soon became contested.40 Into the 1960s and beyond, US medicine experienced a proliferation of state schemes and federal funding for services. However, whereas Britain nationalised hospitals and contracted GPs en masse, public financing of health services in the USA focused on reimbursement and subsidy and became filtered through intermediaries. The result was an intensification of market-based provision and new forms of regulation.41 Notably, large-scale (multi-hospital and cross-sector) corporate suppliers of health services came to dominate. They offered increasingly bureaucratic employment for doctors, and placed greater emphasis on the standardisation of practice than in Britain, primarily to facilitate payment and enhance cost-control.42 Similarly, in an insurance-based market system, economic analyses were applied much more readily to healthcare than in Britain, and assessment of quality and value for money (often invoked in the name of the consumer) emerged earlier in the USA.43
In the absence of Britain's comparatively centralised medical and political institutions, therefore, US doctors were less able to negotiate institutional and cultural pressures, and their activity became managed (by themselves and others) through new forms of payment, regulation, and review.44 Although academic and administrative clinicians moved to control managerial structures, the greater array of interests converging on managed care in the USA meant that managerialism was much more readily aligned with external agencies and cost-control than in Britain.45 Although the relationships between chronic disease and professional management in the USA are only beginning to be examined, close links between long-term sickness, service costs, and healthcare reform might suggest at least indirect connections, especially in light of the role that health management organisations play in the care of chronic disease and their emphasis on guidelines and audit.46 As with managerial medicine more broadly, further comparative histories are needed to throw the relationships between chronic disease and professional management into greater relief.47
Professionals, professionalism, and the state
What, then, does the emergence of professional management in post-war Britain say about the changing nature of professionalism? And what do more recent developments indicate about the shifting relationship between professionals and the state?
As the foregoing history of diabetes management shows, medical professionals in Britain were rarely united in the post-war period, and new forms of activity embodied in chronic disease care and professional management were contested. Like those in the USA, British academic clinicians and health service researchers, although often involved with teaching hospitals, assumed new managerial roles over medical practice when creating guidelines and audit systems for local and national implementation. Service reviews noted the resentment felt by some rank-and-file doctors at such interference, and practitioners highlighted the problems of being ‘flooded’ with guidelines in the medical press.48 Moreover, through letters, articles, and satirical cartoons, these professionals highlighted the often contradictory nature of existing guidelines. They queried the strength and validity of evidence on which many protocols were based, and wondered how abstracted knowledge could be applied to the individual patient.49 Conflict could also be reproduced at the local level. Numerous practitioners avoided participating in shared diabetes care schemes, whilst others only half-heartedly engaged.
The professional division that could have posed the most serious problems for the emergence of new approaches was one that had been intimately linked to the development of medical hierarchies in the nineteenth and early twentieth centuries: that between GP and consultant. This divide had been historically fuzzy. However, it was hardening in major cities by the 1900s, and GPs had registered complaints about the role of outpatient clinics in undermining their patient base.50 As discussed in Chapter 2, the NHS consolidated divisions between community-based GPs and hospital-based clinicians, and its affirmation of the referral mechanism served simultaneously as a rationing device and a support to a rationalising division of labour.51 Institutional divisions were also repeated nationally in terms of material interests, with hospital clinicians being employed and reimbursed in different ways from GPs.52 Although Britain's new arrangements provided clearer distinctions between (and greater financial security for) the two sets of practitioners, the division between general practice and the hospital continued to be a source of tension into the post-war period.53 GPs during the 1950s and 1960s complained of the dull nature of much of their work, disappointed that the most interesting cases and technologies remained the purview of the hospital. For their part, specialists remained wary of GPs, and some complained about their lack of medical competence.54 Mutual distrust even threatened to disintegrate some community-based diabetes care schemes.
Yet chronic disease care and related forms of professional management provided areas of shared concern for clinicians and GPs at multiple levels of the profession. As noted in Chapters 1 and 2, extending diabetes management into primary care interested both GPs and hospital clinicians but for different reasons: GPs sought to diversify their clinical practice and move into preventive work, whereas hospital clinicians saw an opportunity to ease their workload and refocus on the most complex cases. Nonetheless, novel schemes provoked concerns about standards of care. Both GPs and hospital consultants feared the dangers of poor co-ordination and GPs’ unfamiliarity with disease management processes. New records, protocol, and audit measures were first introduced as means to facilitate care across sites and practitioners, as well as to ensure that key processes were not missed. New technologies thus facilitated new ways of working by smoothing mistrust and co-ordinating activity.55 Undoubtedly, some hospital clinicians saw such systems as a means to discipline the care of GPs. Yet several prominent schemes were designed through GP–consultant co-operation, indicating a mutual interest from both sides of the professional divide. Likewise, at the collective level, GPs had formed the College of General Practitioners (later the RCGP) during the 1950s to provide a vehicle for raising standards through organising research and improving education.56 Over the 1970s and 1980s, this body championed practice organisation and proactive care, with diabetes and chronic disease management as central elements of its professional project. The College and its leading figures were keen proponents of structured general practice and shared care schemes, and received support from significant specialists in the field. Moreover, they collaborated with the other Royal Colleges, and with specialists in the BDA, to create guidelines and conduct service reviews of new programmes, highlighting how shared interests could transcend professional boundaries.
The coalescing of these institutions around technologies of management suggests that this period saw the emergence of new visions of professionalism in medicine. During the early twentieth century, the freedom for individual practitioners to make decisions regardless of external lay or medical figures was something of a hallmark of being a professional. Collective regulation of standards for qualification and discipline may have been essential features of professional status, but, as one distinguished physician proudly declared in 1926:
There is no voice to which you must … give heed that can inscribe on tables of stone a series of medical commandments, or that can compel your subscription to thirty-nine or some other number of articles. Whether for good or for ill, the life offered by medicine is a life of intellectual liberty where every honest man may hold his own convictions, express his own judgements, and follow his own policy; and this without fear either of authoritative censure or official excommunication. However dignified and commanding certain professional organizations may be, none of them has the skill or competence to discharge thunderbolts against the practitioner who chooses to exercise his right of private judgement.57
By the late twentieth century, elite practitioners and institutions clearly felt that such freedom was for ‘ill’. Instead, they suggested, being a good professional meant embracing external guidance and being open to self-review and peer review.58 This reworking of professionalism has continued into the twenty-first century, and various agencies within and without medicine have sought to construct professionalism around discourses of evidence, accountability, and productivity.59 Individual professional autonomy certainly remains important to practitioners, and a significant proportion of newly qualified doctors are choosing occupations according to their control over working hours and conditions.60 However, unaided clinical autonomy is no longer prized as it once was, and engaging with external input and critique has become essential to good practice. Undoubtedly, therefore, being a professional means something different at the beginning of the twenty-first century to what it did at the beginning of the twentieth, and the transformations in medical management reviewed in this book would appear to provide part of the reason for such a change.
To what extent do shifts in the outlook and practice of medical professionals reflect a colonisation of medical professionalism by the state and its construct of managerialism?61 The present work would suggest that a division between professionalism, managerialism, and the state rests on faulty assumptions. The regulation of medical practice (often connected with ‘managerialism’) was a professional project from the 1970s onwards, and in some form can be traced further back, to the emergence of laboratory practices and clinical research in the late nineteenth century.62 Its origins, therefore, rests with neither the state nor the creation of more formal health service management in the 1980s. Furthermore, until the mid-1990s managerial reforms of medicine remained under the purview of medical professionals. The state promoted professional projects for its own ends. However, audit remained individualised, and guidelines were generally produced by Royal Colleges.63
In the twenty years following the mid-1990s managerial trends have intensified, and the regulation of medicine has become less individually focused. Elite professionals, patients’ organisations, and state bodies have placed a tighter mesh of guidance and surveillance around the NHS and its medical practitioners, encouraging greater convergence between professional and performance management strategies. The rise of Evidence-Based Medicine and its hierarchy of evidence has, for instance, placed greater stress on codification of norms and standardisation of practice.64 Furthermore, sociological work by Ruth McDonald, Stephen Harrison, and others has suggested that changes made to the structure and financial arrangements of the NHS since 1997 encouraged medical professionals to increase their own emphasis on performance standards.65 This has particularly been the case for primary care, where between 2001 and 2013 emphases on target-oriented pay strengthened, the NHS moved to contracting organisations (rather than individual GPs), and indicative budgeting encouraged the creation of contracting consortia.66 These shifts altered the dynamics of primary care, with GPs even in collegiate practices assuming monitoring roles, reviewing their own work and the work of fellow practitioners in order to ensure standards were met. Similarly, the deputation of responsibility for purchasing and budgeting decisions to consortia boards established new forms of oversight and administrative relationships between primary care staff. Performance data, practice norms, peer review, and delegate visits for practices were used to encourage adherence, supported by accountability agreements and practice reviews of referral and prescribing.67 The effects of recent changes from Primary Care Trusts to Clinical Commissioning Groups are not entirely clear. However, the ‘scaling up’ that the new changes involve may see such pressures increase.
In traditional sociological terms, therefore, it might be said that the relative power of the state has increased at the expense of the profession over the past twenty years. Given present trends, such dynamics are unlikely to change in the near future. However, though insightful, such a framing perhaps underplays the continued role of medical professionals themselves in creating managerial structures. Whilst undoubtedly aligned with projects to reduce state expenditure and ensure resource efficiency, healthcare governance also continues to be the product of negotiation between visions of how to manage the medical profession.68 It should be stressed, moreover, that scholars over the past two decades have highlighted a range of ways in which doctors could ameliorate pressures for conformity. Into the present century, doctors appealed to traditional forms of therapeutic individualism – the idea that familiarity with individual patients and drugs should inform prescribing – and integrated protocols with personal knowledge.69 GPs thus incorporated such tools primarily when they supported experience and ongoing medical work, or simplified tasks and pre-existing practices.70 Even with the added scrutiny that more recent NHS arrangements brought to care, discourses and perceptions of voluntarism have been central to making them work.71 Setting norms and monitoring performance has undoubtedly become a central part of medicine, and certain discourses of professionalism have equated ‘vocation’ (doing what is best for clients) with adherence to guidelines and review practices.72 However, such transformations have been consciously undertaken and multi-directional, and doctors have yet to be completely trapped within Weber's iron cage of modernity. 73
The past, present, and future of diabetes care and professional management
Historical perspective may provide useful context and points of departure for prognostication, but drawing definitive conclusions from history is something of a fool's errand. Nonetheless, if asked what the future might hold for diabetes care – in the absence of radical breakthroughs to cure or prevent the condition – I would say it is likely that structures for professional management will be central to whatever innovations are to come. Many of the features that fostered structured care and professional oversight in the post-war period remain in the present. The NHS continues to be subject to financial constraints. There are, moreover, considerable political pressures to reform the service's structures in pursuit of integrated and more efficient care.74 Equally, in recent years commissioning and contracting practices have been extended across the health and social services, and auditing bodies have firmly established themselves as essential parts of clinical government.75 Partly as a result of financial squeezes and extension of oversight machinery, we are still subject to regular medical and public health scandals, holding anxieties about professional performance and competence in place. Such concern has even found cultural outlets in popular prime-time television dramas, and is reinforced by those audits and reviews that highlight divergence from agreed standards of care.76 In terms of diabetes, reviews of care by parliamentary bodies and patient organisations have encouraged the development of new frameworks and action plans.77 As in the 1970s and 1980s, therefore, the potential ‘failure’ of existing governance frameworks has been productive of more intensified varieties of the same system.78 Medical professionals and academics have also been central to this managerialisation, and a whole raft of institutions and career trajectories are invested in the pursuit of ‘best practice’. In the absence of significant structural, political, or cultural change, it is safe to assume that managerial approaches to diabetes care (and British medicine more broadly) are here to stay for the foreseeable future.
Perhaps the big question overhanging any assessment of the future is ‘are such systems beneficial?’ Would the continued existence of managerial systems be a bad thing for patients and practitioners? Modern historians are not generally used to passing explicit moral comment on their subjects.79 In the account preceding this Epilogue, for example, my interest has been to trace the changing contours of diabetes care in post-war Britain, and to consider the relationship between the management of chronic disease and emergence of systems for managing professional labour. I have legitimated such work in terms of historiographical benefit – opening vistas onto the dynamics of post-war British medicine and government, as well as providing useful insight into the histories and character of professionalism. Moreover, I have tried to explain the emergence and maintenance of such systems in relation to political, cultural, institutional, technological, and epistemological factors, and thus without recourse to appeals of their self-evident or universal benefit.80 Indeed, I have suggested that what was beneficial for one set of professionals could have negative or unintended consequences for others, including patients.
However, historians are often closer to their work than they usually admit, and in producing this book I have found it difficult to completely disentangle myself from normative questions. The research for this work coincided with diagnoses of diabetes in my family, and as part of writing the manuscript I have been fortunate enough to interview actors involved with structures for managing the health service and its professionals. As a result of these experiences, I have come to appreciate the potential value of managerial technologies.81 Practitioners themselves want reassurance that they are providing the most efficacious treatment for their patients, and – within the current capacities of therapeutics and the health services – it is certainly useful for patients, political bodies, and healthcare teams to know that specific tests or consultations are important, and whether crucial actions have been missed. Depending on one's political position, moreover, data on the performance of welfare services can help to improve policy and hold governments (as well as medical teams and institutions) to account.82 On a personal level, the geographical inequalities in amputations for patients with diabetes in my home region of East Anglia have provided a stark warning that improvements need to be made in areas of deprivation or rural provision.83
Yet an overwhelming focus on management systems can also have negative consequences. On a macro-level, it can divert attention away from the factors underpinning inequalities. We may be aware of the connections between economic and social marginalisation on the one hand and higher rates of diabetes prevalence and morbidity on the other because of the surveillance and analytic systems at the heart of managerialism.84 However, this inequality will not be properly addressed through technical solutions alone, by refining managerial frameworks to refocus professional attention on specified groups. If certain structures (of employment or discrimination) are simultaneously subjecting populations to increased risks and excluding them from mainstream institutions, then they will not come under the care of health services in the first place.85 Undoubtedly the connections between marginality and morbidity are complex, but they will probably require fundamental changes in income distribution, social organisation, physical environments, and embedded cultural practices to produce more equitable outcomes. A political emphasis on management to the exclusion of broader thinking can, therefore, be dangerous in itself.
Furthermore, in the absence of significant institutional support and resourcing, an emphasis on new forms of working and auditable accountability at a micro-level can result in either a ‘gaming’ of the system, formalistic ‘box-ticking’, or an unhelpful skewing of priorities.86 In such situations, all parties in medical encounters become unsatisfied and no-one receives the care they need. This is to say little about how intensive emphasis on performing routine tasks can result in simple bureaucratic fatigue (as discussed in Chapter 3), or how undue stress on targets and performance can result in serious problems of anxiety, depression, and physical ill-health in professionals.87 To speak from experience with teaching staff in Britain's new academy system, the results can be personally devastating and professionally problematic: if work environments become so unwelcoming that we struggle to recruit professionals willing to work in them, everyone will lose out, and systems will become further impaired.
As this book has tried to highlight, those persons experimenting with, or promoting the use of, professional management tools have never intended these outcomes. In terms of diabetes care, prominent figures in policy creation see managerial systems as part of broader solutions, even if large-scale economic change remains outside the purview of acceptable policy, as during the post-war decades.88 Nonetheless, in terms of the future, considerations like those above should allow us to pause and think about potential over-investment in systems of professional management as routes to quick technical fixes. Although by no means providing a guide to what we should do, this work and the historical and sociological materials on which it draws do suggest that emphasis on singular policy fixes is unlikely to be successful.89
In reflecting further on the past, or at least our framings of it in the form of history, this work has contributed to a growing body of literature on diabetes care, chronic disease management, and medical governance. It has suggested that historical perspectives can give new meaning to contemporary analysis, and proposed that histories of disease and technologies of management can provide new and important insight into twentieth-century Britain. Such work is by no means complete, and further research remains. Perhaps in years to come, broader comparative perspectives will reveal different avenues for investigation and interpretation. At the very least, however, it is hoped that this close analysis of managing diabetes has provided new light in which to view the history of managed medicine.