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.
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 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.
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 chapter traces the development of standards documents in British diabetes care from the late 1970s to early 1990s. It argues, firstly, that the nature of guidance shifted dramatically over this period, gradually encompassing process and outcome standards, and setting standards for care and audit that encompassed proxies of managerial performance. New instruments thus opened care to external management, and challenged traditional views about clinical decision-making. Secondly, the chapter suggests that the growing role of elite professional and international organisations in guideline creation and audit marked the beginning of a more fundamental shift in the organisation of British medicine, one structured by political, cultural, and social trends but nonetheless driven in part by medical practitioners themselves. Amid decades of academic, popular, and political critique of medical practice and professional accountability, bodies like the Royal Colleges and World Health Organization moved to more tightly manage local practitioners in pursuit of ‘quality’ care. Though not all rank-and-file practitioners supported the proliferation of standards or the increasing role played by elite agencies in their creation and audit, by the early 1990s a growing professional and political consensus was growing around their centrality in securing quality medicine.
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.
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.