‘A DISEASE FOR GENERAL PRACTICE’State and Professional Reactions to ‘Non-inuslin requiring diabetics’, 1968-1992

QUESTIONS

Thesis: What role did ‘chronic illness’

play in the transformation of British

clinical practice in second half of the

twentieth century?

Paper: How did the partial alignment of

different state and professional projects

alter diabetic care from the 1970s

onwards?

ARGUMENT

State and vocal portion of the profession shared an interest in moving care out of clinics and into surgeries.

Motivations different: state = cost of care and welfare; GPs = status and conditions.

Mismatch produced ironic results: care moved but subject to greater constraints when practitioners argued for enjoyment of greater diversity.

R.D. LAWRENCE, THE DIABETIC LIFE, 1965

‘But the principles which Allen

[foremost proponent of starvation

diets prior to invention of insulin]

established, namely of restricted

diets, normal blood sugars where

possible, and of pancreatic rest, are

still important considerations [in

treatment regimes].’

QUANTITATIVE DIAGNOSIS OF DIABETES

‘diabetes itself is not a discrete and

specific disorder...which a person either

has or does not have; rather it is a

departure from normality more or less

marked. There seems to be no natural

division between diabetes and non-

diabetes and the distinction is therefore

essentially arbitrary’. Oakley et.al.

Diabetes and its Management, 1973.

HARRY KEEN ON CLINICS IN THE 1950S, WELLCOME INTERVIEW, 2000

‘other [doctors] just ploughed through

twenty five or thirty patients in a

morning.  They can‘t really have been

offering them very much more than...a well-

trained Alsatian hound might have done. But

the patients sat there really very

patiently, and I felt a bit angry on their

behalf... I think it was out of this sort

of mass clinic that the notion grew...that

we ought to do things differently’.

NETWORK

D.L. Crombie

British Diabetic Association; Birmingham shared care.

John Malins

Archie Cochrane

Department of Health and Social Security (DHSS)

Friends; Research Associates.

Royal College of Physicians (RCP)

THE FUTURE PRACTITIONER, 1970

The GP is ‘doctor who provides

personal, primary and continuing care

to individuals and families’.

J.M. WILKS, On Hospital Diabetes Patients, JRCGP, 1973

‘[newly diagnosed patients are] doomed

to take time off work, travel and wait

to see a fresh houseman at almost every

attendance... His notes get thicker and

thicker so that both he and the young

doctor find the fleeting consultations

more and more unrewarding’.

GP CLAIMS OVER PATIENT BENEFITS

Ease of attending local clinics.

Continuity of Care/Familiar Staff

Feel like an individual during consultations.

Practitioner Benefits: ‘Interesting and Varied’

GPs will no longer ‘feel that the clinical

care of an interesting condition is being

taken from him’. – Malins and Stuart,

1970.

‘simple to diagnose, long in its course

and gratifyingly responsive to treatment…

the ideal for GPs to diagnose, observe and

treat with interest.’ – Wilks, 1973

THE PROMISE OF SAVINGS

‘the optimum use of resources is rarely

the same as the maximum’. – Wilks, 1973.

‘[Devolving some care to GPs would]

allow more time and effort to be spent

on those who do require hospital

facilities.’ – Archie Cochrane,

Application for Support, 1970.

DHSS MEMO, 1983

‘cost-effectiveness of services [i]s

the single issue…of most importance to

us, and [i]s the keynote of any future

strategy’

T.M. HAYES AND J. HARRIES, BMJ, 1984

‘This study, however, shows that routine

care by general practitioners is not as

satisfactory as routine care by hospital

clinics...

...the simple transfer of responsibility

for continuing care from hospital

clinics to general practice is unlikely

to maintain care.’

Fin(Fun-Loving) Editor,Gareth ‘Millie’ Millwardwww.pgfhom.org