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‘This is the sort of health services research we need more of’

‘This is the sort of health services research we need more of’. Evidence and Bureaucratic Medicine in a UK Government Pilot Scheme, 1977-1985. Martin Moore Centre for the History of Medicine University of Warwick Postgraduate Forum for the History of Medicine www.pgfhom.org.

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‘This is the sort of health services research we need more of’

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  1. ‘This is the sort of health services research we need more of’ Evidence and Bureaucratic Medicine in a UK Government Pilot Scheme, 1977-1985. Martin Moore Centre for the History of Medicine University of Warwick Postgraduate Forum for the History of Medicine www.pgfhom.org

  2. Bureaucratic Medicine – Clinical and Political Governance Merge Managing economic and biological costs + Neoliberalism = Web of regulatory bureaucracy and administrative co-operation between patient, profession and state.

  3. Diabetic Retinopathy • Blood vessels grow over the retina, burst, and bleed into the vitreous humour (jelly bit!) with resulting permanent scarring. “Normal” Vision Retinopathic Vision Courtesy of the National Institutes of Health (NIH)

  4. Project Timeline Part 1 – ’76-79 • ’76 – Lancet paper – half risk in treated. • e’77 – Response – Faculty Ophthalmologists contact English DHSS to discuss issue. • Nov. ’77 – Initial DHSS interest – Pincherle paper discussed with experts in Nov. = Trial Centres • ’77 on – no efforts to set up directly; only ‘sympathy’ for applications of interested AHAs.

  5. Dr Richings (DHSS) to Trent Regional Health Authority, 1978 • ‘there are no specific Departmental funds earmarked for setting up these centres… If Trent would like to submit a research proposal…it would probably be given strong customer support… However, it would [also] have to be assessed…in competition with other proposals in the usual way.’

  6. Dr Sweeney to Dr Pincherle (DHSS Memo) 1982 • ‘one of the most exciting in practical terms I have seen in a long time [and] the sort of health services research we need more of.’ • ‘The humanitarian aspect is important and continuing and for a change and a bonus establishing a programme could actually save money’.

  7. Minutes of a Meeting between DHSS and Ophthalmologists, August 1983 • ‘[research on the organizational elements of screening] would be necessary before guidance on the service aspect of such screening could be issued to Area Health Authorities.’

  8. Project Timeline Part 2 – ’82-85 • August ‘82 – Foulds Paper • December ’82 – Pincherle Draft • ‘83-84 – Discussions with diabetologists, ophthalmologists and opticians • ‘84 – Finance warning, but ministerial support • ‘85- Funding secured to begin work in April

  9. T.J. Matthews (DHSS Finance) to Pincherle (DHSS Senior Medical Officer), 1983/4 • the resources for hospital and community health services (the source of funds for SMD’s) are being reduced this year following the Chancellor’s statement on public expenditure reductions.’

  10. Anonymous DHSS Memo • ‘cost-effectiveness of services [i]s the single issue…of most importance to us, and [i]s the keynote of any future strategy’

  11. Bureaucratic Medicine:Forms and Level of Bureaucracy • Physician-Patient: Surveillance medicine – registers, records and reviews. • Screening, as in diabetic retinopathy an important element in managing ill-health and risk. Encouraged by the state, especially in 1990 contract. • ‘Population level’ interventions performed on an individual basis between clinician and patient.

  12. Bureaucratic Medicine:Forms and Level of Bureaucracy • State-Physician: Using forms of assessment and review used in medicine and business – such as audits – to ensure ‘quality’. • Development of guidance notes used to standardize and ration care = reduce costs. Also used to expand practices which may have long-term savings – community screening. • Administrative structures and policy communities utilized to give profession access to state in other direction. Bureaucracy and representatives employed to reach profession ‘population’.

  13. Bureaucratic Medicine:Forms and Level of Bureaucracy • State-Patient: Creates patient as a category using ‘averages’ and abstractions. • Definitions determine needs, therefore resource allocation and policy affirmation (like screening). • Indirect relationship to patient: design policies around population level data and enforce via bureaucracy around physician.

  14. 1990s • Evidence-based medicine: making clinical decisions based upon ‘best’ (read accumulated RCT) evidence. • Guidelines grounded in this evidence and delivered by new institutions. • Transforms relations between patient, profession and state – but uses groundwork laid in 1970s and 1980s.

  15. Advice on a concept: currently suspected half-baked. • A footnote in your honour…

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