‘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
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.
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)
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.

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.’
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’.
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.’
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

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.’
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’
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.
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 longterm 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’.
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.
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.

Advice on a concept: currently suspected
half-baked.

A footnote in your honour…