Freidson noted that to be a professional was not just to be part of a profession but to act with professionalism, defined in chapter two as qualities and characteristics which include self-responsibility, expertise, special skills and ethical behaviour. He recognised that the most “critical test of professionalism” is a demonstration that the profession will not use its position of professional power for “selfish advantage.”587 Chapter 3 identified that paramedicine has a long history associated with altruism. This chapter identified that altruism is not just a feel-good virtue that health professionals talk about but are not held accountable for delivering. The National Law provides a mechanism to hold practitioners to account for their actions and has an expectation that regulated practitioners will act with professionalism.588 The National Law acknowledges the importance and centrality to professional health practice of acting with professionalism. For example, the accreditation standards for paramedicine that will be required to be developed by the Paramedicine Board will require all paramedic programs of study to provide persons who complete the program not only with knowledge and skills but also professional attributes necessary to practise the profession in Australia. The identification of those attributes and the way in which they are relayed throughout the paramedic community will be a matter for the Board to determine. This mechanism demonstrates how self-regulation under the National Law will provide paramedics via the Paramedicine Board with an opportunity to develop not only education and accreditation standards that define what and who a paramedic is but also what paramedic professionalism looks like. The Board can also use other guidelines, codes and policies (discussed in more detail in chapter 7) to shape a culture and ethos of paramedic professionalism. This is entirely consistent with Freidson’s suggestion that the ideology of professionalism regulation is that a professions’ specialist knowledge and skills should be used for public benefit, as distinct from bureaucratic or free-market regulation which both have alternative objectives.589
Paramedics have benefited from the push for structural reform in Australia’s healthcare workforce and the introduction of legislation that facilitates that reform at a time when they had sufficiently professionalised to take advantage of the legislative change. There
587Eliot Freidson, Professionalism Reborn: Theory, Prophecy and Policy (Polity Press, 1994). 217.
588 For example, as discussed previously in this chapter, definitions and power to act to sanction
unprofessional conduct.
may be registered health practitioners who, in a popular view, may not be considered as a profession but it is beyond the scope of this thesis to identify this. To consider if all health occupational groups are considered a profession according to the Freidson criteria would require a separate thesis for each profession and so it is beyond the scope of this thesis to consider if, for example, the less well recognised professions like Indigenous Health, Chinese medicine or Chiropractic are in fact a profession according to the Freidson criteria. However, it is an argument in this thesis that regulation under the National Law maps closely against the Freidson criteria and thus grants to any occupational group that is regulated by it, sufficient authority to establish themselves as a profession. The final steps to professional status require conduct by the profession itself, for example, their respective boards to establish enforceable competency and conduct standards that reflect the profession and establish expectations of what it is to act with professionalism. The law vests this power in the Board and if they undertake the tasks that the law authorises, then it carries the occupational group over the threshold to professional status. It follows that if paramedics are regulated by this law, and the Paramedicine Board undertakes the tasks authorised by the law, paramedicine will become a profession.
The literature and submissions made by the profession noted in Chapter 4 outline why paramedics were seeking this form of regulation and demonstrates that they were looking for self-determination, to be free to establish for themselves their standards of education, competency and conduct, to determine who is and who is not eligible to be a part of the occupational group. As per table 2 above, it is evident that regulation under the National Law will grant paramedics the legal and professional status that they have been seeking. This chapter has demonstrated that the National Law will facilitate the professionalisation of paramedicine according to the Freidson elements for a profession, as demonstrated in table 2 above, by recognising their unique purpose, specialist knowledge and skills and allowing them to self-regulate. In so doing the Paramedicine Board will have an opportunity to set education and accreditation standards that will develop and disseminate paramedics’ specialist knowledge and skills. The law will not prescribe paramedic professionalism but it will provide a mechanism for the Paramedicine Board to determine what paramedic professionalism should look like via the development of education and accreditation standards, clinical guidelines, a code of conduct and associated policies.
With respect to identity and power, a goal of the paramedic professionalisation project was to establish ‘a coherent model or concept of the role and responsibilities of a professional paramedic that provides a firm basis for discussion with regulators and other stakeholders’.590 This has not yet been achieved but is essential that the Paramedicine Board develop this if the discipline hopes to effectively transition to not only being legally recognised as a profession but to utilise the power it gains in becoming a profession. The Paramedicine Board will face some challenges in attempting to establish its governance framework over the 12 months from the time the Board is constituted, in large part because there is no agreed or clear definition of what a paramedic is and what a paramedic does. There is no nationally consistent uniform protection of paramedic title legislation that sets out the definition of a paramedic. There are no nationally agreed practices or education standards; the reluctance of NSW to relinquish its control on its education model will make the establishment of a uniform standard even more difficult. Additionally, the discipline has no code of conduct and as such no evidence of any agreement on the profession’s values and culture. The lack of a code will make establishing core educational curriculum criteria difficult as well as limiting the ability of the discipline to determine the legal standard of a ‘reasonable paramedic’ for the purposes of disciplinary matters or even to establish the character requirements to be met by those seeking to be registered for the first time. Once paramedics are regulated under the National Law, their obligation to act with professionalism – which in essence is to put the patients’ interests first – will be codified (that is, it will be made legally consistent, transparent, explicit, binding and enforceable) in a way that it has not been before. It is therefore essential that paramedics develop an understanding of what it is to be a professional paramedic and to act with professionalism to ensure that they act with the required standard of conduct and competency as set by their peers. There are very many similarities between medicine and nursing but unlike those professions, paramedicine has struggled to define itself. Chapter 3 provided clear evidence that paramedicine has slowly been developing its role and character over a few hundred years and just as nursing did, it jumped forward in establishing its unique purpose and specialised knowledge during the Crimean War. However, despite its attempts to professionalise and ambitions to do so, as described in Chapter 4, the
590 Gerry Fitzgerald and Ray Bange, ‘Defining a Regulatory Framework for Paramedics: A Discussion
Paper’, (2007) 5(2) Journal of Emergency Primary Health Care. From a report prepared for ACAP,
discipline has still not set out clearly who it thinks it is and what it stands for. This is an issue that will need to be addressed by the Paramedicine Board once the board is
convened and constituted. It is essential for the success of the professional development of the profession that it utilise the power of self-regulation it has gained by being regulated under the National Law, to unite together as one discipline and determine clearly its identity as a group that has specialised knowledge and skills in the area of emergency out-of-hospital care; and that it establishes a core set of competency and conduct standards that reflects who the profession is and what the profession does and in so doing being to develop a culture and ethos of professionalism.
The UK undertook similar legislative reform in response to similar scandals and falling confidence in the health professions a number of years ago. The UK regulatory scheme includes paramedics. The next chapter examines the way paramedics are regulated in the UK and identifies lessons that can be learned from the UK’s experience of paramedic professionalisation that may be helpful for Australian paramedics as they move to become regulated as a profession.
Lessons from the United Kingdom Paramedic
Regulatory Experience
The UK has had paramedic registration in place for 15 years, providing an opportunity to compare its regulatory scheme with that proposed for Australia, and also with the Freidson elements for a profession, to determine whether the UK model would be more likely or better able to provide the elements of professionalism that are missing from Australian paramedic practice. This chapter provides a comparative analysis of the way in which paramedics are regulated in the UK and the effectiveness of that regulatory regime for the professionalisation of paramedics.