The changing face of community and primary care in England

Nursing Primary Care Staffing

In 1987 Brian Turner wrote a seminal text detailing the sociology of the para-medical professions. Whilst some of his work would be contested in a contemporary context (e.g. Nursing may no longer associate itself as para-medical), some of his work still applies. Namely, his assertion that the non-medical health workforce undergoes a process of professionalization. One modern day exemplar of this may be the role of the Ambulance service Paramedics.

Arguably this has been a quiet revolution. One generation of workers has seen the shift from the traditional ‘ambulance man,’ promoted from driving council vehicles, to the graduate profession who now have a place in primary care to assess, prescribe (legislation pending), treat and maintain a patient in their own home. This places them on a par with Nurse Practitioners and other professional such as Physiotherapists and Pharmacists who define themselves as Advanced Practitioners.

There is little to critique in term in terms of the efficacy of these roles. There is widespread consensus that many clients can and should be treated at the right place and right time, rather than taken into a hospital environment. However, there is the wider question of how these roles have emerged and in whose interest do they serve?

A benefit of health policy from 1997 was the principle that each area of the UK can seek to review its own specific health needs and meet these through local health service specifications. This included workforce planning. However, there is a need to undertake this with a view to the longer term and not, as we assert, to fill a void perpetuated by the current Governments Neo-liberal approach to health policy.

There is a notable lack of regulation for all roles that describe themselves as ‘Advanced’. Nurse Practitioners in both secondary and primary care have been arguing for their roles to be recognised through regulatory frameworks for well over a decade.

Without nationally agreed regulation of Advanced Practice (as we do see in Scotland and Wales), Governance will not keep pace with changes in practice. Without Governance, organisational structures will continue to struggle to understand the distinction between roles that specialise and those that are advanced. This debate is not one of semantics, but a very real and distinct method of health care practice.

Whilst the neo-liberal approach to policy in this field (ie a lack of), then there will continue to be a plethora of health professional titles across the sector. To again use Ambulance Paramedics as an example, a quick review of literature finds that Paramedics use the same ‘Advanced’ title if they specialise in trauma and intubation or if they practice in a primary care setting seeking to see, treat and maintain a person in their own home.

Not only is this true in the context of Advanced Practice, there is an emergence of new professional roles such as Physicians Assistants and Primary Care Pharmacists which is adding to the confusion around roles and responsibilities. This crowded primary care environment with a plethora of illegible titles, professions and roles is hard enough for those working within the profession to keep pace with. How then should the wider public, let alone those who are unwell and their families and carers understand this picture? Whilst there may be more areas and professions to seek care from, it may be suggested that there are more professions who may turn clients away for ‘not meeting their criteria’.

The more crowded and confused the landscape becomes, then the more professions may lose sight of their primary purpose. Turner (1987) commented that with the process of professionalization also comes the ‘rise and fall’ of competing professions. Clearly a neo-liberal landscape may be a catalyst for this. We would argue that this is counterproductive and not in the public’s interest. We would seek for professions to focus on their primary aim, the delivery of care for their clients and wider community and not have to be in a position whereby they have to compete for professional space. This competition not only detracts from our professional imperative, but also leads to short term planning through a race to be the first to meet the next policy agenda.

This is not a call for nurses and paramedics etc. to ‘know their place’; we do assert that all health professions should be involved in the wider political context. But rather an argument to seek an end to the competition between professions and to plan for practice in the longer term, practice that is carefully underpinned by socially just principles.

See Turner B, 1987, Medical power and social knowledge, Sage London

Paul Mackreth is a District Nurse and Senior Lecture in Community Nursing at Leeds Beckett University

Fiona Needham – who also contributed –  is a Senior Lecture at Leeds Beckett University and Course Leads a Programme for Advanced Practitioners