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- Author or Editor: Susan Nancarrow x
The allied health professions have gained legitimacy through the pursuit of research evidence and the standardisation of practice. Yet there remains very little analysis or understanding of these professions.
Adopting theory from the sociology of health professions, this unique text explores the sociological, economic, political and philosophical pressures that have shaped the professions. Drawing on case studies and examples from occupations including optometrists, occupational therapists and physiotherapists to emerging vocations, including pedorthists and allied health assistants, this book offers an innovative comparison of allied health professions in Australia and Britain.
By telling the story of their past, this original book prepares the allied health professions for a new and different future.
The chapter begins by describing the allied health workforce, before exploring from a neo-Weberian perspective the development of the support workforce associated with the allied health professions with a focus on the United Kingdom and Australia – not least by considering the reasons for introducing a support workforce, the contexts in which it is used, the negotiation of its boundaries, and the challenges and opportunities for allied health professions and its support workforce. In particular, this chapter claims that the heterogeneous allied health support workforce has evolved through two models, with different types of workers. The first is the profession-led model, which supports the neo-Weberian idea of the professional project, in which allied health professions developed support roles to expand and maintain their market monopoly and autonomy in niche areas. The second is the managerial model, which instead privileges the ‘patient-centred’ goals of increasing role flexibility by recognising and rewarding individuals’ skills and competencies and working across traditional professional and organisational boundaries. The chapter finally outlines some of the key challenges to allied health support workforce going forward.
This chapter examines the concept of allied health as a collective comprised of constituent professional groupings. Here, we describe the development of the allied health professions over the past century from the perspective of both the development of individual professions and the emergence of allied health under medical hegemony. Concepts that will be explored include considerations around a heterogeneous group of occupations attempting to work together to achieve a single professional project. We also examine the international health and social care organisational and policy contexts and the importance of the various regulatory frameworks.
The allied health professions are distinct from the medical and nursing professions in numerous ways. Collectively, allied health professions comprise approximately one third of the total health workforce. Due to large jurisdictional variations in inclusion in the allied health collective, as well as challenges in capturing allied health workforce data, the exact numbers and scale of the allied health professions vary widely and are difficult to determine accurately (Olson, 2012; Nancarrow et al, 2017).
Unlike medicine and nursing, which have strong brand recognition, large individual professional size, internal hierarchies, recognised specialisms and, importantly, a strong political voice, the allied health professions are a confederation of independent disciplines, each of varying size and focusing on a niche area of practice. Allied health professions face the dual challenge of negotiating their discrete professional territory within the boundaries of the allied health collective, while attempting to achieve recognition and a voice alongside their larger medical and nursing counterparts.
The allied health professions, and indeed all contemporary Western professions, have been shaped by a set of distinct social forces and contexts that were a product of their formative era. The Industrial Revolution saw the rapid organisation of labour at a time when social class, British colonialism and paternalism were dominant themes in much of the Western world. For the professions, the consequences have included a highly organised, hierarchical and strongly gender-differentiated workforce. Social policies have evolved over the past half-century to try to explicitly reduce gender and racial inequalities in education, the workplace and health service delivery, with varying levels of success in allied health.
This context is important for understanding both the evolution of the professions through a sociological lens, and also their contemporary context. In many ways, the world has moved on but the professions (particularly the highly structured and gendered health professions) are relics of their post-industrial era formation. At the start of the 21st century, the stereotypical allied health profession is still predominantly female, middle-class and white. The narrow analysis of any areas of diversity from an allied health perspective means that this is a limited field; however, there are dominant paradigms in the literature on the sociology of the professions that are important for diversity. Gender is the obvious position; however, ethnicity and socio-economic status are also important considerations.
Intersectionality recognises that social differences and divisions do not operate separately, but rather intersect. Examining diversity from an intersectional perspective enables us to consider that several classification systems coexist and interact – such as gender, ethnicity/race, sexuality, socio-economic status and even professional status – without reducing them to singular positions (Styhre and Eriksson-Zetterquist, 2008).
The largest recognised group of allied health professionals is comprised of the established state- and self-regulated professions. These professions have claimed clear philosophies and sometimes anatomical domains and scopes of practice that differentiate them from each other, and other emerging disciplines. This chapter draws on the examples of optometry and radiography, one of which was established prior to the advent of the era of medical dominance, and the other during it. It thus illustrates the way allied health professions responded to the challenge posed by medicine in defining the new health division of labour that took hold in the early 20th century. It also illustrates the different ways in which these professions later identified with other allied health professions: one as part of the broader collective; the other remaining separate from it (Larkin, 1983; Boyce, 2001, 2006). As was explained in Chapter 2, and should be borne in mind when considering the context of the account that follows, they also serve as useful exemplars of the contrasting gender divide within the allied health professions. Radiography became a primarily female profession, and optometry remained a mainly male profession (though, interestingly, the former remains stable but the latter is becoming more feminised) (Register, 2010; Healy et al, 2015).
Those allied health professions with a long pre-modern history – that is, the groups that emerged prior to the period in which medical dominance became firmly established – experienced medical opposition and resistance in their bid for recognition and state registration during the early to mid-20th century (Larkin, 1981, 1983, 2002).
The health professions are in a constant state of growth and evolution, with new professions continuing to emerge, many in response to new techniques and technologies, and being included under the umbrella of allied health. This chapter explores the emergent allied health occupations, that is, those groups that have recently achieved a level of consistency of title and organisation to then pursue professionalism.
Examples of occupations that have professionalised since the middle of the 20th century include exercise physiologists, rehabilitation counsellors, ODPs, DEs, genetic counsellors, perfusionists and sonographers. In 2020, AHPA introduced affiliate membership for a range of professions, including some emerging ones, for example, lymphoedema therapists, counsellors, diabetes educators, hand therapists, dermal clinicians, hearing aid audiologists, myotherapists, pedorthists, psychotherapists and spiritual counsellors. Not all these professions are recognised allied health professions in all jurisdictions.
A notable exception to the recognition of new allied health professions is the NHS. When the Professions Supplementary to Medicine Act 1960 was introduced, 12 professions were recognised. At the start of 2020, the NHS formally recognised 14 allied health professions: arts therapy, chiropody (now podiatry), dietetics, dramatherapy, medical laboratory sciences, music therapy, occupational therapy, orthoptics, physiotherapy, radiography, prosthetics and orthotics, speech and language therapy, clinical sciences, and paramedics (Larkin, ). Since 2005, just after the formation of the HPC, the recognised allied health professions in the UK have remained relatively stable. An important contribution of this chapter is the way that regulatory frameworks and funding structures influence the development of new professions.
This chapter examines the support workforce associated with the allied health professions. We have used the term ‘support workers’ to describe this group because they do not occupy a fully professional space, and they have emerged from the division of allied health labour (Saks and Allsop, 2007; Saks, 2020). We acknowledge that numerous other titles are used to describe workers in this domain of work (Buchan and Dal Poz, 2002; Saks and Allsop, 2007; Bach et al, 2008; Lizarondo et al, 2010). Support workers tend to be vocationally trained and, in many cases, their roles are designed and adapted to meet local requirements.
We distinguish the support workforce from the emerging and existing allied health professions on the basis that support worker roles are derived from the division of labour of existing allied health roles, whereas emerging professions (described in Chapter 4) have generally developed a niche professional repertoire and practise autonomously. Support workers are differentiated from ‘professions’ because they do not have ownership over a unique body of knowledge or theoretical framework that defines their role. Contemporary taxonomies of allied health professions tend to reinforce the notion of the professional project (Larson, 1977) by specifying minimum standards, such as required levels of training, continuing professional development, codes of conduct and quality monitoring standards (Health Care Professions Council, no date; Allied Health Aotearoa New Zealand, no date; Allied Health Professions Australia, no date). As we discuss in this chapter, there are few opportunities for support workers to become allied health professionals unless they meet these requirements.
There are several allied health professions that may be regarded as ‘mature’, in the sense that they have become an established part of mainstream health service provision, been recognised by the state and have a voice at policy level (Larkin, 1983; Hugman, 1991; Witz, 1992). Within that broad definition, they are also marked by a structure characterised by internal divisions recognised as specialisms within the discipline, demanding further forms of education, training and credentialing beyond baseline registration requirements (Hugman, 1991). Largely, these specialist fields of practice comprise roles with higher-level skills and knowledge, and thus attract a greater degree of prestige and, commonly, better remuneration (Hugman, 1991; Borthwick, 2000). While many of the long-standing allied health professions possess some types of internally recognised speciality forms of practice, relatively few enjoy state recognition in the guise of separate regulatory provisions or legislation. However, state health policies aimed at workforce flexibility have led to new opportunities for allied health professions to secure formal recognition for roles that were previously exclusive to the medical profession.
A discussion of the pursuit of specialisation for physiotherapists in Australia sheds light on some of the challenges faced by allied health professions as they seek to develop their own recognised specialisms (Bennett and Grant, 2004). In particular, the specialist areas need to be: recognised by peers and external agencies; associated with a career structure for clinicians; and associated with a commensurate remuneration and reward structure.
This chapter examines the way the allied health workforce is being redefined and reshaped in the 21st century to respond to an increasingly complex healthcare delivery context. Specifically, we explore the way that new types of roles and workers have been systematically engineered through a process of disaggregation of health profession work into discrete tasks that are then reconfigured into new roles (Pain et al, 2018). We use the term ‘post-professional’ to describe this workforce (Randall and Kindiak, 2008; King et al, 2019). These new roles are designed to meet the needs of specific populations and may or may not align with traditional profession-based profiles and values.
This chapter explores the emergence of a growing ‘post-professional’ workforce, which comprises qualified health practitioners from a range of clinical backgrounds (typically allied health and nursing) who adopt new skills, either formally or informally, to become part of a new workforce with common skills and a shared title while also maintaining their primary profession. In other words, a range of existing professions actively codify and commodify new and/or existing tasks that are then adopted by other professional groups to form a new professional identity. These workers could be described as ‘interprofessional practitioners’ (Shield et al, 2006), as opposed to an interdisciplinary team, in which multiple practitioners come together to achieve a common goal. In some cases, these new identities are formalised into new roles, such as the diabetes educator, rural generalist or generalist mental health practitioner. In other cases, the roles may be less formal, such as assessment and case management roles.
In this book, we have illustrated that the allied health professions are innovative, responsive, nimble and able to adapt to a wide variety of changing population needs and organisational contexts. On the one hand, as illustrated by the example of the podiatric surgeons in Chapter 6, allied health professions have successfully used managerialism to contest one of the most highly protected domains of medicine – orthopaedic surgery. On the other, as the example of the OTA role suggests, managerialism is eroding the core philosophies of the allied health professions and replacing them with an emphasis on technically focused tasks and competencies. Further, where the dominant, neo-Weberian theories of the professions focus on the protection of a monopoly of knowledge, the allied health professions are actively and consensually involved in the disaggregation and codification of their work so that it can be transferred to other allied health professions and the support workforce.
Allied health professionals have also demonstrated that they can adapt to a range of different organisational and clinical contexts, adjusting their roles and responses accordingly. However, unlike their medical and nursing counterparts, which have large institutionalised hierarchies to support their roles, allied health professions are often moving outside their narrow clinical boundaries and across organisational and institutional settings without a clear structure to fortify them. Perhaps this reflects the shift from a pure profession towards a hybrid profession (Noordegraaf, 2007), which has flexible boundaries, adapts to a range of organisational contexts and responds to the needs of the clients with which they work. The implications of this shift for the allied health professions themselves are still unclear.