Struggling free from casualty

Professions allied to medicine have come of age but face challenges to their development, Roger Ellis argues.

Paramedical is a term to use with care. Literally it means those nice people in green uniforms who seem to do most of the work in Casualty. It is often used, inappropriately, to refer to physiotherapy, occupational therapy and similar professions.

This the professions consider very disparaging. Who would want to be para anything as opposed to the real thing? The official registering body for physiotherapy and occupational therapy, chiropody, dietetics, radiography and medical laboratory science is the Council for Professions Supplementary to Medicine, which is not much better.

They prefer to be called the Professions Allied to Medicine with its implications of equality and complementarity. Changes in the education of these professions over the past 20 years have been aimed, in part, at moving from a subordinate status to medicine to one of equality and alliance.

The history of physiotherapy and occupational therapy - Physio and OT to their friends - and the issues involved are readily generalisable to the other CPSM professions.

Education for any profession includes initial training and continuing professional development. The most dramatic changes have occurred in pre-registration education and training. Twenty years ago most entrants qualified with a diploma awarded by the Chartered Society of Physiotherapy (CSP) or the College of Occupational Therapists (COT).

These diplomas were recognised by the CPSM as leading to a license to practise. Candidates had to sit examinations set and marked centrally by the professional body. Students would attend schools or colleges which were either privately run or, like colleges of nursing, part of the NHS.

Students now are likely to study in a university for an honours degree in their subject. They will be assessed through examinations and course work set and marked in the university and recognised as appropriate by the professional body and CPSM. They will be taught not only by practitioners in their chosen profession but also by lecturers in relevant academic disciplines.

These two apparently different systems have one thing in common. Supervised practice in hospitals and the community is still the central element of the courses. So the degrees are applied and practical in nature: it is impossible to gain a degree in physiotherapy or OT on the basis of theoretical knowledge alone. However the degrees have focused on the theoretical and academic basis of professional practice in two ways.

All professional degrees are intended to produce reflective practitioners who can question orthodoxies, develop and evaluate new approaches. This is sometimes described as developing a research base for professional practice and this has happened to some extent.

Degree education practitioners are thought better equipped to provide a cost-effective quality service and more able to cope with rapid technical, social and professional change than their diploma-holding predecessors. Furthermore, they are more able to contribute to change in the system and its practices as fully-fledged health care professionals.

The theoretical basis of practice has been clarified as multidisciplinary and a mixture of the natural, physical, behavioural and social sciences. All of these are thought necessary to understand the complex phenomena concerned. These professions, along with nursing, have in some ways shown the way to medicine in the need for understanding of social and psychological factors in healthcare.

However, the knowledge base of these therapies is still strikingly reliant on established academic disciplines, for example psychology, anatomy and physiology. Professional practice itself and its associated university departments have not yet produced sufficient literature to support degree programmes without imports from other disciplines.

The path to an all-degree professional qualification has been difficult. Twenty years ago government policy was that the diploma was a perfectly satisfactory entry level qualification. Any arguments that practice was increasingly complex and justified a higher level of qualification were countered by suggestions that further study could be undertaken in-service. This would be at the professional's own expense or subsidised by employers if they saw the point of it.

The first degree and subsequent honours degree in physiotherapy were launched in Northern Ireland at the Ulster Polytechnic. Here a combination of institutional initiative, a forward-looking government department and less rigorous monitoring from Whitehall established a precedent soon followed in England and Scotland.

Unfortunately the success of physiotherapy inhibited progress in occupational therapy where a somewhat equivocal professional policy coupled with a more vigilant government held up the introduction of degrees until 1984.

In that year the newly established University of Ulster flexed its chartered muscles to break new ground with an honours degree in occupational therapy. This was in the face of government opposition which stopped short of challenging a university's right to award degrees to whatever it saw fit.

The Council for National Academic Awards played a central role in validating the degrees in physio, OT and related areas. Initially the council's health and medical services board stipulated four-year courses on the ground that degrees which required a year's practice for professional license were effectively three-year academic degrees plus a year's placement. This the board saw as equivalent to degrees in engineering, teaching and social work.

The government response, following the Ulster breakthrough, was to admit that degrees were possible and even desirable but to insist that they should be no longer than the three-year existing diplomas. Inevitably, in response to institutional submissions the CNAA shifted ground and three-year unclassified degrees were approved followed by three-year honours degrees.

Three-year honours degrees in physiotherapy or OT are now the norm. They are characterised by their central focus on the development of professional competence but within the context of critical reflection. They are committed to research-led practice and the application of relevant academic discipline in their authentic form to professional issues and problems.

The duration and structure of these degrees owes as much to financial pressures as to academic and professional considerations and it is difficult to avoid the conclusion that students and ultimately clients are being short-changed compared with the longer period of education and training afforded to other comparable professions.

Teaching to honours level has required a sustained policy of staff development for the professionally qualified staff who have had to gain bachelor degrees, taught masters and latterly higher degrees by thesis.

There are some signs that a research tradition is being established by these staff and by a small proportion of honours graduates from the initial training degrees.

However, it is still questionable whether the new degrees draw on an active research tradition and literature in the way that more established subjects do. The new degrees are therefore unduly reliant on what would in medicine be described as the pre-clinical phase and are not yet fully-fledged research-based university disciplines. There are only two professors in physiotherapy and one in occupational therapy in the United Kingdom and research ratings are low or non-existent.

The shift of assessment from professional bodies to degree awarding institutions has had several effects. First, the work of lecturers who have to prepare and mark examinations as well as course work and honours dissertations has shifted from a predominantly teaching to a teaching and assessment mode. Second, there has been a dramatic increase in the demand for external examiners from a relatively inexperienced stock. Locally set examinations do not assure comparable standards for the degrees in question, despite external examination which is itself open to challenge. The lack of a single common achievement measure makes it more difficult to compare the effectiveness of teaching and learning across institutions. This is of course a problem which faces the university sector as a whole and one solution would be to return to common national examinations of the sort these professions have set aside. The move of health care education into universities has been accompanied by the introduction of purchaser-provider relationships and associated tenders, bids and contracts. This process is thought to render quality assessment redundant since contracts are supposedly placed only where quality is assured. So there is, at present, no system to assess quality across the UK for these subjects.

Degree status and university education are the norm for initial training but research is still embryonic. Hard-won independence from centrally-set examination may be overtaken by a general return to national examinations. Significant changes in the demands on lecturers are relatively unevaluated in the absence of quality assessment for teaching in these subjects.

Occupational therapists and physiotherapists provide a valuable service which is sought after and highly regarded. But professional practice is complex and problematic and as much in need of analysis. Development and critical evaluation as ever.

The new degrees are demanding practical courses that graduates are competent, critical practitioners capable of further study and development to master and doctoral levels with projects dedicated to the evaluation and enhancement of practice should confirm the status of the professions as allied to medicine.

Roger Ellis is professor of psychology and dean of the faculty of social and health sciences and education at the University of Ulster.