Developing an 'Intermediate Space': Challenges and Potential in Breaching the Professional/Non-Professional Divide

1. Breaching the ‘Professional/non-professional’ divide: the challenges and potential of developing an ‘intermediate space’ ASME Symposium, Edinburgh, 1 March 2013 Professor Alison Fuller, Email: a.fuller@soton.ac.uk

2. Outline • Context and background • Defining the ‘intermediate space’ • The project and cases • Findings • Issues and implications for career/job structures and career transitions

3. Wider context • Workforce capacity at ‘intermediate level’ identified as weakness in UK economy compared with other countries • Key policy response is to grow technician/intermediate level workforce (successive governments) particularly in STEM occupations • How well does the concept of technician/intermediate level map onto the occupational landscape in healthcare sector?

4. Some challenges in the healthcare sector • Population trends (ageing, long-term conditions) and concerns about patient care/safety underpin growing demand for staff and development of workforce • Growing awareness of ‘potential of education as a lever for service improvement’ and on employers’ role in ensuring a ‘high quality workforce’ and career progression for (all?) staff • Changing expectations of staff as some tasks devolved from registered to non-registered staff and from doctors to AHPs in some occupational areas • Changing context for commissioning – any qualified provider (NHS, private and voluntary sectors) – 2012 Health and Social Care Act – England (intra-UK differences)

5. Tensions and drivers • Drive for ‘efficiency’ requires workforce reorganisation plus technological innovation facilitates changing skill mix – both underpin case for developing intermediate level • Competent and safe workforce – role of voluntary/statutory registration, how much regulation and for whom? • Trend to full-time education (growing availability of graduates) and away from work-based route to registered posts has implications including for: • Access, widening participation and social mobility, workforce diversity • Work organisation and competence • Individual career prospects and transitions • Workforce planning

6. Understanding the ‘intermediate space’ • Surprising little is known about intermediate level jobs - that can be defined in terms of: • The content of work, what staff actually do, and the nature of their knowledge and skills • Where they are positioned in occupational, organisational and qualification hierarchies (broadly between semi-skilled and professional levels/grades)

7. But there’s ambiguity and debate • About content and the extent to which: intermediate jobs are/should be technically/scientifically based, have supervisory responsibilities, autonomy and discretion, support the activities of more highly qualified staff • About hierarchical position: in relation to roles above and below in occupational and organisational hierarchies, and in terms of qualification levels – sub-bachelor qualifications at L4 and L5, and in UK policy at L3 – including (all?) Advanced Apprenticeships

8. Locating the intermediate in hierarchical structures • Skilled/associate professional grades but varies across occupational groups in healthcare sector • Intermediate positioned mainly at AfC band 4 but not always- band 4/5 distinction critical for work organisation, registration and career transition • Intermediate positioned mainly at NHS career framework Level 4 • Intermediate qualifications positioned mainly at QCF/NQF - L4 or L5; some L3 (but there’s L3 and L3!)

9. Ambiguity • Registered occupations, usually start at AfC band 5 and require a bachelor degree (L6) but not always • Intermediate posts eg APs usually associated with Foundation Degree (QCF L5) and AfC band 4 but not always • In some occupations L3 qualifications (containing substantial content) provide access to statutory register eg Pharmacy Technician (GPhC), Dental Technician (GDC) • No automatic read across from NHS career framework level to AfC band

10. Project aims • Develop a statistical picture of intermediate-level staff • Identify E and T pathways to and beyond intermediate jobs • Consider the drivers, barriers and opportunities for the development of intermediate roles • Explore the potential role of voluntary and statutory registration for intermediate level staff • Methods: deskwork and KI interviews (regulators, professional bodies, employers, providers, individuals)

11. Case Studies • Exploring concept of technician/intermediate roles in four occupational areas selected to represent diverse characteristics: • Dental technician • Radiography support • Healthcare science • Maternity support

12. Statistical picture of intermediate staff • Ambiguity about classification and visibility in datasets (SIC, SOC, although NHS workforce data – now includes AP category) • Binary presentation of data – ‘qualified’/‘unqualified’ divorces the actual level and nature of qualifications of intermediate workforce (and support workforce generally) from their position in occupational and organisational hierarchy • Failure to differentiate between levels renders intermediate workforce invisible – implications for workforce planning, education and training • Indicative findings suggest that intermediate level small relative to ‘semi-skilled’ and ‘professional’ levels

13. Influence of professionalisation/graduate entry on access and progression • Changing patterns of entry into regulated healthcare professions • Graduate-only entry recognises increasing knowledge and expertise required in these fields but loss of work-based route previously available to existing staff can • reduce availability of intermediate level staff (eg trainee posts in healthcare science) • limit ‘widening participation’, social mobility • inhibit transitions and progression up career framework and through glass ceiling to registered professions

14. Education and Training pathways • Uneven geographical and occupational availability • Unstandardised curricula and qualifications – locally developed and determined • Debate about generic and specific content at intermediate level • Uneven, often poor articulation with routes to higher level (registered professional) courses, qualifications and careers inhibits career transitions and progession

15. Regulation • Underpinning rationale for regulation is patient safety – statutorily regulated/registered professions delegate according to scope of practice protocols to non-registered groups • In wake of criticisms, initiatives to assure standards of care being pursued for HCAs– but policy silence on contribution of intermediate level staff to patient safety – could there be distinctive expectations? • Qualitative evidence suggested support for statutory registration for intermediate roles

16. Relationship between statutory registration, E/T and qualifications • Requires development of shared definitions of specific occupational role (standardisation) which feeds into development of recognised curricula for formal approval • Strengthens individual’s labour market position – those without registration cannot access available jobs • Enhanced occupational identity, visibility and status for individual

17. Challenges and opportunities • Employer concerns about cost of management and ‘policing’ of registers • Registration raises questions about work organisation and accountability - articulation of intermediate roles with ‘professional’ roles, devolvement of tasks • Shift from work-based E and T pathways to FT programmes affecting opportunities for career progression • Clarifying intermediate role, E/T and qualifications in diverse occupational areas relevant to challenges facing the whole healthcare workforce including medical

18. Radiography • Shortage of radiographers (graduate profession) stimulated development of Assistant Practitioner (RAP) allowing for devolvement of some tasks to ‘intermediate’ level and from Radiologist to Radiographer

19. Work reorganisation and changing skill mix “What you call super APs, because they’re very experienced now...there is this area of ‘what can an AP teach’ because we have student Radiographers within areas where only APs are there, but they have to teach student Radiographers...likewise Radiographers coming will see an AP do a chest X-ray...and it’s fantastically brilliantly smooth and they’ll think that’s a great Radiographer...” (Employer)

20. Intermediate E/T pathways • Work-based route to Foundation Degree (L5) linked to Band 4 (RAP) post for existing employees • Possibility to top this up to bachelor degree to become Radiographer • Transition to FT study has limited progression via work-based route also raises concerns about students opportunity to gain experience and competence through FT pathway

21. Maternity Support • Midwifery an all graduate profession - split between qualified/registered midwives and clinical support staff • Inconsistent terminology applied to maternity support eg HSW, auxilliaries, maternity/neo-natal support worker • Slow development of recognised intermediate role despite concerns about devolution of tasks “I think that there are people out there that, you know, in both nursing and midwifery that are doing things that they shouldn’t really be doing… if we have regulation we can address that” (Educational Provider)

22. Education and Training • FT degree programme route the norm with limited potential for progression via work-based route for staff below this level • Intermediate role and associated Education and Training (eg FD) under-developed • L3 qualifications e.g. Diploma in Maternity and Paediatric Support or acquired through Advance Apprenticeship programme - weak platform for progression to degree • Tension between generic healthcare and specialist occupational content of programmes and qualifications affects currency for progression

23. Conclusions Focus on intermediate space: • Reveals intermediate level workers as knowledgeable and skilled practitioners making substantial (clinical) contribution to patient care • Reveals E/T barriers and uneven opportunities for career transitions/progression in healthcare professions • Raises questions about work organisation, devolvement of tasks and implications for accountability/regulation/registration across (whole) healthcare workforce • Reminds us that perhaps biggest challenge is career articulation between allied healthcare and medical professions