Abstract
At the time of writing this review (winter 2022), ambulance workers in the UK are preparing to go on strike over pay raises and improvement of working conditions. 1 The decision for industrial action comes after decades of overstretched resources and excruciating workloads, worsened still by the COVID-19 pandemic. The news is currently reporting that the government is discussing the idea of training army soldiers to drive ambulances during the walkouts. 2 This ‘solution’ has been criticized by union representatives, who argue that it shows a poor understanding of what pre-hospital care actually looks like and stress that thinking of paramedics as just ‘ambulance drivers’ is wildly misguided. 3
Leo McCann’s ‘The paramedic at work: A sociology of a new profession’ (2022) is a book for these times. An exploration of what it is to be professionals under neo-liberal logics – a topic that will resonate with many academics and readers of Organization – this work examines the complex and ever-evolving nature of ambulance work. Its focus is the professionalization of paramedicine in recent decades, which has shifted ‘from a blue-collar occupation rooted in manual work, first aid, and transportation, to a clinically advanced profession staffed by highly trained and increasingly autonomous experts’ (McCann, 2022: 4). As McCann explains, the common image (fuelled by the media) of ambulance workers as high-octane and heroic emergency responders is misleading because it brackets out the broader range of unexciting and ordinary activities with which paramedics are required to engage. While providing emergency services remains a core aspect of their job, today only a minority of time is spent attending to life-threatening situations. For the most part, paramedic work is punctuated by less eventful calls related to primary care or social care. This expansion of scope is not accidental nor occasional. Instead, it is part of a deliberate strategy that the UK National Health Service (NHS) has been implementing in the last 30 years to cope with the increasing patient demand on a system that is simultaneously overloaded and underfunded. As McCann notes, decades of New Public Management initiatives aimed at cutting costs and pushing for a consumeristic model of healthcare provision have progressively changed ambulance work into ‘a peculiar mixture of a clinical, bureaucratic public service, NHS-type bearing [. . .] and a more industrial or military sounding world’ (McCann, 2022: 58). This unique and often contradictory combination of ‘blue collar’ and ‘white collar’ elements lies at the core of the emergent profession of paramedicine, which McCann investigates with depth and nuance, offering a thorough account of what it is to be a paramedic in the UK today, and how paramedics themselves make sense of their professionalism.
The book comprises seven chapters plus an appendix detailing McCann’s research process. Chapter 1 sets the stage by introducing the main topic of the book, namely the complex and contested transition of paramedicine from an ‘occupation’ to a ‘new profession’ (Evetts, 2011). The conceptual framework is outlined in chapter 2. Here, McCann fuses together insights derived from different strands of scholarship, ranging from the sociology of professions to the ambulance work literature, from contributions on uniformed and extreme work to ones on public administration and managerialist control, especially in relation to New Public Management practices. The empirical findings of McCann’s ethnographic fieldwork and in-depth interviews with paramedics are presented from chapter 3 to 6. Specifically, chapter 3 focuses on the work ‘on the road’, detailing the vast number of activities that characterize the daily routines of paramedics. Ambulance culture, its peculiar mixture of hierarchical elements typical of uniformed work (e.g. policing or firefighting) and more caring and compassionate attitudes associated with clinical settings is discussed in chapter 4. Chapter 5 focuses on the dark side of paramedic work, describing how stress, burnout, frustrations and work overload affect paramedics’ lives and health, and exploring their coping strategies. The last empirical chapter, chapter 6, explores how paramedics make sense of their professional identity, highlighting how, in their eyes, good paramedic work has nothing to do with achieving managerial targets, and everything to do with ‘providing what is needed given immediate patient and situational need’ (McCann, 2022: 208). Reflections on possible future directions of the development of paramedicine are shared in chapter 7, where the need for serious structural changes and massive investments in public services are brought to the fore. The book ends with an appendix where McCann explains the unfolding of his research process and discusses the methodological, practical and ethical issues he encountered on the way.
‘The paramedic at work: A sociology of a new profession’ offers a vivid portrayal of the deep contradictions, paradoxes and frustrations that characterize professional work under neo-liberal logics. As McCann details, on the one hand, paramedics are increasingly credentialled and able to deploy a wide array of clinical skills. Yet, they are simultaneously at the mercy of impossible-to-achieve performance targets, constantly pushed to their limits by inhumane workloads and stretched thin to cover the lack of primary and social/psychiatric care services. While it would have been easy to present these findings in the one-dimensional manner that often characterizes media or political portrayals of ambulance workers (and some of the literature on extreme work), McCann prefers to keep a sober tone. Instead of reducing paramedics to ‘heroes of the grind’ or ‘moaners’, his balanced approach accounts for hardships, struggles and frustrations, but also spotlights the pride, genuine care and will to help the public that ultimately provides meaning to paramedics and enable them to keep showing up day after day. For me, this adamant commitment to capture the complex, multifaceted and gruelling nature of paramedic work under managerialist regimes realistically constitutes one of the main strengths of this work. This commitment is also evident in the stylistic choices McCann makes when mobilizing his conceptual repertoire. A combination of so many different literatures could have easily turned the book into an exercise of complexification for its own sake, perhaps piquing scholarly interests, but ending up being ignored outside of the Ivory Tower. Yet, McCann does not bother with self-indulgent academic tendencies, and stitches together a rich and nuanced sociological imaginary that, in its ‘elegant simplicity’ (Tweedie, 2022: 2), is able to render the complexity of ambulance work without alienating ambulance workers themselves, but writing for them. The positive reception that this book has been having amongst paramedics, 4 and the invitation McCann received to speak to the House of Lords’ official inquiry on emergency services 5 suggest that this book is connecting to ‘the real world’ and its issues. But this connection is not necessarily exclusive to paramedics. The accounts and the sentiments presented in this book will strongly resonate with the experience of who, just like ambulance workers, find impossible to cope with managerialist regimes of their own institutions. As academics, many readers of Organization find themselves sharing the same struggle (e.g., Brandist, 2017; McCann et al., 2020; Ratle et al., 2020; Smith and Ulus, 2020), and possibly being on the picket lines again very soon in the UK, joining many other workers – paramedics included – in their fight for dignity.
