Transcending identity politics in paramedicine: Start shaping the health system

I recently found myself in a familiar setting, lukewarm conference coffee in one hand, snatching short conversations with long-time friends, catching up on matters serious and not-so-serious. We were taking part in the Paramedicine Board of Australia's recent national consultation on the Advanced Practice Paramedic model, attending alongside paramedic colleagues representing clinicians, regulatory bodies, universities, the Australasian College of Paramedicine, unions, and employers. Also attending were stakeholders from other health professions, colleges, regulatory and health advocacy bodies, and health jurisdictions. Of the many people I spoke with, a chance conversation with a state health policy advisor has remained with me, leading me to reflect afterwards on the self-imposed career limits we have placed on our profession by focusing solely on advocacy for the role of paramedicine within the health system. Whilst not unimportant, this single focus neglects the equally important contribution that paramedicine can make to the broader health system.

My reflection was tangential to the conversation with the policy advisor – we didn’t speak directly about paramedicine career development; I instead had the opportunity to listen as he described his work in strategic policy development and its implications for the whole health system. His passion for making a real difference to the community was infectious and I became curious about how he found his way into this policy domain.

He commenced his clinical career in allied health, developing gradually a drive to impact the provision of safe, quality health care at a system level. He was not concerned with how he could represent the interests of his profession or create more career opportunities for his allied health colleagues within the system. Whilst his allied health experience informed his engagement in health policy and system development, he decided to step away from clinical practice and his profession to pursue a career broadly in health policy and strategy. His professional identity was no longer located in his practice as an allied health professional. I have rarely heard paramedics talk like this.

I should not be surprised that an allied health professional might choose this path – many role models have walked this before him, becoming senior leaders, policymakers and executives throughout jurisdictional health systems. The path is equally well-trodden for other health professions. Curious, I looked up the backgrounds of the current leaders (Secretary, Director-General, and Chief Executive) of jurisdictional health systems in Australia, New Zealand, the United Kingdom and Canada. The professional backgrounds of individuals in these roles include medicine, nursing and public service administration. Engagement in health policy and strategy that transcends a focus on a specific profession's issues is a well-established, valued, and encouraged career option for many health professions. This is not yet the case for paramedicine.

In their paper ‘Building Bridges and Moving Upstream: Paramedics as Policy Architects’, Bolster and Batt ¹ encourage serious conversation on paramedicine's role in health policy and strategy. They explore the concept of paramedics in policymaking, the perspectives paramedics bring to strategic decision-making, creating novel career pathways, and enhancing professionalisation. Their description of paramedics as ‘policy architects’ recognises this career pathway as one that moves beyond passive engagement or consultation to active participation in health system design. The authors posit paramedicine as a profession with both the lived insight and moral authority to contribute meaningfully to upstream reform.

Their exploration is grounded in the Paramedic Association of Canada's Career Framework for Paramedics ² pioneering inclusion of a ‘Policy and Strategy’ career pathway alongside traditionally recognised pathways. The 2024 Canadian framework seeks to articulate to all stakeholders, including paramedics, the roles and abilities paramedics can contribute to the Canadian health system both now and in the future. Bolster and Batt are right to recognise this inclusion as a pivotal development for the profession.

Interestingly the Canadian Framework's description of the ‘Policy and Strategy’ pathway appears to largely, if not exclusively, locate implementation within paramedicine. The Framework draws attention to the lack of senior policy positions (in paramedicine) that participate in decision-making concerning paramedicine's intersection with the health system. Bolster and Batt highlight that decisions concerning paramedicine's contribution to the health system are generally taken in absentia of paramedicine participation. They give real-world examples of paramedicine's inclusion in Canadian health policy-based initiatives, including changes to opioid-agonist prescribing regulations, and the integration of community paramedicine models of health care delivery. However, they also note the limited direct participation of paramedicine in policy creation for these initiatives. The Australasian College of Paramedicine's advocacy for more effective utilisation of paramedics within the Australian health system embodies the perspectives of Bolster and Batt. ³ The UK Association of Ambulance Chief Executives' recent discussion paper ‘Developing a Public Health Approach within the Ambulance Sector’ explores the value of engagement in policy and strategy from the pragmatic perspective of a health service provider with a large paramedic workforce. ⁴

An explicit and recognised policy and strategy career pathway within and for the paramedicine profession mutually benefits the community and the profession. There is an opportunity, however, to expand the scope of this conversation and set our aspiration higher, transcending the current focus on specific paramedicine system contributions.

Bolster and Batt ¹ see the role of the Chief Paramedic Officer within health jurisdictions as critical to paramedicine policy participation and the effective representation of paramedicine within health system development. They highlight the advocacy this role would have for ‘paramedic-enabled models of care, and regulatory advancements, ensuring paramedics are integrated into broader system reforms rather than operating in the margins’. ¹ Most paramedicine representatives and advocacy bodies have historically supported this position, and in Australia, the value of the role has been clearly demonstrated in the jurisdictions of Victoria and the Northern Territory.^3,5,6

Are we still, however, seeking to have our professional status affirmed, as ‘equal’ to other professions, through the symbol of a Chief Paramedic Officer? This may be akin, perhaps, to thinking, as some do, that attaining inclusion within the Australian regulatory system responsible for the regulation of registered health practitioners (the National Registration and Accreditation Scheme), was about professional recognition, not a public policy step to provide regulatory protection for the public by managing the inherent risk in the practice of paramedicine.

A strategy and policy career pathway that extends from ‘within paramedicine’ to ‘beyond paramedicine’, that aspires to produce public value transcending, without denying, our specific professional identity, could signify a truly mature health profession. A pathway that promotes those from a paramedicine background to aspire to public service no longer grounded in advancing the profession's interests but rather the overall efficacy, accessibility and equity of the entire health system. This aspiration resonates with frameworks of civic professionalism,^7,8 where the clinician's role expands to include public advocacy, ethical leadership, and systems stewardship. By positioning ourselves as civic professionals, paramedicine can move beyond professional validation and play a meaningful role in healthcare system governance. I look forward to the day when the Secretary, Director-General or Chief Executive of a health jurisdiction lists paramedicine as their professional background. In the meantime, the Paramedic Association of Canada's Career Framework for Paramedics has shown the first step towards realising that aspiration.