Professionalization As a Consequence of State Form: The Political Economy of Skill Development and Professionalization in the United States and English Ambulance Services

Do states have the capacity to create professionalized occupations? If so, can these professionals be formed within an already dominant profession? This paper discusses and analyses the consequences of political centralization and decentralization as state forms on the professionalization of ambulance crews in the United States and England. In the United Kingdom, the centralized state constitutes a profession. Said another way, a workforce that is enshrined by the state is the workforce that takes over a domain. This is what has happened in the paid English National Health Service ambulance service. These providers have high degrees of professionalism and autonomy, and a low degree of volunteerism. The result is a fleet of professional, largely autonomous pre-hospital care providers. In the United States, however, state and policy decentralization has produced a mix of paid and unpaid ambulance service providers. While English and US crews undergo similar training courses and certification procedures, the mix of paid and unpaid ambulance service providers in the US has resulted in a floundering quasi-profession with an unstable mixture of salaried professionals and unpaid volunteers. Additionally, grassroots activism and emergency provider mobilization in the US has failed to produce systematic changes in the autonomy of ambulance crews. While decentralized American governments are much better at building a voluntary labor force than centralized governments, the centralized government of England is in a position to create useful and efficient professions that further organizational incentives to promote professional autonomy.