Dr. Armstrong is a contributer to "Social Determinants of Health:  Canadian
Perspectives." coming July 2004.
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http://www.thestar.com/NASApp/cs/ContentServer?pagename=thestar/Layout/Article_Type1&c=Article&cid=1081375811179&call_pageid=968256290204&col=968350116795

A flaw to make Nightingale wince
Toronto Star, April 8, 2004

PAT ARMSTRONG

There is an enormous missing piece in the discussion of private companies
building and managing hospitals ? the so-called P3s.

It is a gap encouraged by the Romanow report but not by either history or
the literature on health. Florence Nightingale certainly did not miss this
piece when she began reforming hospitals to make them safe for care.

I am speaking of the work done by cleaners, cooks, laundry and dietary
workers, clerical and maintenance staff in hospitals. The Romanow report
called them ancillary workers, and implied that their work could be
contracted out to for-profit firms without harm to care.

Increasingly, these workers are referred to, as they were in a Star story
last month, as non health-care workers.

Research here and abroad tells us that under P3s they would be employed by
for-profit firms focused on reducing costs by speeding up the work and
lowering the wages, benefits and job security of workers.

Yet Nightingale began by teaching nurses to clean up the hospital and to
feed the patients properly.

Her efforts are supported by all of the research we have on the
determinants of health. We know the social, physical and psychological
environments influence everyone's health.

These determinants become critical within the health-care workplace,
reflecting the specific nature of health-care work.

Health care is about vulnerable individuals who are profoundly influenced
by their environments. Moreover, the environments for care are much more
likely than other environments to constitute risks that are particularly
dangerous to those requiring care.

Health-care laundry that has not been appropriately handled can become
life-threatening for patients. It can be equally dangerous to those doing
the work, with hepatitis A or B providing only one example.

The environments for care are part of care, and can be as critical to
health as clinical interventions. Indeed, they can influence whether such
interventions succeed or fail.

That's why those doing this work are health-care workers and why their work
must be recognized as skilled for care.

Health care necessarily involves a team that includes those who do surgery
and those who make sure the surgery is clean; those who determine whether
patients eat and those who help them eat; those who determine what records
should be kept and those who keep them.

Team members are interdependent in ways that mean distinctions between
ancillary and direct care are blurred.

All those who work in health care require health-specific knowledge, and
most describe themselves as health-care providers, whatever their job in
care.

The British House of Commons Health Select Committee warned, "The often
spurious division of staff into clinical or non-clinical groups can create
an institutional apartheid which might be detrimental to staff morale and
to patients."

Just such apartheid would happen in P3s.

Perhaps, most obviously, health care is about life and death; about healthy
possibilities and dangerous consequences.

This means the risks of poor quality are high and the importance of skilled
work greater than in other sectors.

It also means that the health of the workers can have an impact on those
needing care.

Workers without extended health benefits come to work sick, jeopardizing
patient health. Temporary workers often lack familiarity with patients or
workplaces, creating possibilities for critical errors.

Lack of security in jobs or income can mean less commitment, less training
and more strain, which can lead to poor quality that creates risks to
recipients' health.

Lack of control can mean workers cannot use their skills to respond to the
variability in work demands and to crises which are regular aspects of work
in care.

In short, the more precarious the work, the greater the risk not only to
workers' health, but also to the quality of care.

And history tells us that jobs in for-profit firms are much more precarious
than those in public health care.

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Dr. Pat Armstrong is professor of sociology and women's studies at York
University.

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