Health Reform Cutting costs at patients' and workers' expense

Text Size: Normal / Medium / Large
Printer-friendly versionPrinter-friendly version

Hospitals need to heed the lessons of Florence Nightingale

by Pat Armstrong with the National Coordinating Group on Health Care Reform and Women

There is an enormous missing piece in the discussion of private companies building and managing hospitals — the so-called P3s (public-private partnerships). It is a gap encouraged by the Romanow report but not by either history or the literature on health care. 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 implies that their work could be contracted out to for-profit firms without harm to care. Increasingly, these workers are referred to in the media as “non health-care workers.”

Research here and abroad tells us that under P3s these workers 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 that 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 workers help 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 an 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 care 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.

For more information, visit: or call: 1-888-818-9172.

A version of this article first appeared in the Toronto Star. Revised and reprinted with permission.