Take Care: Warning Signals for Canada's Health System 9781442603004

Table of contents :
Contents
Acknowledgments
Introduction
Health Care in Canada
Health Care as a Business: The Legacy of Free Trade
Voices From the Ward: A Study of the Impact of Cutbacks
Closer to Home: More Work for Women
Epilogue: Listening to the Voices from the Ward
Bibliography

Citation preview

TAKE CARE

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TAKE CARE

Warning Signals for Canada's Health System Pat and Hugh Armstrong Jacqueline Choiniere Gina Feldberg Jerry White

Garamond Press Toronto

Copyright © 1994 by the Authors. All rights reserved. No part of this book may be reproduced or transmitted in any form by any means without permission in writing from the publisher, except by a reviewer, who may quote brief passages in a review. Printed and bound in Canada Garamond Press 77 Mowat Ave., Ste. 403, Toronto, Ont, M6K 3E3 Canadian Cataloguing in Publication Data Armstrong, Pat, 1945Take Care: warning signals for Canada's health system Includes bibliographical references ISBN 0-920059-23-6 1. Medical Policy - Economic aspects - Canada. 2. Medical planning - Canada. 3. Medical personnel Canada. 4. Hospitals - Canada - Staff. I. Title RA395.C3A7 1994

362.1 1 0971

C94-931439-0

The Publishers acknowledge the financial support of Canadian Studies and Special Projects Directorate of the Department of the Secretary of State, Government of Canada

Contents 9

Introduction Joel Lexchin MD

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Health Care in Canada Pat Armstrong and Hugh Armstrong

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Health Care as a Business: The Legacy of Free Trade Pat Armstrong and Hugh Armstrong

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Voices From the Ward: A Study of the Impact of Cutbacks Pat Armstrong, Jacqueline Choiniere, Gina Feldberg and Jerry White

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Closer to Home: More Work for Women Pat Armstrong

in

Epilogue: Listening to the Voices from the Ward Jerry White

Pat Armstrong is a professor and a former Chair of the department of Sociology at York University. Hugh Armstrong is Co-ordinator of the Health Research Project, Ontario Federation of Labour. Jacqueline Choiniere is a Registered Nurse, a PhD candidate in Sociology, and is currently working as a policy analyst in the health field. Gina Feldberg is an Associate Professor in the Social Science division, co-ordinator of the Health and Society Programme, and the Director of the York University Centre for Health Studies. Jerry White is an Assistant Professor of Administrative Studies at the University of Western Ontario and a Fellow in the York University Centre for Health Studies.

Acknowledgments This book in many ways is a product of the issues raised by health care workers and their unions. Health Care in Canada was written in response to a request from the Ontario Council of Hospital Unions. The Union asked us to help organize a conference designed to provide information on how the health care system worked. All of the authors in this text participated in some way in that Conference. One of Pat and Hugh's contributions to the Conference was this article; an article which was formatted by Charles Brabazon and distributed by the Union. Voices from the Ward was a direct product of that Conference. Health care workers went to the microphones and offered examples of how cutbacks could risk the health of patients and increase costs to the system in the long run. We were very moved by these examples and decided to collect them in a more systematic, scientific way. Harriet Rosenberg was involved in the initial design of the project as were Pat Jackie, Gina and Jerry. We received financial support from York University, from the Ontario Council of Hospital Unions and, through that organization, from the Ontario Ministry of Health. OCHU also helped us find participants for the research groups, locating volunteers who fulfilled the requirements of our research design. The focus groups were conducted by Jackie and the interviews were analyzed by all four members of the research group. The final document, written by this group of four, was formatted by Charles Brabazon and printed by OCHU. The first version of Closer to Home was written by Pat for the British Columbia Hospital Employees Union. HEU asked for an assessment of the impact of proposed health care strategies on women in the province. This Union published and distributed the report The version published here extends and updates that analysis. Health Care as a Business was initially written for an academic conference organized by Rianne Mahon and Jane Jenson. A version of the text was edited by Ed Finn and published by the Canadian Centre for Policy Alternatives. The revised

version which appears here owes a great deal not only to these people but also to those workers who have developed a critique of free trade. Joel Lexchin was involved in planning the Conference that gave rise to two of the articles published here. Although other time pressures prevented him from continuing with the project, he efficiently, effectively and eloquently responded to our request for an introduction to this collection. We wish to thank all those who contributed to the articles which appear here, including those who helped with the funding, publication and distribution. We are particularly grateful to the 98 workers who were so concerned about what was happening to patient care that they gave up their free time in order to share their experiences with us. Their stories, only some of which are included here, so clearly came from caring that we could not help but be profoundly moved by them. The people at OCHU - Charles Brabazon, Steve Eadie, Michael Hurley and Lyn Lathrop - offered a whole range of crucial support without ever trying to influence our analysis of the data. Their dedication to defending our health care system is a modelforusall. Similarly, the people at HEU, and especially Chris Allnutt and Chris Gainor, were extremely supportive without being directive and were equally committed to public health care. We would also like to thank Katherine VatriBoydel, who provided Pat with very useful references, Dick Butcher, who did the bibliography and Marc Plumb, who worked on the footnotes, and Rosanna Moretti, Randee Holmes and Tracy Shannon, at the York University Centre for Health Studies who fielded the many calls from those wanting to talk about Voices from the Ward. SarahArmstrongdidaverythoroughandeffectivejobofcopy-editing. And we thank Peter Saunders of Garamond Press, who so quickly and enthusiastically responded to our suggestion for this book on health care. April 1994

Introduction Joel Lexchin MD The history of the Canadian health care system, or as the Armstrongs put it the complex array of health programmes at the municipal, provincial and federal level, is usually written as the history of legislation, physicians' groups, politicians and' 'great men.'' While all of these play a role, workers and their unions are consistently left out of these narratives. Indeed, without the energy and vision of the labour movement Canada would not have its much vaunted health care programmes. In his analysis of why the United States does not have either a national health insurance scheme or a national health programme, Navarro1 innumerates four key health concerns of the labour movement in developed capitalist countries: 1. universalization of health benefits. 2. control by and/or participation of the labour movement in the direction of the health care system. 3. state responsibility for the management of funds. 4. support of the health care system by a progressive system of taxation. Navarro" s conclusion is that "the major social force behind the establishment of a national health program has been the labour movement (and its political instruments-the socialist parties) in its pursuit of the welfare state." The chapter on Health Care in Canada shows that all the points listed by Navarro have been, to a greater or lesser extent, incorporated into Canadian health programmes. Presently, the health care system is deemed to be in' 'crisis.'' Politicians and business leaders are continually hammering away at unacceptable rises in health care expenditures. The message that keeps coming through is that we can no longer afford a Cadillac level ofserviceand will have to learn to make do with less. Various measures are suggested, such as rationing services, imposing user fees ("the zombies that will not stay buried" as one commentator calls them), rationalizing services - the list goes on.

10 /Take Care

Much of the crisis is myth. For example, the increase in the number of elderly Canadians by itself has very little to do with rising costs. Rather it is the number of services and procedures that the elderly generate that is driving costs up.2 While some of those services are of value, many are questionable, certainly in the area of prescription drugs. Physicians are increasingly replacing older, less expensive medications with newer, more costly ones. There is little evidence that many of the newer therapies are producing any benefit.3 Not only are newer Pharmaceuticals of marginal value to the elderly, but the same applies to medical interv entions in general. One Manitoba study compared the health status of 1971 and 1983 samples of elderly persons (80 years of age and older) and found that while the elderly were living longer in 1983, their health status was poorer than it had been 12 years previously. There was a 29 per cent increase in the number of elderly persons, but a 73 per cent increase in the number of elderly who were in poor health, whetherjudged by functional status (ability to perform activities of daily living), number of different health problems reported, mental status or the rate of hospitalization for serious co-morbid disease.4 The rise in health care costs is real, but the Canadian health care system has always been one of the most richly supported in the world. However, costs are not increasing any faster now than they have during the last forty years. What is different is that there has been a considerable decline in the growth of the Canadian economy so that health care costs are taking up a larger proportion of the gross domestic product.5 Couple the economic downturn with the federal cutback in contributions to Medicare that the Armstrongs describe along with the obsession with the deficit at all levels of government, and we have the so-called crisis in health care funding. The Armstrongs point out in their chapter on the legacy of the free trade agreement that while the Tories were in power their response to this crisis and to public spending in general was to convince Canadians that they are living well beyond their means. The Conservatives embarked on a wholescale privatization of public services and at the same time set the philosophical and financial agenda that encouraged the shifting of the burden for the provision of services from the market to unpaid volunteer and household workers. It is not the free trade agreement per se that is the problem but the conservative mentality toward health care that has accompanied the agreement. This mentality has been carried over into the health sector, where decisions are increasingly made based on a market-first approach instead of on a patient-first approach. Of course, parts of the health care industry have always been governed by a free market system. The pharmaceutical industry, dominated by multinational companies, has traditionally been profit-driven and as a result has invested in

Introduction / 11

products that promise the greatest sales potential and not necessarily the greatest health potential.6 This philosophy is invading areas like hospital care which have previously been isolated from this type of thinking. As Walker argues:' 'The subordination of the equity concerns of social policy to the cost-efficiency concerns that dominate economics and economic policy follows from and reinforces the assumption of the superiority of the market, and paves the way for the adoption of policies aimed at reducing the size of the welfare state when economic growth no longer provides a sufficient welfare surplus."7 The effect of these changes in public policy and public consciousness and the cutbacks in health care that have been generated is the main thrust of the last three chapters of this book. This is a topic that has generated reems of newspaper copy, a multiplicity of magazine articles and enough books to support a small publishing house. However, just as histories of the Canadian health system neglect the role of labour, most of these accounts leave out the effect of the cutbacks on the people who do the bulk of the work: the nursing assistants, the orderlies, the cleaners. The authors help to correct that imbalance in this book. They vividly illustrate how the changes that have been initiated across the country have a profoundly negative impact on the quality of working life and ultimately on the care that patients receive. One way in which governments hope to save money is through deinstitutionalization--moving patients out of hospitals and into the community. Whatever the advantages of this move in terms of patient care, this option is particularly attractive to government because of the potential short-term savings. 1981-82 figures from Britain show that in the case of elderly people in the "high dependency" category the costs of providing paid neighbourly helpers and home care assistants were, respectively, 21 per cent and 23 per cent of the cost of an acute hospital bed, 29 per cent and 32 per cent of the cost of a geriatric hospital bed, and 71 per cent and 79 per cent of the cost of a place in a senior citizen's home. In the introduction to Closer to Home: More Work for Women Pat Armstrong quotes from the recent British Columbia report "New Directions for a Healthy British Columbia" that one of the government's objectives is to provide health service at home or close to home "with the support of family members and friends." But transfering patients into the home and the community also means transfering the locus at which care is given and who gives the care. In both cases, women are the primary care givers, but in the institutional setting those women are being paid to provide the care while in the home it is usually female relatives who are doing the caring on an unpaid basis. Even when homecare givers are in the paid labour force, they are usually not unionized and their wages are far below those of unionized hospital workers.

12 /Take Care

There is little evidence that in promoting home and community care, the state has paid any significant attention to the needs felt and expressed by the women who provide the care. Therefore, there is no organized support provided to the women who deal with the uncomfortable reality of a great deal of caring work: hard manual labour, dirtyjobs, sleepless nights, and mental stress on top of their other activities at home and in the labour force. Pat Armstrong concludes her chapter with a cogent discussion of the costs of this caring to the women who deliver it, to their patients and to the companies that employ the women who are conscripted into caring. In all cases, there are serious negative consequences that cannot be ignored. Finally, Voices from the Ward gives us first hand accounts of what hospital cutbacks and restructuring has meant to workers and patients. I have seen some of the effects of these cutback in the emergency department where I work. Clerical services have been cutback so that when someone is off on break or at a meal they are no longer replaced. When the phone rings there is no one to answer it so it just keeps on ringing, no-one is around to check that old hospital records are being delivered or that laboratory results are coming back in a timely fashion. Hospital management cannot replace injured or ill workers so a memo was circulated to the emergency physicians asking us not to give people time off if they were hurt or sick. Instead we are supposed to instruct any hospital employee we see to go to the employee health services department presumably so that management can make sure that people are not taking too much time off. The interviews with registered nursing assistants, dietaiy and housekeeping staff, clerical workers, porters and others paint a grim picture of life in hospitals across Ontario. Unfortunately, so far the response has not been to look at the problems that these workers have identified but instead to shoot the messenger. The report has been attacked on the basis of its methodology--thatsince it only involved workers from nine hospitals its conclusions are not representative and are merely isolated examples of bad practices rather than reflecting a growing reality. The consistency of messages from the workers argues strongly that the problems are, in fact, pervasive. By discussing the effect of health care cutbacks from the perspective of labour and by letting us hear the voices of workers the authors have added a new dimension to the growing debate about how to reform our health care system. The prospects for reversing the market oriented changes that we have seen may not be encouraging, but I do not believe that all is doom and gloom. In the past, it was the actions of workers and other progressive people that created our health care system. Workers are now standing up and being heard, and coalitions of like-minded people can once again have a decisive influence over the course that Canadian health care will take.

Introduction / 13

notes ' Joel Lexchin works in the emergency department of The Toronto Hospital. He has been a member of the Medical Reform Group of Ontario since it was founded in 1979 and is the author of The Real Pushers: A Critical Analysis of the Canadian Drug Industry as well as numerous articles about prescribing and the pharmaceutical industry. 1 Navarro V. "Why some countries have national health insurance, others have national health services, and the United States has neither." International Journal of Health Services 1989;19 pp. 383-404. 2

Barer M.L., Evans R.G., Hertzman C. et al. "Aging and health care utilization: new evidence on old fallacies." Social Science and Medicine 1987;24 pp.851-862. 3 Lexchin J. "Prescribing and drug costs in the province of Ontario.'' InternationalJournal of Health Services 1992;22 pp.471-487. 4

Roos N.P., Havens B., Black C. "Living longer but doing worse: assessing health status in elderly persons at two points in time in Manitoba, 1971 and 1983.'' Social Science and Medicine 1993;36 pp.273-282. 5

Stoddart G.L., Barer M.L., Evans R.G., Bhatia V. "Why not user charges? The real issues. "(The Premier's Council on Health, Well-being and Social Justice, September 1993.)

6

Lexchin J. The Real Pushers: A Critical Analysis of the Canadian Drug Industry. (Vancouver: New Star Books, 1984.) 7

Walker A. ''Enlarging the caring capacity of the community: informal support networks and the welfare state." InternationalJournal of Health Services 198 7; 17 pp. 369-3 86.

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Health Care in Canada There is no such thing as the Canadian Health Care System. What Canada has is a complex array of programmes at the municipal, provincial and federal level that have different sources of funding, operate under different forms of control and provide different kinds of services. Moreover, these programmes are undergoing considerable changes, as all levels of government seek to reduce health care expenditures. It is no simple task, then, to describe Canada's best loved social programme.1 What follows is a broad outline of how health care in Canada is generally funded, structured, delivered and controlled.

Who Pays? In one sense, nobody pays for health care, because a whole array of services are available without charge. In another sense, everybody pays for health care, because health care in Canada is primarily funded from tax revenues. But the actual funding and payment arrangements are much more complex. While the British North America Act that established Canada in 1867 gave responsibility for health care to the provinces, it gave most of the financial resources to the federal government. Since Confederation, the federal government has provided care for Natives, for Veterans and for members of the Armed Forces. It has also screened immigrants arriving in Canada and been responsible for the quality of food and drugs. But the federal government has been mainly involved in health care through its financial contribution to provincial health care services. The federal government became a heavy contributor to provincial health care in the period following the Second World War.

16 Wake Care

Canadians came out of the war demanding a better life. "There was a mood of rebellion against the universal risks of unemployment and sickness, disability and old age, widowhood and poverty, a pervasive dissatisfaction with precarious minimum wages, drought-stricken farms, grudgingly-granted relief payments, and a suspiciously-administered, means-tested old age pension."'2 The federal government responded with a series of proposals on a range of social programmes, including health insurance. Although the Conference on the proposals collapsed, largely because the provinces could not agree, the idea for national health grants did not disappear. Announced in 1948, the grants committed the federal government to matching provincial expenditures on hospital construction. The grants were cut in half in the early 1950s and later disappeared, but they had a profound impact on Canadian health care. The Prime Minister of the time saw these grants as "the first stages in the development of a comprehensive health insurance plan for all Canada."3 They stimulated an enormous expansion in hospital construction and reinforced the increasingly hospital-based, acute care focus of the system. It was another decade before the federal government moved on to provide support for hospital services Under the Hospital Insurance and Diagnostic Services Act introduced in 1957, provinces operated and financed their own plans but the federal government paid for half of specified services. Included in the insured costs were accommodation and meals in a standard ward, necessary nursing services, laboratory and other diagnostic tests, drugs and similar preparations, use of operating rooms and anaesthetic facilities, routine surgical supplies, radiology and physiotherapy as well as the services of other hospital employees. Provinces could also elect to ensure abroad range of out-patient services and they all did so, although the specific sendee provided varied from province to province.4 Physicians' services provided in the hospital were not covered under this plan and nursing homes as well as home care sendees remained largely in private hands.5 These financial arrangements also had an impact on the structure of health care. The plan meant that "provincial governments had financial incentive to fund as much in-patient care through hospitals as possible."6 Doctors no longer had to be concerned about a patient's ability to pay for a wide range of hospital procedures. Indeed, because only services performed within the hospital were paid under this scheme while services provided in doctor's offices were not, many procedures were transferred to the hospital where costs were higher and techniques often more complicated7. Similarly, because the hospital insurance scheme did not cover chronic care or psychiatric facilities, many patients who could have been more cheaply and perhaps more effectively cared for in other institutions were admitted

Health Care in Canada /17

to general hospitals8. It should be noted, however, that the plan did not initiate these trends. It merely reinforced them. "The main increase in hospital utilization had occurred before the national program."9 In part because most hospitals had been run on a non-profit basis and in part because a number of provinces had already introduced a form of hospital insurance, there was little sustained opposition to the hospital insurance plan. Of course, the insurance companies were concerned about lost revenue and were supported in their opposition by the Chamber of Commerce. Catholic hospitals were concerned about government control and so were the doctors. The Canadian Hospital Association was concerned about the emphasis on general hospitals and the neglect of homes for the aged and home-care programmes. But the federally funded health survey that demonstrated the direct link between care and income, combined with provincial disparities and limited resources, as well as pressure from unions and more general popular support, provided a firm basis for the hospital insurance scheme10. Opposition to insurance covering medical services was much more hostile and much more sustained. Doctors in particular mobilized to fight Medicare. When the province of Saskatchewan introduced legislation in 1962, doctors went on strike and organized demonstrations that included many of their patients. The social democratic government eventually prevailed, but at considerable cost. The provincial government abandoned the plan to put many doctors on salary and agreed to a feefor-service payment scheme based on private practice and professional autonomy. Fearing similar responses to any plan that limited doctors' power, the federal government used Saskatchewan's plan as a model for the federal Medical Care Act introduced in 1966. This strategy did not prevent further protests but by 1971, all provinces had a scheme similar to Saskatchewan's in place11. As was the case with Hospital Insurance, Medicare left responsibility for services in provincial hands but the federal government promised to pay half of specified provincial expenditures. Under this plan, doctors negotiated their fees with each provincial government. In most cases, only medical doctors were part of the fee for service payments. Optometrists, dentists, nurses, midwives, chiropractors, physiotherapists and naturopaths were not part of most provincial fee for service plans12. Drugs, eye-glasses, ambulance services and various prosthetic devices were excluded in most provinces. Provinces did, however, pay such expenses for the elderly and those with low incomes. Doctors could opt out of the scheme entirely, but few did so. While most provinces paid for these fees out of general revenues, Quebec used a payroll tax to fund part of health care costs. Three provinces charged premiums to those deemed able to pay but these premiums did not cover the entire cost of the

18 /Take Care

services. Some provinces also allowed physicians to extra-bill over the government fee13. The method of payment to individual doctors varied. In Quebec, for example, patients simply gave the doctor their medicare card and the doctor was paid directly. In Ontario, on the other hand, patients usually paid the doctor and then billed the government. Like the National Health Grants and the Hospital Insurance schemes, the federal funding of Medicare helped shape provincial programmes and sustained the emphasis on hospital and medical services. The scheme did do what its proponents argued it would do. It significantly improved access to medical services for those with lower incomes. A study by the Enterline team noted "the increased frequency with which physicians were seen for a series of common and important medical symptoms. This suggests that the removal of economic barriers to medical care may actually improve the general level of health of the population."14 In the short run, overall volume of service decreased and waiting time increased, especially for wealthier patients. Medicare did not have a negative impact on doctors, as others had argued it would. Indeed, doctors hours of work decreased, as did their number of home visits15. At the same time, doctors incomes went up, as governments guaranteed payments for all services. "In 1980 the average net income from all sources for physicians was over $64,000...higher than that of lawyers ($49,481), dentists ($56,977), accountants ($43,799) and engineers and architects."16 Arguing that the matching payments based on provincial expenditures made it impossible to plan and that costs were rising much too rapidly, the federal government introduced new funding arrangements in 1977. Although separate payments continued to be made for hospital and medical care services, the principles of payments for both were the same. The new formula had several parts. First, there was a per capita payment, based on previous expenditures and adjusted regularly in relation to the GNP, so that support would grow with a growth in the economy. Second, the federal government transferred tax points to the province, meaning that it reduced its tax rate so that the provinces could raise theirs. Third, because the value of tax points would vary among provinces, some equalization payments were included. Fourth, an additional, indexed, per capita payment was made to help pay for nursing home and other residential care as well as for home and ambulatory care. This arrangement partially replaced earlier welfare payments covering those with demonstrated financial need17. With funding no longer tied to current costs, provinces had greater flexibility both in terms of how much they spent on health care and of how expenditures were allocated. " Under the new funding format, provinces shifted a lot of chronic and

Health Care in Canada /19

long-term care out of hospitals into special care institutions, a process that was particularly pronounced in the case of psychiatric services."18 And they started to look for ways to cut other costs, given that new dollars spent in the province no longer meant new dollars from Ottawa. Efficiency and productivity became critical concerns. Hospital budgets stopped growing and labour time per patient was reduced. "Some analysts see this budget-induced reduction in personal hours to patients as an increase in productivity, while others see it as a reduction in the quality of care."19 With transfers tied to economic growth, federal contributions to health care continued to rise. Arguing that the deficit must be controlled, the Conservative federal government changed the funding formula. In 1986, it was announced that transfers would be based on economic growth minus two percentage points. This became minus three percentage points in 1989. In 1990, there was a further reduction when the federal government declared a total freeze for two years. This temporary freeze would be followed by a return to the earlier minus three percentage points formula. In 1991, the Conservatives reneged on that promise and announced that the freeze would continue until the end of the 1994-1995 fiscal year20. '' With overall entitlements frozen or restrained to increases of 4.5 percent a year and the part of EPF [Established Program Financing] funded through tax transfers going up eight per cent a year, the cash part of the program is bound to keep shrinking."21 The National Council of Welfare estimates that if this formula were retained until the turn of the century, the provinces would lose close to $ 100 billion in transfers for health and higher education and would have to rely almost exclusively on their own tax revenues. This policy is bound to put increasingly severe financial pressures on health care. It will also increase disparities among provinces, given that provinces have very different potentials for collecting taxes. In 1988-89, the federal government contributed $8.2 billion in cash outlays and $6.6 billion in cash transfers. Provincial spending amounted to $23.9billion, while municipal spending reached just $6 million. Private spending, including voluntary and non-profit groups, was estimated at $ 14.8 billion22. As the federal government continues to reduce its contribution, provinces are frantically searching for ways to cut their costs. There is more and more discussion of charging for a range of services, of making health care no longer "free." While the need to cut costs may seem obvious, it should be noted that Canada spends less to serve more people than is the case in the United States. In 1987, "Canadaspent9.0percentofitstotal output on health care," compared to 10.8per cent in the United States23. For this amount, Canada covered virtually everyone for basic costs while it is estimated that in the United States "37 million citizens have

20,Take Care

no health insurance and another 50 million are under insured."24 Canada spends relatively more than Australia, Finland and the United Kingdom but it spends no more than Germany, France or the Netherlands25. In 1983, health care costs as a proportion of GDP were 8.7 in Canada, compared to Australia's 7.5, Finland's 6.6, theU.K's6.2, Germany's8.7, the Netherlands' 8.8 and France's 9.3. In other words, Canada's cost are not out of line with other countries that have national health care schemes. Moreover, health care "costs have in fact escalated much less rapidly during the 1980s than in any of the three previous decades." Yet the federal government, and in its wake the provinces, is using an argument from costs to justify the undermining of Canada's most popular social programme. Moreover, health care costs"have in fact escalated much less rapidly during the 1980s than in any of the three previous decades."25a

Who Decides? It could be said that every Canadian decides on their own health care, given that individuals have the right to choose their own doctor, to see that doctor as often as they wish and to refuse or accept the prescribed treatment26. Moreover, all adult Canadians have the right to vote for the municipal, provincial and federal politicians who determine health care policy. But the actual decision-making process is much more complex, and much farther from individual or even collective democratic control. Although the federal government lias a very limited constitutional basis for making health care decisions, it has used its very considerable economic clout to develop and shape a national health care scheme. When both hospital insurance and medicare were introduced, the federal government promised to pay half the costs of certain services only if the provinces conformed to five principles27. These priniciples were based on the assumption that "no financial barrier should hinder access to health care."28 In order to be eligible for federal payments, each provincial plan would have to allow for: 1. Universality. According to the legislation establishing the federal scheme, provinces had to provide coverage for at least 95 per cent of insurable residents. And insured services had to be provided under uniform terms and conditions. In other words, there was not to be one service for the rich and another for the poor and there was not to be primary coverage through private insurance companies. Private insurance companies could still offer coverage for such things as drugs prescribed to ambulatory patients.

Health Care in Canada / 21

2. Accessibility. The form of payment was not to limit "reasonable access to insured services by insured persons."29 Utilization fees were not forbidden but they could not result in restricted access. Benefits could not be linked, as was the case in many private insurance schemes, to age, to disease, to past health record or to employment. 3. Comprehensive coverage. Insured benefits were to cover necessary in-patient and some out-patient services as well as medically required services provided by a physician and by some dental surgeons. Specified ceilings were not allowed, as they were in some private insurance schemes. Private insurance could be used to cover extras such as private rooms and amubulance services, however. 4. Non-profit public administration. Provincial plans were to be administered by a public authority responsible to the provincial government. This did not mean that non-governmental agencies could not be involved but it did mean that their accounts and procedures were assessed by a provincial agency. 5. Portability. Canadians were to be covered if they temporarily left the province or moved from province to province. When Canadians moved into a province, they could not be required to wait for more than three months to become eligible for the plan in their new province of residence. During the waiting period, they were to be covered by their old provincial plan. Although the new fiscal arrangements introduced in 1977 had ended the itemized scrutiny of provincial accounts, the five conditions were not redefined. Extra-billing and opting out by physicians became increasingly common30. Poll after poll indicated that Canadians supported their old healthcare system but it was slowly being eroded by provincial government policies and physicians' practices. In spite of somevery heavy opposition from physicians in particular, the Liberal government in Ottawa introduced legislation designed to maintain a "free'' health care system in Canada. The 1984 Canada Health Act penalized provinces for extra billing, reducing transfers according to the amount of extra billing allowed. It also redefined hospital services to include all services "medically necessary for the purpose of maintaining health, preventing disease or diagnosing or treating an injury, illness or disability. 3I This included services provided to both in-patients and out-patients at a hospital and was designed to prevent user fees for people provinces had defined as"temporary chronics.'' As well the Act took a first step in challenging doctors' monopoly over billing under Medicare. The new wording referred to "health

22 Wake Care

practitioners" and opened the door to billing under Medicare by other health care workers such as nurses. But the doctors have strongly resisted any action on this change and provinces have not moved to allow nurses direct billing rights32. The Canada Health Care Act virtually eliminated extra-billing and demonstrated the importance of the federal transfers in maintaining a national health care scheme. With federal cash contributions steadily dwindling, federal influence will also diminish. Even though Canadians have given every indication that they support the old scheme and even though Canadians have not been given a choice at the ballot box about these changes in the federal voice, Canada' s national plan is in real clanger of disintegrating as a result of federal financial withdrawal from health care. Provinces have always had the constitutional right to determine health care and the 1977 changes in federal regulations increased their decision-making possibilities. Within the conditions set by the federal government, provinces not only decide how much to spend but also how to spend the health care dollar. Because a growing proportion of their budgets go to health care, provinces have begun searching for ways to reduce health care costs. Andbecause hospitals account for such a large share of provincial health costs, provinces have looked first to hospitals for cost savings. Much like the new federal-provincial funding arrangements, .hospitals were given cwglobal budgets" based on annual forecasts. The decisions on how to spend these fixed amounts were then left largely to each institutioa Provinces have also encouraged the growth of non-hospital care, some of which is provided outside the public sector and organized for profit. While extended care facilities and residential homes can provide better alternatives for care in many instances33, much of the decision-making about quality has been left to owners operating the services. This is the case in spite of the fact that governments pay between 65 and 70 per cent of special residential care costs.34 4 "Many provinces do not enforce rigorous standards of care, and some rely upon profit-making residential facilities whose appropriateness in dealing with frail, dependent people is questionable."35 Although some have argued that the privatization of services results in "more efficient, effective and responsive" care, others have maintained that privatization results in lower "quality of services, lack of accountability and responsiveness, and unequal access to services."36 Similarly, provinces have encouraged institutions to release patients, arguing that many will be healthier and more independent if they are integrated into the community. In the case of Manitoba, this de-institutionalization has been accompanied by a home care program that offers a range of services including nurses, social workers, homemakers, therapists and volunteers as well as other facilities and equipment37. But because this strategy is often primarily seen as a cost-cutting

Health Care in Canada / 23

measure, most provinces have not significantly re-allocated resources to provide for these people released from institutions Those who would prefer to stay within such institutions too often have little choice about leaving them38. Provinces also have the right to determine how doctors will be paid, what they will be, paid, how many doctors will be educated and how doctors will be governed. But in reality, these terms are negotiated with doctors and doctors have frequently won on most of their demands. All provinces primarily rely on fee for services payments and fee schedules in the 1980s significantly exceeded the inflation rate39. While fees have generally increased more rapidly than inflation, the number of doctors has increased at a rate faster than the increase in population. Between 1968 and 1983, the number of physicians increased by just over 80 per cent40. By 1983, there was one doctor for every 603 people, compared to one for every 909 in 196841. Moreover, physicians are self-governing, given that most provinces have delegated their regulatory power to the medical profession. And physicians are prepared to fight hard to maintain thiscontrol. When theprovincial government in Ontario tried to monitor physicians? billing practices, the doctors appealed to the courts and won42. In general, provincial governments have not moved very far to restrict doctors' income, power or numbers. Although provinces determine the global budgets for hospitals, the decisionmaking within hospitals is largely determined by the hospitals themselves. Over 90 per cent of Canadian hospitals are public43 and most are formally operated by boards of directors that include public representatives. Only 4 per cent of hospitals are privately owned. Of the public hospitals, some are operated by the provincial or municipal governments and some by voluntary lay bodies, by religious organizations or by the Red Cross. A very small number of publicly-owned hospitals (2.6 per cent) are operated by the federal government. Decision-making varies considerably from hospital to hospital. In all hospitals, doctors retain important decision-making powers on the formal boards and committees. However, these powers are increasingly being challenged by a variety of groups. The most important group in these terms is the health service executives who are responsible for developing and administering the hospitals' internal budgets. The power of these executives has grown as Canada's health care system has become increasingly dominated by giant hospitals44. With pressure to reduce costs, these administrators are increasingly monitoring the work of all those working within the hospital. These data collected on patients and on services are used to implement standards for length of stay, for amount of personnel required per case, for the degree of cleanliness, for preparation of food; indeed, for all aspects of care within the institution. Claiming efficiency and productivity concerns, these

24 Wake Care

administrators have been central in the decisions to close beds, increase reliance on out-patient services, reduce the length ofhospital stays, lay-off workers, increase the use of part-time workers, amalgamate hospitals and privatize some services. It should not be assumed, however, that these strategies in fact result in significant cost savings. Indeed, Ontario's Auditor General recently reported that the amalgamation of several giant hospitals in Toronto was done without any evidence indicating where money would be saved and there is still no evidence that money has been saved. Another Toronto hospital turns out to be deeply in debt, largely as a result of financial speculations, but this debt was not evident to the board of directors. And several hospitals that laid-off significant numbers of staff and closed beds seem to be paying their hospital executives between $350,000 and $400,000 annually. Both the public accountability and the efficiency of these executives is being questioned. It is not only administrators who have been challenging decision-making structures within the hospital. Canada's hospitals are highly unionized and these unions are demanding an increasing say in how hospitals are run. Most hospitals have unions. While service workers are the most highly unionized, unions are becoming increasingly common among nurses and technicians as well. Strikes have also become increasingly common. This is the case even among nurses, although nurses have no right to strike in a number of provinces. Unions have demanded better wages, better working conditions and more job security as well as more say in overall decision-making. At the time of Medicare's introduction, wages in some hospitals were" 'below what the Economic Council of Canada sets as the poverty line."45 And the labour force made-up primarily of women and immigrant men had little say in what they did or how they did it. Unions made a difference. Wages improved considerably, although they remained below the Canadian average46. Workers gained the right to say no and to have orderly dismissals. But unions have been less successful in gaining a say in overall administration and in preventing lay-offs. Cutbacks have come primarily at the expense of these unionized workers. With afocus on shorter hospital stays, high tech treatment, de-institutionalization, day-surgery and privatization, hospitals have reduced the number of cleaners, laundry workers, kitchen staff, clerical workers, nursing aides and even nurses. It has not only been workers who have been demanding more say in the structure and delivery of health care. Patients' rights groups have also been challenging what and how things are done in the health care system. Women's groups in particular have organized opposition to current practices. Their success in some areas can be attributed at least as much to cost-cutting concerns as they can be to concerns about

Health Care in Canada / 25

power, however. So, for example, hospitals have agreed to let babies stay in the room with their mothers. Indeed, in some hospitals babies must stay in the mother's room because the staff in the nurseries has been drastically reduced. Similarly, midwives may soon replace doctors at some births in Ontario, but births with midwives will be cheaper than those with a physician in a high tech room. Although all these groups threaten physicians' dominance, it is still doctors who determine who gets what done to them where, by whom and for how long.47 Public hospital insurance and medicare did not transform doctors into salaried workers. They simply meant public payment for private practice.48 Even doctors whodo most of their work in hospitals are primarily paid on a fee for service basis. While figures suggest that doctors account directly for only about 16 per cent of total health care expenditures49, they are estimated to control approximately 80 per cent ofhealth care costs50. Patients can choose which doctor to see, howmany doctors to see and whether to follow the prescribed treatment. But doctors determine who is admitted to hospitals, what drugs and tests are carried out and how long patients stay. Fee for service payment means that it is in the doctor's financial interest to do more treatments and to do more complicated treatments with each patient. Cutbacks in beds do mean doctors have more restrictions on their access. But few such restrictions have been placed on their office practices and doctors have not been laidoff in an effort to cut costs. Indeed, the transformation of more hospitals into hightech centers for acute care make these institutions even more doctor centered. * 'But perhaps the most significant power we give to physicians is the right to define what is and what is not a health problem. "51 Doctors also have a profound influence on the overall structure ofhealth care. Doctors are chief advisors to the ministries ofhealth on a wide range ofhealth related matters. This is particularly important in a system that is publicly funded. But their influence does not stop here. Although a 1972 Conference of Health Ministers recommended the creation of a system of community health centres staffed by multidisciplinary teams ofhealth care workers, physicians have effectively blocked their development. OnlyQuebechasasubstantialnumberofthese centres52. Doctors have been able to block such moves even though there is considerbale evidence to suggest that health centres reduce costs by reducing the number of hospital admissions and by promoting health53. As the federal government gradually withdraws from providing direct payments that allow it to shape a national health policy, more and more decisions are left to the provinces. Provinces' choices are increasingly limited by the financial constraints resulting from this withdrawal, however. Provinces in turn leave hospitals and doctors an enormous amount of discretion, although provinces too are changing

26 Wake Care

theparameters by reducing the amount of money available to hospitals in particular. Hospitals have responded by de-institutionalizing patients, amalgamating hospitals and reducing some services while privatizing others, lay ing-off workers and closing beds. All these strategies significantly reduce the choicesof both healthcare workers and patients. In spite of considerable discussion about the need to redesign care and focus on prevention, the system remains doctor-centered. The veiy complexity ofthe system makes it difficult to do anything except provide less of the same. In the process, health care is being changed in ways that bear little relation to choices made by patients and voters.

Who Has Access? It is extremely unlikely that any Canadian would be refused admission to a hospital or treatment by a doctor on the basis of income or ability to pay. Nor are many Canadians likely to go into debt in order to pay for health care. Hospital insurance and medicare have significantly improved access to health care. But inequalities remain. The two provinces of Alberta and British Columbia still charge premiums for health care. While premiums are forgiven for the old and the poor and no-one is likely to be denied care because they have not paid their premiums, these premiums do place a greater burden on those with limited incomes.' 'People who cannot afford the premiums and who for one reason or another do not receive a premium waiver from the provincial government must pay their bills themselves; this likely deters them from using some services."54 Moreover, most provinces leave drugs, dental services and nursing home care in private hands55, making ability to pay a factor. Many of those with good, stable jobs have these "extras" covered by private insurance companies. Again, the old and the poor are subsidized but low income people are left to fend for themselves. Moreover, fewer and fewer people have good, stable jobs. And provinces are increasingly finding ways to charge for services or are cutting back on services that are part of the care package. Metro Toronto, forexample, has decided toend welfare subsidies for eye-glasses and the province has been unwilling to fill the gap. Quebec has decided to reduce the extent of dental service provided without charge to the young. Laboratory staff in many hospitals has been reduced, increasing the length of time people who cannot afford private service will have to wait. Access is also limited by location. Canada is a vast country with a sparse population outside the major metropolitan areas. Doctors have been reluctant to locate outside southern urban centers and this is especially true of specialists. There are considerable differences among provinces and among regions within provinces

Health Care in Canada / 27

in terms of access to doctors and specialized treatment56. Quebec has used a combination of rewards and punishments to get doctors into outlying regions. New doctors are fmancia ily penalized if they practice for their first three years in big cities and specialists are required to practice in areas designatedby the government for four years57. Most provinces, however, allow doctors to make the choice. Native Canadians in particular surfer from their choices, given that they form alarge portion of the population in outlying regions. Most provinces do, however, subsidize travel to the closest available service. As hospitals become increasingly specialized and centralized, access also becomes more limited. More and more people have to travel to health care facilities outside their immediate area. This will be the case for even more people if provinces carry out plans to close more small hospitals. Moreover, the mega-hospitals make it very difficult for people to find their way through the system. This is particularly the case for the growing number of Canadians who do not speak either English or French and who are not familiar with the dominant cultural practices. Even within urban areas, there is a shortage of care facilities for the elderly and for those who have been de-institutionalized. Women of all ages have argued that there is also a shortage of facilities that can respond to their particular needs. Furthermore, the way these services are scheduled may make it difficult for low income people to use them. This may well explain why people with low incomes make greater use of the emergency rooms that are open at all hours58. In spite of these limitations. Canada's health system is more accessible than is the case in many other countries. 1983 figures indicate that for every one-hundred thousand people, Canada had one hundred more hospital beds, three hundred more nurses and a similar number of doctors when compared to the United States.

Conclusion Like the United States, Canada has a hospital and doctor dominated health care system that is focused on acute care. Although the system is primarily publicly funded, it is based on doctors" private practices, and patients have a wide range of choices in terms of both doctors and hospitals. Decision-making is, in many ways, highly decentralized. Unlike the United States, patients rarely see bills. Basic care is ' 'free.*' Private insurance has not been eliminated. It is used to cover' "extras" such as private rooms, dentists and drugs. And like the United States, Canada has a federal government that is committed to debt reduction as well as to privatization. Like the Conservative government that preceeded it, this Government has not openly attacked Canada's most popular social programme, but has maintained the complex financial restructuring that is under-

28 Wake Care

mining the national system. The provinces in turn have cut spending, further limiting care. All this is being done even though there is no clear evidence indicating that Canadians are overspending on health care. * The Canadian numbers are not unduly high in comparison with those of other developed countries, nor are they increasing at unsustainable rates/'59

Notes 1

Monique Begin, Medicare. Canada's Right to Health (Ottawa:Optimum, 1987): 118-19. Malcolm G. Taylor, Health Insurance and Canadian Public Policy' (McGill Queen's: Kingston, 1987)2. 3 Quoted in Taylor, p. 164. 4 Lee Soderstrom, (London:Croom Helm, 1978):p. 129. 5 See Vera Ingrid Tarman, Privatization and Health Care. Tfw Case of Ontario Nursing Homes (Toronto:Garamond, 1990). 6 Malcolm Brown, Health Economics and Policy (Toronto:McClelland and Stewart, 1991):p.34. 7 Michael Rachlis and Carol Kushner, Second Opinion (Toronto:Collins, 1989): 16. 8 Brown, p.28. 9 Taylor, p.234. 10 Taylor, Chapter 4. 11 See Geoffrey York, The High Price of Health (Toronto:Lorimer, 1987) and Taylor, Chapters 5 and 6. 12 York, p.78. 13 Begin, p.27. 14 Philip Enterline, Allison McDonald, J. Corbett McDonald, Nicholas Steinmetz. "The Distribution of Medical Services Before and After 'Free' Medical Care." Medical Care. 11,4( July-August, 1973):269-86. 15 Enterline et al., "Effects of Tree' Medical Care on Medical Practice—The Quebec Experience.^ New England Journal of Medicine, 288,22(May 31, 1973):! 152-55. 16 Bernard Blishen, Doctors in Canada, (Toronto: University of Toronto Press, 1991): 138. 17 National Council of Welfare Funding Health and Higher Education: Danger Looming (Ottawa:National Council of Welfare, 1991), pp.12-14. See also Soderstrom, pp.140-142. 18 Brown, p.28. 19 Brown, p.29. 20 National Council of Welfare, 1991,pp.l6-17. 21 National Council of Welfare. 1991, p.21. 22 National Council of Welfare, 1991, p.2. 23 Ministry of Treasury and Economics, Government of Ontario, Supplementary Paper, 1991 Budget, Managing Health Care Funding (Queen's Printer for QntarioToronto, May 1991), p. 1. 24 Ministry of Treasury and Economics, p. 1. 2

Health Care in Canada / 29

25

Brown, Table 1.2, p.22. R.G. Evans, What Seems To Be the Problem? The International Movement to Restructure Health Care Systems Centre for Health Services andPolicy Research, University of British Columbia, 1992, p.2. 26 Barry Edginton, Health, Disease and Medicine in Canada (Toronto:Butterworths, 1989):170-171. 27 While former federal Minister of Health talks about five conditions (Begin,p.25) others such as Soderstrom (pp. 132-133) list four. The difference has to do with whether or not accessibility is seen as a separate condition or as integral to universality. 28 Begin, p.25. 29 Quoted in Soderstrom, 1978:133. 30 Begin, p.27. 31 Quoted in Begin, p. 174. 32 York, p.92. 33 Michael Rachlis and Carol Kushner, Second Opinion, What's Wrong With Canada's Health-Care System (Toronto:Collins, 1989):Chapter 9. 34 Brown, p.34. 35 National Council of Welfare, Health, Health Care and Medicare (Ottawa: National Council of Welfare, 1990), p.64. 36 Tarman, p. 13. 37 Neena Chappell, Laurel Strain and Audrey Blandford, Aging and Health Care. A Social Perspective (Toronto: Holt, Rinehart and Winston, 1986), p. 120. 38 For a more general discussion of this problem, see Grant Gillett, Reasonable Care (Bristol, Great Britain, 1989). 39 Morris Barer and Robert G. Evans, ' 'Riding North on a Southbound Horse? Expenditures, Prices, Utilization and Incomes in the Canadian Health Care System'' In Evans and Stoddart(eds.) Medicare at Maturity (Calgary: University of Calgary Press, 1986), p. 63. 40 Blishen, p.44. 41 Blishen, Table 3.7, p.45. 42 Blishen, p. 121-122. 43 Statistics Canada, Canada Year Book 1992 (Ottawa: Ministry of Science and Technology, 1991 ):Table 4.14, p. 114. 44 George Torrance, "Hospitals as Health Factories." In Coburn, D'Arcy, Torrance and New (eds.), Health and Canadian Society Second Edition (Markham: Fitzhenry and Whiteside, 1987). 45 Quoted in Jerry White, Hospital Strike. Women, Unions and Public Sector Conflict (Toronto: Thompson, 1990), p.41. 46 Terry Wotherspoon, "Training and Containing Nurses: The Development of Nursing Education in Canada." In B. Singh Bolaria and Harley Dickinson, Sociology ofHealth Care in Canada (Toronto: Harcourt Brace Jovanovitch, 1988):Table 1, p.378. 47 Taylor. 25a

SOWakeCare

48

See David Naylor, Private Practice, Public Payment (Montreal: McGill-Queen's University Press, 1986). 49 Statistics Canada, Table 4.11, p.l 12. 50 Robert G. Evans, liDoes Canada Have Too Many Doctors? Why Nobody Loves an Immigrant Physician." Canadian Public Policy (11, 1976):147-60. 51 Rachlis and Kushner, p. 187. 52 Harley Dickinson and David Hay,c % The Structure of Health Care in Canada." In Bolaria and Dickinson, pp.56-57. 53 NicholasRegush,Conc//ftowCn/zca/. Canada's Health-Care System, (Toronto: Macmillan, 1987), p.293 and York, pp.110-113. 54 Lee Soderstrom, Taxing the Sick, Health Policy at a Crossroad (Ottawa: Canadian Centre for Policy Alternatives, n.d.), p. 19. 55 Brown, p. 34. 56 Blishen,pp.44-50. 57 Regush, p.67. 58 Soderstrom, n.d.,p.20. 59 Brown, p. 119

Health Care as a Business; The Legacy of Free Trade The Era of Free Trade In terms of free trade, the Conservatives were right about one thing. It is virtually impossible to separate the impact of free trade from the consequences of the larger conservative agenda. The shift in public policy and public consciousness that was signalled by the Macdonald Royal Commission and carried out by the Mulroney Government has been much more pervasive than a single agreement, however critical the Free Trade Agreement is to the core of conservative thinking and practice. The North American Free Trade Agreement has further consolidated the conservative agenda, based as it is on the understanding that free market principles will apply in all aspects of society. And there is little reason to asssume that the Liberals can or want to challenge this premise. Building on the fear generated by the worst recession in the postwar period, Conservatives and their supporters managed to convince far too many Canadians that we have been living well beyond our means; that the greed, inefficiency and dependency of individual Canadians are responsible for both the national debt and the fragility of the economy. Moreover, and perhaps more significantly, Mulroney and his company convinced far too many that the national debt is exactly the same as overspending on a personal credit card. Such debt, according to them, requires the drastic curtailment of public spending as well as personal sacrifice and greater individual effort. It also requires a transfer of responsibility from the "slipshod" public sector to the "efficient" private sphere, in addition to an emphasis on market discipline and a level playing field that will ensure we all work harder. Our Government was not alone in this effort. Indeed, they were very much in step with international corporations and money managers.

32 Wake Care

As Brendon Martin points out In the Public Interest?1, The World Bank and the International Monetary Fund share the view that' 'the free market knows best and the private sector does best, that the state's main task in economic and social development is to minimize impediments and maximize inducements to private capital accumulation." In many countries, what O'Connor2 called the state's legitimation and accumulation functions have been collapsed. What is legitimate is accumulation, the bottom line. The greater public good has been defined in terms of creating a competitive market-driven economy and a leaner public sector governed by the same rules. It has been achieved in large measure by what might be called the third function of the state-the manipulation ofthe private and the public. This manipulation is reshaping both kinds of public and private spheres in Canada. First, within the market, governments at the federal and provincial level gare privatizing public services and corporations at the same time as they are both subsidizing private enterprises and removing restrictions on their actions and taxes on their profits. Second, they are shifting the burdenfor the provision of services from the market to unpaid volunteer and household workers. The postwar period saw the socialization of the social wage - the spreading of the costs and benefits of services to large sectors of the population. The new free trade era is witnessing the "desocialization' ' of the social wage — the restriction of state sector costs and services. The project that became explicit with the Conservatives seems to have been taken up by the Liberals, albeit accompanied by a somewhat different rhetoric. This new era has involved both fordist and post-fordist strategies. On the one hand, as was the case in the era of Hemy Ford and assembly-line mass production, there remains an overall trend towards mergers, the rationalization and intensification of labour, and increasing control over workers. Simultaneously, however, there are moves towards decentralization, flattened hierarchies, team work and multi-skilling, or at least a reassembling of tasks, and away from the collective agreements and the social safety net that characterized the fordist period. These strategies have an impact on both women and men, but the consequences are different for each sex and class as well as for each racial and cultural group. The infiltration of this conservative thinking into every corner of Canadian society will be much more difficult to change than wouldbethecasewithaparticular piece of legislation, even ones as critical as the free trade Agreements At the same time, however, the contradictions created by these approaches are also creating a basis for resistance to these trends.

Health Care as a Business / 33

The Free Trade Agreements and Care When we are looking at the consequences of free trade for health care, it is therefore necessary to look well beyond the Agreements themselves. This is not to argue, as the proponents of free trade have, that the deal will have no direct impact on health care. The Free Trade Agreement: ..explicitly allows for American private sector management of all hospitals (general, children's psychiatric, or extended care), ambulance services, various types of clinics, nursing homes, homes for the disabled, single mothers and the emotionally disabled, together with all aspects (i.e. notjust the management) of other social services like medical labs...3 That is, it permits any of our public health care services to be managed by a profitmaking group. Monique Begin, former Minister of Health and Welfare Canada, has argued that this means ' 'any American business could come and buy Canadian hospitals and take over their management. Hospitals are not government services and are not excluded from the free trade agreement." 4 In her article on NAFTA and medicare, Fuller5 maintains that private management firms have not yet made significant gains in the wake of the FTA, primarily because the Canada Health Act's requirement for public administration has provided some protection against such inroads. However as the federal government rapidly withdraws from the direct funding of health, the Canada Health Act is more and more difficult to enforce, and thus will provide less protection in the future. It will become increasingly difficult to determine where private management ends and public policy begins, to separate the greater public good from the search for profit, to prevent health care from becoming a business like the rest. Equally important is the fact that, unlike culture, medicare is not excluded from the Agreement. As Margaret Mitchell6, former New Democratic health critic, has pointed out, this leaves the door open for health care to be defined as an unfair subsidy and for pressure to *'harmonize" our health care services with the significantly inferior sendees available in the United States. Although health care is a provincial responsibility, it is the federal funding of medicare that has ensured common provincial standards based on universality, comprehensiveness and accessibility. And it is the same federal government that has negotiated a free trade deal that supersedes the provinces and may well fail to maintain common standards for the provision of care in the face of pressure from the U.S.

34 /Take Care

Moreover. NAFTA "will eventually bind provincial and municipal levels of government to its rules.''7 NAFTA also sets up a process to review services such as health, "to determine the extent to which they constitute indirect subsidies to Canadian traders.''8 Given that there is already talk that cars cost more to produce in the United States primarily because of health care benefits, it seems likely that Canadian medicare will be seen as an unfair subsidy. Although the deal does not protect medicare and does encourage the invasion of for-profit management firms from the U.S., it is not only the specifics of the Agreements that pose the major immediate threat to health care in this country. A national survey by Environics has indicated that "health was ranked first out of fifteen items that made Canada superior to the United States."9 Few governments would be willing to risk a direct attack on a programme with such deep public support. Instead, there has been a quiet undermining of the financing and a rationalizing of the system that is consistent with the overall conservative agenda. The strategy has been reinforced by constant media coverage of deficits in hospital budgets and by publicity- given the ' 'failures'' in the system. Ordinary Canadians are being blamed for excess and are threatened with the loss of their valued system unless they exhibit more individual discipline and unless market discipline replaces public inefficiency. In an interview with Hospital News, Peter Regenstreif, President of Policy Concepts, made it clear that the issue was much larger than free trade.4 "The fact is, the government has run out of money. Despite being in the middle of an economic boon^thisgovernmentisnmningadebtofonetotwobiUiondoUars,.../MOAndthis was before the recession and before additional cutbacks in federal transfer payments. A major part of the solution, according to ft&Maclean 's columnist Diane Francis, is a little market discipline on physicians and, more importantly, their patients.. .The problem is that Canadians have become spoiled brats andpoliticiansaresparingtherod. We are all guilty. Just think about it. Baby has an earache. Run to the doctor. If it happens late at night, go to emergency...Is this any way to run a business?11 That the new emphasis is on running the health care system like abusiness was made explicit by a hospital administrator explaining new management strategies in the service areas:" 'My colleagues are more interested in making sure they are getting good value for their money /* n

Health Care as a Business / 35

These arguments blaming the patients and extolling the virtues of the market system are being disseminated in spite of the evidence to the contrary. Although the U. S has a market system,' 'Hospital administrative costs in the United States are higher than previous estimates and more than twice as high as those in Canada.13 Less widely read by ordinary Canadians than Maclean's, Canadian Business has pointed out that our public health care system compares very favourably with the U.S. marketdisciplined system. We deliver a high standard of care to everyone.. .while spending a lower percentage of gross national product (8.6 per cent in 1985) on health care than the Americans, who spent 10.7% of the GNP that same year while leaving 37 million people with no health-care coverage whatsoever.14 Furthermore, what is taken for a free market system in the prescription drug industry has encouraged both overprescription and high drug prices.15 Indeed, the protection of monopoly patents that was part of the free tradedeal is increasing rather than reducing state health care costs at the same time as state protection for the pharmaceutical industry seems to contradict the notion of free trade. These facts do not suggest more efficient and effective health care results from a market system. It does not provide better care at better prices to more people. Nor do the facts in Canada suggest that patients misuse the system and drive up costs. It is doctors, not patients, who prescribe drugs, and who order hospital stays and all medical tests. These are much more important expenses for the system than the trips to the doctor's office and to emergency that patients control.16 Moreover, doctors also have some say over how often patients visit them and how patients are treated in emergency. There are certainly problems with the current hospital-based, curative approach of our health care system, and many reasons to reduce costs. However, strategies that are derived from management techniques in the market sector and that mainly attribute the problems to individual patients and public sector management are unlikely to address many of the major weaknesses in our health care structure. The rest of this chapter looks at the impact of the increasingly pervasive conservative approach on workers and patients in the health care system. It argues that this philosophy has already led to worsening conditions for health care workers and poorer care for patients. In addition to the dangers described in Voices from the Ward, this approach may well lead to a two-tiered health care system that provides good care for the rich and little care for the poor. However, the consequences of this

36 /Take Care

approach are contradictory and encourage resistance. The search for reduced costs has also undermined many of the old power structures and has contributed to some new and better ways of delivering care. And the efforts to impose market principles have been limited by people, by legislation and by material conditions. Public support, unions and professional monopolies have all served to shape strategies. Market strategies are also restricted by the fact that people, rather than products, are involved and much of their care must be provided in this country rather than abroad. The contradictions resulting from these strategies are encouraging resistance.

Market Management Thepressure tocut costs, combined with the pervasive business philosophy, has been a major factor in the transformation of health care delivery. Increasingly, administrators trained in managerial techniques make many of the major decisions within health care institutions. Between 1981 and 1986, the total number of administrators in medicine and health grew by 67 per cent1? as management assumed a bigger role within the system. In recent years, the move towards flattened heirarchies has meant that many nurses in lower management positions have lost their positions, but there is little evidence that the number of men at the top has declined. The threat of transfer to private management firms, combined with significantly reduced budgets and a new ideology of efficiency defined in money terms, encouraged public sector managers to follow the practices developed for profitmaking systems. Private and public, these managers have sought to rationalize the system, intensify labour, and increase control over workers. This is even the case with the new total quality management systems that are sold as offering empowerment to workers, team work in everything and client-centered care.18 The success of these management strategies has varied both with the nature of the work and with the power of the workers. The consequences have often, but not always, been detrimental to both patients and those providing the care.

Mergers and Combinations Like big business, hospitals and other health care services have been merging as a means of reducing costs and increasing control. While the process has been happening with little public fanfare, the dispute over the merger of Toronto's Women's College Hospital with the giant Toronto Hospital Corporation, which brought together Toronto General and Toronto Western Hospitals, put the issue on the front pages. Those arguing for the merger claimed that costs would be reduced

Health Care as a Business / 37

by joint purchasing and that specialization would make the system more efficient, while increasing the opportunities for advanced research. Other hospitals havejustified joint ventures on similar grounds. For example, when three Kingston hospitals entered into a sharedpurchasing contract with Baxter Corporation, worth more than $20 million over five years, the president of the corporation claimed that it would mean "better cost control in a climate of tight financing and rising prices,''19 According to the contract,' 'Baxter will supply the three hospitals with medical and surgical products, intravenous solutions and laboratory7 and cardiology products." This contract was much more that an agreement to buy, however, for it also included the purchase of management advice. According to Hospital News the' 'agreement assures the hospital costs containment through value-added consulting and services that they are undertaking in partnership with Baxter.''20 An example of the virtues attributed to specialization and connected research can be found in descriptions of Sunnybrook Medical Centre in Toronto. It was a budget crisis reported by the Sunnybrook president that led the hospital' 4to clearly define what business we should be in."21 With business specialization in mind, the hospital now has whatthe president calls' 'six major 'product lines': trauma, cancer, aging, heart and circulation, mental health and rehabilitation." 22 While such specialization can help ensure that the latest equipment and the fastest procedures are available, it is precisely this kind of focus on product lines that worry the Friends of Women's College who opposed the merger. The Friends were concerned that amalgamation with huge hospitals would' 'compromise the quality of care at Women's College.''23 "We're not as high-tech: we're more dedicated to integrated care, quality of life and prevention." 24 Although many of the giant hospitals claim a commitment to'' total quality ",25 they assume a medical model and a curative approach to health care that makes it very difficult to treat the whole person with care and dignity. Based on a medical or engineering model of the body, specialization can easily mean an emphasis onbody parts rather than onpatient care, on treatmentratherthan on prevention, and on technology rather than on people. Patients can be shunted from hospital to hospital until the one specializing in their problem is located. The very size and complexity of the institutions make it much more difficult for patients to understand where they fit in, and for workers or communities to have a say in decision-making. The consequences are particularly acute for those whose first language isnotEnglish, or French in much of Quebec, and who are not familiar with the system.

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The specialization and size also makes it easier to apply techniques developed in the corporate sector for the rationalization of' 'production'' and the intensification of labour. Announcing the consolidation of some units and the closure of beds in others, Toronto Hospital CorporationPresident Vickery Stoughton explained that this'4 should reduce the need for cleaners, food service, telephone clerks and porters in the vacated areas.''26 Those who do these jobs define themselves as health care worker^.27 This definition reflects the fact that their work has a particular, and critical, character in the health care system as the most recent literature on the determinants of health makesclear. But thesejobs are now being redefined as' 'hotel services'' and treated as if cooking, moving people and cleaning in a hospital is the same as doing the work in a hotel. Such jobs are disproportionately performed by women, andby immigrants ofboth sexes. So these cutbacks have a disproportionate impact in these groups. Similarly, while long-term comprehensive purchasing contracts can increase efficiency and reduce some costs, they also serve to reduce the control over purchasing by those within the institution. At the same time, they increase the control of the private sector within the health care system and contribute to the increasing size of the private corporations producing the products. They may also contribute to rising costs in the long run. For example, when a hospital switches to paper diapers because the seller offers a good price and then destroys all the cloth ones, it becomes dependent on the paper diapers and has little choice when prices are raised. Like many of the contracts done in the name of the market, they in fact serve to limit market competition and raise costs in the long run. At the same time as health care services are imitating the merging strategies of giant corporations, they are also following their lead in fragmenting other aspects of the work. In the name of cost-cutting and efficiency, governments are reducing the services that are covered by medicare and those that are provided in hospitals. AsFuller28 points out, this createsasignificantspaceforU.S. profit-makingfirms to move into the void and allows them to avoid the requirements of the Canada Health Act. It also opens the door for a two tiered system; one that offers fast, special services for those who can pay and one that offers slower and fewer services to those who cannot.

Reorganizing Labour

In addition to negotiating mergers and combinations outside their institutions, health care managers have also been rationalizing and merging sections within their institutions, sometimes handing over parts to be managed by private sector firms, sometimes transforming sections still under public management into profit-making

Health Care as a Business / 39

ventures. Along with strategies designed to rationalize, intensify and control labour, these new managerial techniques have a profound impact on the workers within the system and the care they deliver. Nurses form the single largest occupational group within the health care system, accountingfor approximately 38per cent of those with occupations in health and medicine.29 There are more than a quarter of a million registered nurses in the Canadian labour force30 and almost all of them are women. Three-quarters of those withjobs work in hospitals, and 93 per cent of them are' 'employed in direct patient care.''31 Nurses, then, are key players in health care and their labour is critical to the cost of and control over the system. Nurses * licence to provide certain aspects of care, the nature of their work and their strong unions have limited the extent to which managers have been able to transform their labour. However, managers have employed a number of strategies designed to intensify and monitor nursing work. Indeed, it is the success of these strategies that has contributed to the growing militancy among nurses and to nurses either leaving the employ of hospitals in order to work through registry services or leaving nursing altogether. At the same time, managerial strategies have also reduced the number of positions available for nurses. By redefining nursing work primarily in terms of tasks rather than in terms of care, managers have been able to use a variety of techniques to establish a minimum amount of time required for each patient's physical needs. In Quebec, time-motion studies have been used to develop what is called the PRN formula: a computer system that can quickly determine the minimum number of nurses required in each area. In Ontario, many nurses select indicators of patient needs from worksheets that are part of a standardized patient classification system. These in turn are matched to times established in a research setting and are used in the same way as the PRN formula.32 These predetermined times, with their focus on tasks and time-motion concepts, seldom reflect the complex nature of nursing care. Jo Flaherty, the Principal Nursing Officer for Health and Welfare Canada, has provided a graphic example that effectively illustrates the inadequacy of these estimated times. According to some formulas, bathing a patient is alleged to take six minutes.fc 'Well, I suggest that even the Holy Ghost couldn't do it in six minutes unless you lifted the patient out, put him in the chair, hosed him down, let him drip dry, and then put him back in."33 Combining such formulas with an increasing number of part-time or registry nurses; hospitals are able to use the computer to ensure that there is no slack time on the ward, and that nurses are assigned or called for each shift to fill in the gaps

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and to avoid any excess. Hospitals are also increasingly' 'floating'' their full-time regular staff, moving them around from station to station to respond to minimum needs. Gone are the days when fewer babies born last night meant more time to bathe and comfort those who gave birth the day before. This reduction in nursing time has also been combined with a reduction in the time many patients spend in the hospital. Just as there is a formula for the time required for individual parts of the treatment, so too is there a formula for the length of stay required for any illness. Increasingly, patients are allowed to stay for only the minimum time the formula has determined is necessary before survival outside the hospital is possible. In addition, more and more surgery is done on an out-patient basis, without an overnight stay in the hospital. This practice at Toronto's Hospital for Sick Children has been attributed to two basic factors: the'' realization that day surgery placed strain on the family is one; the push for cost-effective patient care is another." 34As a consequence of these developments, each patient in the hospital now requires a great deal of care. Like the just in time production in the profit-making sectors, in the health sector we now have strategies to provide just enough care. These new formulas have been combined with reductions in staff throughout the health care system. Nursing time has been more parsimoniously allocated, but administrators have also worked on cutting back the numbers of those who are not nurses. In some cases, such as intensive care units, only the nurses remain. This strategy reflects that fact that nurses have won the exclusive right to perform some tasks. While nurses can, and do, perform a wide range of jobs done by those below them in the health care hierarchy, those in the lower ranks cannot do the entire range of nursing tasks. It many cases, then, it has made managerial sense to reduce the numbers of registered nursing assistants, orderlies and porters, and have nurses make the beds and transport the patients. Indeed, many hospitals have introduced primary nursing in some areas, making nurses responsible for providing the total care for a group of patients. Much of that care involves work not directly associated withnursing. In fact, this is increasingly the case with all nurses, whether or notthey provide primary care. According to a study conducted by Goldfarb35 for the Ontario Nurses' Association, tcnursesindicatespendinganaverageofalmost30percentof their time on non-nursing tasks.'' The consequences of these strategies for nurses are most often a closer monitoring oftheirwoik, an intensification of their labour, and less time to provide the care for which theyhavebeen prepared. Ontheotherhand,ithassometme^ meant greater responsibility and sometimes the opportunity to treat the whole patient through primary7 care. It has also meant an increasing militancy among nurses, especially as the women who nurse can no

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longer afford to drop out and recuperate on their own time, or leave to have a baby. In the job for life, and faced with deteriorating conditions, these women are actively resisting such management techniques. For patients, the chronic understaffing often means less care and more treatment as a body part. A comparative study36 has indicated that patients on the understaffed unit had a higher incidence of complications. Most frequent complications were infections, urinaiy tract infections, heart conditions (including congestive heart failure and arrhythmias) and GI disorders (including haemorrhage). It also was identified that on the understaffed unit, patients reached a higher acuity level. Most importantly, patients on the understaffed unit had . longer length of stays (LOS) than the appropriately staffed unit. In other words, understaffing makes patients sicker and thus fails to save money in the long run. The "Voices from the Ward'' in chapter three echo these claims. On the other hand, primary care means that some patients know who to call and that patients have a better chance ofbeing treated as a whole person and in an integrated way. Shorter stays, too, have benefits, because they can mean less risk of infection and alienation. But as the concluding chapter in this book explains, they also shift the burden to the home and may mean additional risks to people's health. The consequences, therefore, depend on the extent to which women in particular can provide that care in the home, on the other resources available to the sick, and on how well patients are when they are sent home. The poor, and those without anyone at home able or willing to provide support, are particularly at risk. The invasion of business philosophy into health care has also had an impact on the most powerful health care professionals, the doctors. As the work of Coburn, Torrance and Kaufert 37(1983:418) makes clear, the decline of medical hegemony that began in the 1960s can be attributed to a number of factors: The proximate causes lie in the involvement of the state ofhealth care through national health insurance, increasing competition from other health occupations, more widespread evidence among elite groups of the failure of medical claims to efficacy, and in the late 1970s, more active self-help and consumer groups in health.

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The doctors who struck in Saskatchewan against the introduction of medicare have had some of their worst fears realized. Their power has been challenged by those who pay. Although the introduction of medicare initially served to increase doctors' incomes and reduce their hours,38 doctors no longer have the sole right to determine their fees. Instead, they must negotiate with governments for their fee schedule and even, in some cases, for the limits on their total billings. But more than their incomes are at stake. Medical hegemony is being challenged by the introduction of corporate management strategies into the public sector. Doctors continue to have a significant influence in developing formulas for policy, but the bottom line has become increasingly important in determining the regional allocation of medical technology and the length of patient stays.39 Decisions onceconsideredtobeamecticalprerogativearebeingtranformed into technical and managerial issues. Private sector firms are frequently consulted on medical purchases. Bessi'sadvertisementin//o5/7//^/Ar(?>i'540forexample, offers "assistance with technology evaluation, purchase and management on a professional engineering level.'' And private firms may be consulted on the doctor's place in the system, as well. Explaining strategic planning to the Association of Young Health Executives, Tom Butt of Agnew Peckham and Associates, maintained that the "traditional role of the medical staff has been in credentials, privileges review, development ofby-laws, rules and regulations and medical audits; little or no fiscal responsibility or accountability. But they're a major stakeholder and we suggest, they should be a major owner in health care delivery." 41 Administrators, with the help of computer technology, are monitoring doctors' treatments and prescriptions, and insurance companies are using alternative advice to question doctors' orders. Some of the doctor's work is being fragmented into parcels that can be done by para-professionals, such as midwives and paramedics. Much of doctors' knowledge is being stored on computers so that it can be accessed more readily by those who are not physicians. Pre-recorded telephone messages, designed to answer questions about a range of medical problems, are replacing visits to the doctor's office. Walk-in Clinics, which under free trade rules can be owned by foreign investors, often extend doctors hours. It is more than ironic that this challenge to doctors' power is happening just as women are moving in large numbers into this traditionally male-dominated profession.

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Many have applauded the attempt to reduce medical dominance. Because doctors' orders have determined to a large extent who does what to whom, where and for how long, it is important to develop constraints on their power and to assess the efficacy of their treatments. Factors other than the doctor's particular training and diagnosis need to be taken into account in the health care system. For too long, doctors have not had to consider other issues, other workers, or patient preferences. The kind of reallocation of power to a health care team promised by total quality management42 or to alternative therapies could benefit both patients and other health care workers. However, power has been reallocated more to managers and to formulas than to patients and other health care workers. Decisions are based as least as much on money as they are on care, and power has in many ways become more, rather than less, concentrated at the top. Although managerial strategies have affected both nurses and doctors, a major focus of the new business approach has been the ancillary services that have a ready equivalent in the private sector. Increasingly, these services have been privatized, with profit-making companiescontractingtodo the work. Between 1989 and 1991, the number of government-paid workers in health and social service declined by 10,000, while the number of self-employed increased by 12,000,43 indicating that a growing amount of work was contracted out. The president of such a contracting firm, CSL Hospital Services, has explained44 that 14

[T]here are two main reasons hospitals and other institutions turn to contract management services.. .They want satisfactory quality of service, and they want better value for their dollar.. Our savings to our customers are usually in the range of five to ten per cent.'' Similar reasons are given for handing over the management of entire institutions or parts of institutions to management firms. Justifying the twenty-year contract with Extendicare to manage their chronic care wing, the Chief Executive Officer of Toronto's Queensway General Hospital argued that "c [If] the private sector can provide services more economically, and with the same level of quality, then, I think for, ultimately, all our taxpayer dollars, that is going to be the most appropriate decisions and choice. Why not get a bit more for less dollars?." 45

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It is not always clear, however, that hospitals get either better quality or better value for their dollar in exchange for relinquishing control over their services and providing profits to private sector firms. According to the President of North York General Hospital 'we felt the management fees were too high. We had confidence hi our ability to manage a nursing home and break even: taking the money that would have otherwise gone to the management fee, and putting it into more care for the residence. And we believe we've done it. 46 Some health care institutions have responded to the pressure for a business orientationby transforming their services into profit-making ventures runonprivate sector lines. Hospitals with giant laundry equipment have taken in the laundry from hotels and restaurants. Food services have catered to weddings, bar mitzvahs and Meals-on-Wheels. Parking lots rent spaces to the highest-paying clients. The result may be more money in the coffers but a lower priority to patients and relatives of the sick. Private management, or the threat of private management, may serve, as the President of North York General put it, "to keep us on our toes in terms of being efficient*' ,47 but this may mean a deterioration in both the quality of service and in the conditions of work for the workers. An employee of Versa Foods working at Saskatchewan's St. Peter's Hospital was reprimanded and warned that she might be fired for providing coffee to the wife and children of a seriously ill patient. The Union representative argued that " [G]iving coffee to a grieving family instead of making them go all the way to the cafeteria and pay for it., .is consistent with a policy of caring and compassion. But when a private company concerned mainly with profits takes over, supplying free coffee - even to the relatives of a dying patient -becomes a crime rather than a kindness." 48 In many places, the private managers have replaced cafeteria services with vending machines, and meals prepared on the spot in each area of the hospital with centralized kitchens and prepackaged food. Food between meals may be very difficult to get, and this may be particularly problematic for those on special diets or returning from surgery. Bob Waddell, former president of the Ontario Council

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of Hospital Unions, maintains that "[Dietary doesn't do any cooking any more. Instead of having butchers and bakers and pastry makers in the kitchens, we are now seeing Hostess Twinkies delivered. That is what is happening now. Food is coming prepackaged, pre-cooked. 49 Cleaning and food sendees have been rationalized according to strategies developed in the private sector. Work for the dietary and housekeeping employees has been intensified and unions often undermined in the process. As the Voices from the Ward chapter makes clear, some of these changes made in the name of efficiency can be dangerous to the health of patients and workers. Many hospitals have introduced new formulas for cleaning as a means of reducing the number of workers. With cycle cleaning, certain areas and certain tasks are to be done on alternative days, according to a management schedule. In between the scheduled cleaning, there is to be police cleaning,fc "like a lick and a promise."50 On the basis of this new formula, one woman explained,' 'they give us all this extra work, plus they give us more area to cover. 51 Like the formulas for nursing care, those for cycle cleaning significantly underestimate the time required and hold the worker responsible for ensuring that the work is done. Another woman on the same hospital housekeeping staff pointed out that'' [Y]°u see the cycle cleaning as means to do something you don't do every day, but we have to do it every day ."52 Some hospitals have also replaced regular, full-time housekeeping staff with casual employees on the weekends. Too often the consequences are less cleaning done for the patients and more work for the cleaners. Traditional union rights are undermined by the introduction of private service workers, by threats of lay-offs and by part-time help. But this new approach has also served to reduce the differences between male and female labour in housekeeping, laundry and dietary areas, making it increasingly difficult to retain unequal wage structures previously justified on the basis of heavier male loads. However, it may mean a harmonizing down for all workers. That is, male wages and duties may become more like those traditionally associated with women. In general, the reorganization of the health care labour force along business lines has encouraged a deterioration in both care and the conditions of labour. However, the effect has been contradictory The reduction in the power of doctors, andthenewemphaseson short hospital staysandonprimary care could lead to better conditions, if the appropriate supports are available at home, if variations in patients' needs are recognized and if enough health care workers are retained. These changes have also encouraged a growing militancy and a far-reaching reassessment of traditional care.

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Reviving Family and Community, Individual and Business Responsibility The same ideology that provides the basis for free trade promotes what is maintained to be the traditional role of family and community, individuals and business in providing support and care. The practice is de-institutionalization, a privatization of health care services, an increasing dependence on volunteers, and a reduction in state funding for' "family matters," combined with tax deductions for charitable and research donations. The practice is justified by a myth, however, for families and communities never had to deal with so many elderly who lived so long, with so many disabled who survived, with so many mentally handicapped who are drug dependent, or with so many people recovering from complicated operations. Corporations and individuals never provided adequate support for the kinds of basic institutions and basic research that are necessary in today's conditions. In general, these conservative strategies have served to increase the unpaid workload of women, to threaten women's paid work and to leave many people with little support and few resources. However, like many other developments in the health care field, the impact of these strategies has been contradictory. For example, de-institutionalization, group homes, day surgery, plans that encourage chronic care patients to go home for short periods and the elderly to remain in their houses, can not only cut costs but can also improve health or recovery.53 However, when these community strategies have costcutting rather than health as their primary goal, it is too often the case that the necessary community support services are missing and health is endangered rather than enhanced.54 Patients and workers alike may suffer. AIx>ndon,OntariobasedRegisteredNureingAssistantandunionrepresentative maintains that, as RNAs are increasingly moving outside traditional institutions, they are finding that" [c]ommumty-based jobs are usually non-unionized and lower paid.''55 Health care aides, the workers who provide much of the daily care in the home, are rarely unionized. Most are paid little more than the minimum wage and are usually paid only for the hours they are actually in the home and not for the time it takes to travel between homes. And woricers in group homes often find themselves with little formal training and a great deal of direct responsibility. Far too often, as Closer to Home, chapter four, makes clear, female relatives or neighbours are expected to fill the gap left by the stretched resources of community services. And far too often it means little or no care for the poor, for Natives, and for recent immigrants.

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Si milarly, volunteers have always done some work in heal th care and they have often provided veiy important support services or instruction for those in need of assistance. The patients have benefitted and so have the volunteers, who not only feel they are making a contribution but also gain valuable experience. However, volunteers are increasingly being used to do work that would otherwise by done by a paid, and probably female, worker.'' In hospitals, for instance, financial pressures have forced boards to use volunteers as porters, aides, cafeteria workers, admitting clerks and receptionists." 56 Those replacing the paid workers are also usually women. "The young and middle-aged housewives long hailed as the staple of volunteerism are becoming scarce resources as economic demands force more families to become two-paycheque households," according to a volunteer coordinator at a major Ontario hospital.57 Instead, volunteers are now mainly women who work all day at another job, female students and elderly women along with immigrants of both sexes. So it is primarily women without pay who are doing jobs formerly done by women for pay, often serving to reduce the demand for female workers and sometimes undermining the strength of those who keep their jobs. Volunteers can be used, for example, tojustify limited nursing work to specific tasks. The co-ordinator of volunteer service at Etobicoke General Hospital explained that "as nurses' jobs become more technical they can't afford the 'hand-holding' time with patients that they would like. Volunteers fill the gaps that a busy nurse doesn't have the time for.'' 58 But the volunteers are usually not there in the middle of the night, when the hand holding may be most in demand. Volunteers also have a long history in fund-raising, and business has often contributed to the construction ofbuildings as well as to the provision of services and the funding of research. But health care and health care research are becoming increasingly dependent on private money or at least on matching grants or joint research. This strategy for finding resources makes funding precarious and overly dependent on business priorities. Canada's famous Connaught Laboratories, for example, are now a profit-making concern. Connaught's former corporate vicepresident made the goals clear:" I think it' s important to recognize that our research is very much market-oriented research rather than being purely curiosity-driven. We're not doing pure research. The research that we do is really trying to fulfill a need, a practical need. 59 However, it is primarily the curiosity-driven research that has lead to the major medical breakthroughs such as pencillin and insulin, not research directed at a practical need. The underfunding of universities, combined with the new state emphasis on finding partners in business, may mean that more and more research is directed towards the needs defined by profit-making concerns.

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Along with the increasing stress on community and family has come a reduction in funding for homes for battered wives and for women who have been sexually assaulted, for planned parenthood and for women's health information services This, too, is part of a conservative agenda that maintains such matters should be family matters. In the wake of free trade, the federal government has specifically targeted women'smagazines and women's centres that have provided acritical view of current policies and a place for women to share their concerns. As Eleanor Wachtel pointed out in a Toronto Star article,60 afeministmagazinecanbea'directservice' in furnishing information, referral, and survival techniques. Healthsharing actually saves the government money, taking pressure off our expensive medicare system by focusing on self-help, prevention and well-being. This feminist health magazine had its total budget cut, not by the women's program that had initially allocated the funds, but rather by the finance minister directly. The loss of funds eventually led to the magazine's demise. Clearly, the point was not the promotion of health.

Conclusion Although the consequences of the conservative agenda have been contradictory, the overall trend is towards a deterioration in conditions for both patients and workers. The gradual undermining of the health care system through the reduction in funding, the complete privatization ofsome services andthecontractingoutofothers within public agencies, the mergers and the shift to the community without a concomitant shift in resources have all increased the pressure for more private health care facilities. The impact is already uneven, with more women than men suffering from inadequate services and poorer conditions of work, with smaller centres and hospitals suffering more than the giants in urban areas, with white middle-class patients suffering less than other groups. A continuation of the conservative strategy can only serve to increase these differences, making us more like the United States where there is one health care system for the rich and virtually none for the poor. However, the contradictions are also creating spaces for change. As more and more women have little choice but to stay in their nursing jobs and as fewer of them can provide the care for which they have been prepared, resistance is likely to grow. As more and more people are sent back to be cared for at home by women who no longer have the time or even the skills to provide the care, more people are likely to

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object. As fordist and post-fordist strategies increasingly conflict, tensions are likely to mount just as people see alternative possibilities for organizing care. The era of free trade may be more than the strategists bargained for.

Notes Martin, Brendon, In the Public Interest? Privatisation and Public Sector Reform, (London: Zed Books, 1993), p.6. 2 O'Connor, James, The Fiscal Crisis of the State. (New York: St. Martin's, 1974). 3 Darcy, Judy, "A Futuristic Nightmare" Healthsharing, (Fall), 1988, p. 19. 4 Begin, Monique, "Free Trade Will Destroy Our Precious Medicare". The Toronto Star, October 28, 1988 5 Fuller, Colleen,c "A Matter of Life and Death: NAFTA and Medicare'' Canadian Forum, October, 1993:14-19. 'Mitchell, Margaret, 1988. p.l 1 7 Maher, Janet, "Healthcare in Crisis". Healthsharing. 14(2), 1993, p. 13. "Ibid. 9 Sgambati, Fred, "Is Our Health Care System in Good Shape?'' Hospital News, December, 1988, p.6. 10 McNinch, Elaine,c Tree Trade and Health Care''. Health News, December, 1988, p. 11. "Francis, Diane, "A Radical Proposal to Cure Health Care." Maclean's, March 6,1990, p.19. 12 McNinch, Elaine, "Contract Services. It Can Mean Good Value For The Money". Hospital News, 1988, December, p. 13. 13 Woolhandler, et al., * 'Administrative Costs in U.S. Hospitals'', New England Journal of Medicine, Aug. 1993, p.400 14 Stoffman, Daniel, "Losing Patience. Are Hospital Costs Killing the Taxpayer". Canadian Business. November, 1988, p. 68. 15 Lexchin, Joel, The Real Pushers: A Critical Analysis of the Canadian Drug Industry. (Vancouver: New Star Books, 1984). 16 Naylor, David C. Private Practice: Public Payment, (Kingston: McGill-Queen's University Press, 1986); Rachlis, Michael and Carol Kushner, Second Opinion: Mat's Wrong With Canada's Health Care System. (Toronto: Harper Collins, 1989); Regush, Nicholas, Condition Critical. Canada's Health Care System, (Toronto: MacMillan, 1987). 17 Statistics Canada, Occupational Trends 1961-1986. Ottawa: Supply and Services Canada (Cat. no. 93-151). November, 1988, Table 2. 18 Hassen, Phillip, Ex for Hospitals: New Hope for Medicare in the Nineties, (Toronto: Stoddart, 1993); United Nurses of Alberta, Total Quality Management of Programs; More Work For Less Money, (Edmonton: United Nurses of Alberta, 1993). ^Hospital News, "Hospital Purchasing Contract Worth $20 Million Over Five Years". September, 1988, p.3. 20 Ibid.

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2l

Stoffinan, Daniel, "Losing Patience. Are Hospital Costs Killing the Taxpayer". Canadian Business. November, 1988, p.72. 22 Ibid. 23 Moralis 1990:3 24 Steed, Judy, ''Renewed Battle Begins Over Future ofHospital". The Toronto Star, March 25,1990, p. 16. "Hassen, op cit. 26 Dunlop, Marilyn,c 'Hospital to Lay Off 50, Staff Fears' ?. The Toronto Star, April 4,1990, p.A6. 27 White, Jerry, Hospital Strike. (Toronto: Thompson, 1990). fuller, op cit. 29 Statistics Canada, 1991 Census Occupations. (Cat no. 93-327). Ottawa: Ministry of Industry, Science and Technology, 1993, Table 1. ^Ibid. "Employment and Immigration Canada,' 'The Labour Market For Nurses in Canada.'' A Summary Discussion and Analysis, (Ottawa: Numeo, February, 1989), p.3. 32 Campbell, Marie,' 'Management as 'Ruling': A Class Phenomenon in Nursing''. Studies in Political Economy, 27 (Autumn). 1988, p.36. Choiniere, Jacqueline, "A Case Study Examination of Nurse and Patient Information Technology'' in Armstrong, Choiniere and Day, 1993. "Flaherty, Testimony Before the Ontario Pay Equity Tribunal, Haldimand-Norfolk Case, 1990:79). "Hospital News,'' Day Surgery Cases Increasing Dramatically at Sick Kids''. Volume 3( 8), 1990, p. 15. 35 Goldfarb Corporation,' 'The Nursing Shortage in Ontario.'' A Research Report for Hie Ontario Nurses' Association. Toronto: Mimeo, March, 1988,52. 36 Babad, Arlene, "Financial Implications of Understaffing". ONA Newsletter, August, 1988, p. 14. 37 Coburn, David, George M. Torranceand JosephKaufert,' 'Medical Dominance in Canada in Historical Perspective:The Rise and Fall of Medicine?'' IntemationalJoumal of Health Services, 13(3). 1983,p.418. 38 Enterline, P.E., V. Salter, A.D. McDonald, et al "Hie Distribution of Medical Services Before and After 'Free' Medical Care - The Quebec Experience. New England Journal of Medicine, 1973, pp.1174-1178. Evans, R.G. "Beyond the Medical Marketplace" in S. Andreopoulos (ed.) National Health Insurance: Can We Learn From Canada. (Toronto; Harcourt Brace Jovanovich, 1974). 39 Stevenson, H. Michael and A. Paul Williams,"Physicians and Medicare: Professional Ideology and Canadian Health-Care Policy'' in B. Singh Bolaria and Harley D. Dickinson (eds.). Sociology of Health Care in Canada. (Toronto; Harcourt Brace Jovanovich 1988), p.94. *°&essi, Hospital News, February, 1990.

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41

Sgambati, Fred,"Creative Thinking Needed to Handle Changing Problems". Hospital News, April, 1989, p. 34. 42 Hassen, op cit. 43 Statistics Canada, 1992:Table2 ^Keddy, Bethany, "Hospitals Cite Pros, Cons in Contracting Out Services". Hospital News, February, 1990, p.22. 45 Sgambati, Fred,"Private Sector Management of Hospital Wings". Hospital News, December, 1988, p. 10. "Ibid. 47 Ibid. 48 The Leader, "Hospital Worker Scolded for Kindness". The Leader, March, 1987, p.l. 49 McNinch, Elaine, "Contract Services. It Can Mean Good Value For The Money". Hospital News, December, 1988, p. 13. 50 CUPE 1744 and Toronto Western Hospital, Transcripts; Grievance Regarding Housekeeping. March 10, Toronto. 1989, p. 17. 51 Ibid. p.40. 52 Ibid.p.l02. 53 Rachlis, Michael and Carol Kushner, Second Opinion: Wliat's Wrong With Canada's Health Care System? (Toronto: Harper Collins, 1989); Regush, Nicholas, Condition Critical. Canada's Health Care System, (Toronto: MacMillan, 1987). M Rachlis and Kushner, op cit.; Regush, op cit. 55 Culp, Kristine, "RNAs Told to Look Positively at Shift to Community". Hospital News July, 1989, p.5. 56 Cressy, Gordon, ''Feeling the Strain: How Chronic Underfunding is Causing Tension Between Labour and Voluntary Agencies", The Public Employee, 1987. p.7 "Hospital News, "The New Volunteerism". Hospital News June 1988, p.12. 58 Ibid.p.l3. 59 Sgambati, Fred, "Report Urges Research Partnership Between Sectors''. Hospital News December, 1988, p. 14. ^Watchel, Eleanor, * c When Budget Cuts Seem More Like Censorship'?. The Toronto Star March 21,1990 p. A27.

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Voices from the Ward

A Study of the Impact of Cutbacks

Introduction After considerable research and long deliberations, the Ontario Premier's Council on Health Strategy identified the key determinants of health and, on this basis, criteria for establishing reforms in the health care system. Reports in other provinces echo these conclusions, indicating a clear consensus on how health is achieved and on what principles should guide new approaches to the provision of care. These include: •' "The fundamental importance of social andphysical environments to individual health''! • Psychological factors as critical to the body's immune system and the capacity to both resist and recover from disease. • The active participation of citizens in "decisions that affect their health"2 • "Improved equity among the various providers."3 ^'ConUnuousqualitv improvement using quality assurance mechanisms, including "teamwork in everything; customer or patient satisfaction; a total quality approach; employee empowerment;

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automation; innovation by everybody; management through vision and values; strategic choices; developing core competencies; and focusing on the interdependencies in the organization." The overall goal is to provide more effective and efficient care in ways that reduce costs while ensuring health outcomes that are equally accessible to all. This goal is to be achieved by: • Promoting health, thus reducing the need for care services •Providingasmuchcareaspossiblein households and communities • Re-structuring institutional care This study focuses on the third ofthese means, there-structuring of institutional care. It is based on interviews conducted with ninety-eight workers in nine hospitals of various sizes, located throughout the province. The twenty-four focus groups included registered nursing assistants, therapy assistants and nursing assistants; dietary and housekeeping staff; clerical workers, laboratory assistants and porters. Together, they represented almost 1500 years of work experience in health care institutions. The analysis of these interviews is divided into four major sections that reflect principles set out by the Premier's Council. The first section is concerned primarily with patients. It assesses the extent to which hospitals have adopted a client-centred approach that recognizes the fundamental importance of psychological factors and social environments to health. The second section looks at hospitals as physical environments, examining the way the institutions are cleaned and people are fed. The third and fourth sections are more concerned with employees and with managerial strategies. These sections ask whether or not new strategies promote the equity among providers and the effective and efficient care that were identified by the Premier's Council as critical to their new vision for health. Although these areas overlap in both the interviews and in the hospitals, they are separated here in order to make it easier to assess the impact of cutbacks on care. While there are some variations from hospital to hospital and group to group, there is a remarkable consistency in these workers' claims about the consequences of changes in the provision of care. Some changes, they say, are beneficial. But most reforms are not based on the key determinants of health identified in the Premier's Council reports. And, when combined with new management techniques, these

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reforms too often risk rather than promote health. Instead of creating more effective and efficient care, the reforms often serve to increase costs in terms of patient and worker health as well as in terms of future expenditures for the health care system.

Responding to Population Needs The reports from the Premier's Council on Health Strategy emphasized the central importance of social and economic supports to the achievement of health. These factors are as important to treatment and to recovery within an institution as they are to prevention and health maintenance outside the institution. The psychological factors which were identified as critical to the body's immune system and the capacity both to resist and recover from disease are obviously of crucial concern in health care provision. This recognition of the link between mind and body, between environment and health, contributed to an approach called "Total Patient Care." This implies that those within institutions will be treated as whole persons, rather than as a set of parts as is often the case under what is called the 'engineering' approach to treatment and care, which views the body as a collection of parts to be fixed. Equally important to health, the reports made clear, is the opportunity for citizens to make decisions about factors which affect their health. Thus, instead of calling people patients, a term that can imply that citizens passively receive treatment, there is talk of clients or customers actively participating in making informed choices about and directing their own care. Institutions, in developing their strategies for reform, specify a commitment to "the notion that you need to understand what your customers' needs are."4 "Total Quality Assurance" that seeks to improve the workflow on a constant basis in ways designed to ensure higher quality service is said to be on the top of the agenda. Through total quality assurance, customer needs will be identified and satisfied. Yet, in spite of the recognition that these factors arecritical determinants ofhealth, the new reforms in the hospital seem to be moving health care in the opposite direction and, in the process, undermining people's health. The housekeeping and kitchen staff, the therapists and registered nursing assistants, clerical workers and nurse attendants all identified very similar trends. Those entering institutions have much more severe disabilities or diseases than has been the case in the past and therefore each requires more care. The emphasis on community care means that people are not admitted to an institution until they are very dependent and require extensive services. And they are released very soon after treatment. As one nursing assistant in a chronic care ward explained, "We are getting more and more problems because of people

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keeping their parents, the elderly people, at home. They all get this homecare. By the time they come to us, they are total care.'' When people enter the hospital for surgery or disease, most require intensive care. As one worker said about the hospital in general,' "You got to be practically dead before they even keep you here now.'' Moreover, consolidation of hospitals means that, in many cases, there are a much wider variety of illnesses and conditions to treat. This too increases the need for treatment and care. At the same time that each patient requires more work, the number of workers has been steadily, and often dramatically, decreased. According to these workers, every area of the hospital has experienced significant reductions in employees. However, sometimes there have been increases in the number of administrators. In interview after interview, the health care workers said they no longer have time to perform even the minimum tasks required, let alone have time to treat people as whole persons who also require explanation of their treatment and a great deal of care. And this need for explanation and support is even more critical as an increasing number of patients face complicated surgery or severe illness and chronic disease. The Premier's Council recognized that people need more than bandages and needles, IVs and monitors. They also need social and emotional support. Yet the capacity to provide such support within the system seems to be decreasing just as we have established its importance. As one RNA put it, "What makes me sick is like, they want to cut on nurses. They want to cut on everything but they don't cut on operations, they do more. Like last week, it was crazy... it's no good for the patients/' The stress on decreasing expenditures, worker after worker said, is transforming the institution and making it more difficult to provide caring support. "We're not a hospital anymore. We're [supposed to be] there to look after patients. I find they're being lost in the shuffle. We're being lost in the shuffle. And it's become a business to a point where all it [is] is money.... It's not the nurses' fault and its not housekeeping's fault. They're trying the best with what they have. But you can't blame people for getting bitchy.'' Contracting out services reinforces this tendency to focus on cost rather than on services and quality. Methods developed in the private for-profrt sector are applied in the health care system even though the job to be done is quite different than the work involved in making cars or soap. And many of these methods do not work when people, rather than chocolates, are involved. ' 'The problem there is that the hospital is supposed to be a service industry, right? You are supposed to be providing services to people who need care and yet you have this company that is essentially there for profit.'' Throughout the hospital, "Their motto is; money is time and time is money.... It's not human anymore. The

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patients aren't number one. Patients used to be number one and they are not anymore/' And most of the time, we are short of staff... we are not giving quality, we are giving quantity.'' The increasing workloads, combined with reduced staff and a new business orientation, make it extremely difficult to provide a client-centred sendee that deals with the whole person in ways that ensure quality and help people get better, or at least live with dignity.

Clients and Customers The notion of client-centred care arises not only from the idea that we have the right to control our own lives and have our individual needs met. It also arises from the fact that psychological factors, including a feeling of independence and choice, are critical health determinants. Much of the argument for sending health care closer to home has been based on the assumption that the social and emotional support that is essential to health will be found there. But people who are critically ill, are facing complicated surgery or are in chronic care often have an even greater need for social and psychological support than have those who are sent home. They certainly need to be treated as people in crisis, rather than as parts that need fixing. However, many changes within hospitals are making it more and more difficult to treat patients as whole people in need of social and emotional support. One worker expressed the view7 of many when she said "I will not go in the hospital for nothing, because I know what's going on. And pretty soon we're going to have one of those conveyor belts, the people get put on there and out the door they are." As a clerical worker put it, "We process people just... like in a chocolate factory.'' There was a consensus that "now we're relegated to doing the basics'' and even the basics often don't get done. According to an RNA,' 'I don't have time to ambulate or do extra things with patients. If I wash their hair I'm really happy. I used to be able to do their nails and a lot of extra things which we can't do now.'' Bathing patients becomes an 'extra', with Ml baths or showers now done only once a week in most of the hospitals these workers described. More and more patients are diapered because there is no-one to take them to the toilet or help them with bladder training. And in more and more places, the diapers are changed only three or four times a day and beds only when really necessary. The 4 " nurses, they don't have the time. So the people get pretty peeved off sometimes. So they rip up their diapers apart ortakethefood and throwit. They get upset becausenobodyseemstohavethetime." 'Rubs' have also disappeared because nobody has the time. Night nourishment has disappeared for the same reason and so, often, have water jugs. And, as a physiotherapy attendant explained,' 'We're not getting them up in the evenings

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anymore. That's part of the process, because of understaffing. We're luckier than extended care because they are only allowed to get them up every second day. At least \ve get them up at least once a day.'' In some cases, the bells are taken way from the patients who ring them often. But, at least according to some health care workers, patients ring them often "only because the guy is—like—I want somebody. And he has to do it ten times until somebody comes'' because everyone is so busy. For those who are mobile, there is often no one at the nursing station to answer their concerns. Everyone is too busy elsewhere. The housekeeping staff used to help by chatting to patients, getting them a drink, a newspaper or a kleenex, or "taking patients out, you know, for a smoke or a walk or something like that.'' But they don't have time anymore either. Even these basics may not be provided if one of the staif is sick, because in many institutions the sick worker is not replaced. Then, "nobody gets their bed changed and they only get their private parts washed and they only get up once or whatever." And on weekends, many sendees such as physiotherapy disappear. Clearly, such cutbacks have an impact on patient well-being.' 'People [are] not having their hair combed, or hair washed or have somebody to take them to a bath. There is no dignity, there is no privacy, there is no nothing.'' But more often there are bedsores, rashes and even people falling out of bed. Not only can these cutbacks mean that the patients are' 'smelly, they are dirty'' but it also means that gone are the days' "when you used to wash a patient and talk to them and stuff like that.'' As one RNA explained, the time not spent changing the bed does not go into patient care because even if we're not changing them, we don't have the time that we used to, to spend with the patients... you don't even have the time to do the things they are asking you to do now.'' They have ' 'no time to sit down and talk to the patient'', to comfort, console or explain.' 'You quite often don't even get time to look at the OR sheets to know the name of the patient.'' There is no time to learn their name and often no time to prepare them for surgery or discharge, both because the health care workers are so busy and because many patients stay such a short time. Too often the emphasis is on turnover and quotas rather than on the quality of care.' 'What complicates the system at times is we still have a patient in the bed, trying to get them up from discharge and out the door. But [for] some reason, they' re notfeelingwell, or they're elderly so they're slow. As they're tiyingto get outofbed, we're having somebody that is ready to get into that bed. So that part can be very stressful at times because you always feel you are rushing the patient. Like hurry up and get out of here because there's somebody getting into your bed. And some patients feel very upset that they're being pushed like this, especially when you've woken them up at 6 o'clock in the morning for their 7 o'clock discharge.... Usually,

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unless they are extremely ill, and they couldn't manage to go home, they're usually sortofpushedoutthedoor." A clerical worker explainedthat "Wedon'thave time. Maybe there is a patient, you know, and you used to say: Well hi! How's so and so? And how's your mother doing? Is she well? You don't have time for idle chit chat.'' Yet such chit chat may provide important support for a person registering in the hospital, especially when today most people register in hospitals only for quite serious illnesses or surgery. Many patients are depressed and scared but there is little room in the emerging system for the caring that may be critical to survival and recovery. One clerical worker told the story of a woman who was informed she had cancer by a doctor and nurse who then had to rush away.' 'She had just been told and she broke down crying and the housekeeper that was cleaning up went over and she said, 4Do you want a hug? Should you'.... This from a housekeeper. There is no time for compassion.'' An RNA told another story about a dying woman who provided just one example of the kinds of situations that happen regularly. A very ill woman wanted to know if she would have surgery and the RNA only had time to say it's up to you and your family. w 'And you're busy with all these other things at the back of your mind. And you really want to take minutes and talk to the person.... You find now you say to yourself, I'm not even going to question them on that because I know it's going to involve [me and I] don't have that time. So I'm not going to approach them.... I'm ashamed of myself at times but that's what I do." Yet another example of the focus on tasks rather than on care was offered by an RNA. A woman * 'wanted to go back in and say goodbye to her husband" who had just died but there was constant pressure from other staff for the bed. Admitting kept asking' 'how long is it going to be, how long is it going to be?.... And the wife is there and the family is there, and the patient's dead. And they're asking 'When can you get the bed?'." Some hospitals have special bereavement teams but they are only there for certain hours. So if the death happens at the wrong time, there may be no one around to provide support. Increasingly, hospitals are relying on families and friends to not only provide such emotional support but also to get drinks and feed and walk the patient. Many hospitals have open visiting hours, and rooming-in facilities for parents. These relatives and other visitors may be a major help to the patient, although they may also mean that a great deal of care is being provided by amateurs not trained for the job. Moreover, visitors often increase the work of an already overworked staff that cannot respond to all patient needs. As a physiotherapy assistant explained, "'It wouldn't be a problem if the visitors were helping but visitors are more or less directing us to do this with so and so. to do this with so and so. Meanwhile, you're

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just trying to get your work done. They're frustrated and it makes us frustrated too, because they are waiting. It's a reality. They are waiting. They're thinking she's sitting too long or whatever. And it's true. She probably is. But we just don't have that kind of time." Visitors, then, can serve both to increase the workload and stress for the health care workers and to divert attention from those patients who do not have such an advocate. Given the cutbacks in staff, responding to the demands from one family necessarily means not responding to others. Hospital workers report that when familiescomplain to those in charge these patients often have their needs met in ways that divert resources from other patients and that make it more difficult for the caregivers to do their work. Moreover, with many visitors around, everyone's space is limited. As one RNA pointed out,4 'Because people are coming back from the OR and they' re in and out, it just seems to me that there's no privacy for anyone and the room is always full of people.'' Although the visitors may make the work more difficult for the hospital employees and invade the privacy of some patients, patients are still better off with a relative around, given the cut backs in personnel. But the centralization of especially the most complicated services into specialized hospitals in large uiban centres means that many people do not have family around when they are experiencing life-threatening surgery or disease. And because most people, male or female, are now in the labour force, few relatives have the time to offer such care even if they are in the vicinity. Although some hospitals hire * 'sitters'' or ask volunteers to do caring work, the crises often do not happen during the regular hours of these caregivers and the staff no longer have time to make this part of their work. Client-centred care should mean not only that emotional support is available but also that care is adjusted to provide for individual patient needs. But, the workers say, the reverse is happening. More and more rigid rules are introduced, rules that are to apply universally to all patients. Many of these rules make good sense in the general case but may not be useful in a particular case. So, for example, terms such as' fcdear'' and the use of first names have been banned in some hospitals. Yet some patients do not remember their own name and respond better to terms of affection and many prefer to be called bytheirfirst name. Similarly, in several places, workers have been ordered to feed all elderly patients with a teaspoon-a process that means feeding takes longer and therefore is done under greater stress for both the feeder and the patient. This is to be done even if patients are willing and able to eat their soup with a larger spoon. Increasingly, RN As have to follow rigid care plans, although in the past they used their own judgement. One told a story about a psychiatric patient who was put

Voices from the Ward/61

on clear liquids but he was "starving to death in front of us. He wouldn't eat; he wouldn 't eat he wouldn't eat. He didn 't relate to that being food. So the doctor came in and said we're going to leave him on clear liquids because he hasn't been eating. Isaid. "Do you know what I think?.... I think you should feed him. I think you should give him a piece of toast.... Give him a piece of toast and let's try.'' She convinced the doctor to change the order and got the patient to eat. The health care workers are the ones in daily contact with the patients, the ones who understand patients' individual needs. However, increasingly total quality assurance means these workers are no longer allowed to use their judgement. One RNA explained that' "because you've learned your patient so well that you know the various techniques to help them'', you know what kinds of treatments work with and are acceptable to your patient. But these workers now have less and less choice about treatment and less and less time to know their patients. More and more work is done according to a formula, these workers say. Informed choice for patients also seems more of an ideal than a reality. These new rules about procedures often mean patients cannot express their choice about being called dear or about eating soup with a soupspoon. The practice of shaving patients has been eliminated in some hospitals but is still done if the doctor orders it, providingjust one example of how choice does not necessarily belong to the patient. And the rush too often means patients have little time to develop an informed choice. Because the health care workers are so busy doing a range of tasks, they often ask the patients to monitor their own machines and call when adjustment is required. This is a form of participation but it may not bring a sense of control or choice. Instead it may make the patient even more anxious about their health. According to one RNA, fc 'Patients are more involved in their care. They do see a lot of things [but] it's gone a bit too far the other way now. Ijust feel I can't give proper care of people any more now. Lots of times I worry when I go home if I' ve done even the basics for these poor people." At the same time, patients are often asked to make choices about their own lives based on veiy little information. Patients, some RNAs say, often agree to surgery that has little if any possibility of improving their lives.' "But a lot of patients, if they get more information, they might make different decisions. I mean that a lot of patients are not gaining [from surgery]. The doctors are in and out. They hardly ever spend the time, a minute, with them. Very few of them that I see on the floor sit and tell them, explain to them what's going on. They [the patients] don't even know what's happening to them. Like you're having half your lung out. 'Do you know what that means?'''

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In day surgery, the nurses often do not have time to call the parents or other relatives and tell them how the operation went. Some hospitals have special information teams designed to inform patients about their surgery but, like bereavement teams, they are not always on duty when the information is required. And those many who are not getting surgery may not get much information about their treatment either. Needles may simply be given without explanation, pills swallowed without any reason offered for their need and machines altered without reassurance that now the machines will be fine. Patients, these workers say, seemto have less ratherthan more information and choice. There may be patients' rights programmes but as one dietary aide put it, "They 're not in there long enough to complain.'? Another health care worker said, "Sometimes our patients are discharged so quickly, I go to see them and they're gone. And I haven't instructed them on how to get up and down the stairs with crutches. I haven't instructed them how to get in an out of the bathtub after they've had a hip replacement. And they [the staff] say to me. 'Well, they're gone'. And the worse part of it is, I know when they go home, they're not going to see home care right away. They're not going to see physio, or an OT or a nurse maybe for a week. So they're on their own. It's pretty scary and it's sad because you figure somebody in their 80s or 90s, and all of a sudden, bang, out they go. So they come into the hospital and they feel as though they're being pushed out really quickly. They're scared.... I remember one woman in tears." This hardly suggests response to customer needs or even concern about the role stress and support plays in health. It does not suggest that patients actively participate in decisions that affect their health. It is not just that these practices deny the lofty goals of the Premier's Council or the various statements from hospitals. It is also that these practices can be dangerous to people's health and can serve to increase costs in the long run. People who are not walked can end up bedridden for life, dependant onthe health care system. Some evendiefrom embolisms. Andmore than one health care worker told us that this was indeed the case. The stress of monitoring your own machines, effacing surgery without adequate psychological preparation or social support, of being rushed in and out of care can delay or even prevent recovery, as the Council research makes clear. Bedsores and rashes mean more rather than less treatment; people who do not learn bladder control require more, rather than less, care.

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"Total Patient Care" and "Quality Assurance" Total Patient Care is based on the assumption that not only are body parts connected but also that psychological factors are important determinants of health. Patients need to be seen as whole people, rather than as body parts, not just because this is important to their sense of dignity and their right, but also because it is critical to treatment. Total Quality Assurance is based on the assumption that all workers should be continuously involved in improving care and in responding to patient needs. But many of the new practices seem to be leading in just the opposite direction. Quality Assurance, those who work in the system say, is much more about increasing surveillance over workers than it is about Total Patient Care. As one employee put it, "Quality control is about filling in sheets about standards you cannot meet." More time is spent filling in forms, time that is taken away from patient care. Some call the forms' 'lie'' sheets, because they cannot possibly complete the listed tasks. The sheets say the work has been done but this does not guarantee it is done or done properly. "When they see you can't do the task, or keep up with the pace, then they make a rule to enforce it so that somebody' s going to be on your back right away.'' The RNAs say their name goes on a sheet indicating that they have done the task. This means they are held responsible if the teaching or whatever is not done right. Yet new managerial strategies mean they are often working in areas where they have little experience and where they are extremely rushed. "So it's a lot of responsibility, I think, because you might not have a lot of time, and you might not have a lot of knowledge." It is not that the workers want to escape responsibility but rather that they feel they can no longer do quality work. As a dietary aide explained, "it was such a rush job, you don't feel good about it." With only the bare minimum of staff, workers are moved around the hospital to fill in, often into areas where they have little experience or training.'' Bumping puts people into areas they know nothing about.' * And inexperienced workers have difficulty working quickly and appropriately. One RNA reported that she is often pulled down to emergency to work. "Many times during the breaks and stuff, I'm alone there. I have maybe three patients on the monitor. I can look at the monitor, I can tell you, but I can't read it. I can't run a strip off and say, this is exactly what is wrong with this patient their heart. A doctor came in that day and he said. 'What can you tell me about this patient?" I said 4The only thing I can tell you is every time he stands up, his heart rate goes up to 128M said That's the only thing I can tell you. I've got 12 people here. The nurse has gone to lunch. I'm the only person here right now'." She is not allowed to work there on a daily basis because she does not have the training,

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yet she works there in a crisis and such crises happen more and more frequently. Sometimes the only other person in the Holding Unit is a new graduate,"she hasn't been out three months, and me." People are bumped into new areas on an hourly, daily and weekly basis but no one has the time to train them for this new work. In interview after interview, people raised the lack of training as a risk to patient health, as even life-threatening in some circumstances. In housekeeping, for example, people used to be trained for a week." And then all of a sudden the other ones come in, they' re trained two or three days. Some of them are not trained at all.'' In the operating room,' 'they used to take the time to train people to go in there and learn and they can't take the time to train people who are going in there [now]. So even though they want them on a rotating basis, they're supposed to pick up the skills on their own as they go.'' Nursing supervisors used to be on call for all emergencies in another hospital, now they have been replaced by ward clerics who are given two days training in how to handle all emergencies, from train wrecks to fires. A clerical worker' 'transcribes doctor's orders'', although ' 'that wasn't something I was trained for.'' Mistakes are more likely with untrained staff. And mistakes in doctor's orders can be lifethreatening. Even though they have no formal health care training, more and more volunteers are used throughout the hospital and are performing a wider variety of tasks. Even those fully trained in the area may be little help when they come onto a strange ward for a brief period. An RNA said they used to have many more fulltime staff fc 'And now sometimes we'll be on, we'll get half a person, and we'll get them for two hours. And then they' 11 go somewhere else. So it's not very often you get a person for four hours."' When these workers are assigned for such short periods, they cannot even learn patients' names, let alone treat them as whole people. Moreover, the part-time workers may not know the particular practices or treatments in the area and may make mistakes that can be dangerous to patient's health. At best, they are often simply inefficient. According to a clerical worker, placements "cannot keep up because they' re not familiar enough with the routine and with the different people.'' Another clerical worker reported that'wall of the emergency ward clerics felt.. .they were doing so much and they were so afraid that they were doing stuff they didn't know anything about.'' These practices do not easily translate into total patient care.' How would you like to be an 85 year-old lady who has no bladder control and walks down the hall with a bare bum and the little kids are screaming next door and you see somebody is obviously going to die. What a lovely atmosphere to be in. No wonder they are not getting better. No wonderthey're hurting. I think we're hurting our patients more."

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Patients are " "scared, and they're more demanding because they are scared.'' As one RN A explained, "We "re scared too., we've reached our limit." This sentiment was repeated over and over again by workers throughout the hospital who cannot give any more. "What's happening is that the stress is making people physically ill." According to one RNA, "nurses are so scared of losing their job now that there's so much tension on the floors now, and you even have shifts and people on the same shifts fighting against each other." "I think everybody's on edge, very testy. I find the patients have suffered but the patients have become more demanding... because what's happening is we've cut back. And we've cut back on the quality of things and the amount of stuff we're to get. And what happens is when a patient comes in, they say 'Why don't we get this anymore?' 'And why are you not here?' Well, we don't get it anymore, we cannot supply that any more.'' Worker after worker said I used to enjoy my job, to feel like I was helping, to work in a team, but all that is gone. They are simply exhausted, burnt out and scared, both about their jobsandaboutthepatients. We have "no patience for the patients." With such stress and low morale among the workers, it is very difficult for them to think or act in terms of the total patient or to provide support for others. Total Quality Assurance and Total Patient Care, like client-centred treatment, are goals that are not translated into practice. Indeed, new management strategies are making it extremely difficult for those working in the system to handle even the specific tasks, let alone treat the whole person And the stress on the workers is making the caregivers sick, and certainly not helping the patients. The stress may also be making the caregivers dangerous, as they work under rushed conditions and often in areas in which they have not been trained.

Ensuring a Healthy Environment Often we equate hospital care simply with nursing care. However, as the various reports from the Premier's Council have made clear, both the social and the physical environments are critical to achieving and maintaining health. And ensuring a healthy environment is even more important within a hospital than it is outside the institution. The importance of keeping a hospital as allergen-free and germless as possible seems obvious. The administrator, the chief of medicine, the nurses, the housekeepers and the patients all fear the outbreak of contagious infections. But a healthy environment involves much more than being vigilant about isolating obviously contagious and dangerous diseases. It also involves regular and thorough cleaning of the entire hospital, of not only the operating room and the nursery but also the bathrooms, the patients' rooms, the sitting rooms, the halls, the

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closets and the equipment. Only in this way can the hospital ensure that less obvious germs do not spread from patient to patient, worker or visitor. This is especially the case as more and more patients have multiple health problems, more serious illnesses and more complicated surgery, and as more and more visitors spend long periods of time in the hospital. Nutrition is also critical to prevention as well as to recovery. Food serves many purposes. It helps the body resist infection and rebuild after surgery or disease. Conversely, food can be dangerous to health if given to the wrong patient or in the wrong quantities or if badly stored or prepared. Food is also an important part of the social environment. Meals are an event in the day, especially for those who spend long periods in the hospital. The quality, appearance, and variety really matter because many patients need to be tempted to eat. The capacity to respond to preferences is often critical in convincing ill people to take nourishment, and the way food is delivered and served may make the difference in Whether or not patients will eat. Those who work in the system say it is becoming increasingly difficult to make the hospital even look clean, let alone be clean. Indeed, they fear that the physical environment is becoming dangerous to people's health. Similarly, they feel that patients are not receiving healthy, nutritious food that reflects their wants and matches their needs. Food, too, may become a hazard rather than a help.

Nutrition At the centre of food services at any hospital is a basic routine. It involves preparing food, noting patient selections and restrictions, putting meals on trays, delivering them to the patients, feeding people, collecting and cleaning the trays, only to start again. This basic system has hundreds of facets and routines such as dietary planning, patient preferences and special requirements, and sterile working conditions, only some of which could be examined in the focus groups. According to the workers interviewed for this study, however, the entire process is being transformed by new managerial strategies and new cutbacks. And it is being transformed in ways that make it more difficult to provide quality care. How the work is organized to deliver food to patients is a critical component in the provision of care. In the food services, there is a more factory-like atmosphere than in many other departments. Over the last decade, the introduction of increasingly automated technologies has streamlined the work a great deal, but in the process these technologies have increased the pressure on workers. As one dietary aide described it, "Elevenyearsagowedidn'thaveabeltline. Wefoundthere wasn't much stress back then. We weren't rushing... [now] we find it too small for

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a belt line... you're closed in... [there is] little space to actually move.... There isn't time to get everything on the trays.'' Increasing turnover and consolidation mean there are more meals to prepare and there is more variety in the meals that are required. But there are fewer people to do the work. Moreover, some hospitals are earning extra income by preparing meals for outside groups, such as meals-on-wheels. As a result, "you work faster and there's more accidents and you are rushing. People get burned and things because they are rushing. We have accidents, cuts that never happen before. You investigatetheaccidentsandyoufindoutthatthepersonwasunder stress... hadbeen called to the boss's office. Those are things that are happening right now... since the cutbacks start." The reductions in the number of workers not only mean there are more accidents but also that it is more difficult to do a good job.' They are like telling us that they want to provide a good service... food is important ...and you don't have enough staff to give them that.'' The most important thing is speed. "She [the supervisor] don't check trays.... Even some of the supervisors let what is not supposed to be on the [patient's] diet go. wOh, well, this one time won't hurt. That's not quality assurance.'' In hospital after hospital, those interviewed said the basic staff has difficulty getting the work done and this is complicated further by the practice of not replacing workers who report in sick or have accidents. The failure to replace sick employees puts extra pressure on workers to come in even when they are sick, many say. But the workers are concerned about the risks involved when sick people are preparing food; risks for both patients and workers. Along with this increasing workload comes increasing stress. Stress is reported on the rise for every group interviewed. The results differ, depending to some extent on the hospital, but all groups say there are visible effects. And the way of dealing with the stress varies from "...I was so stressed I just booked off sick for two days, went to my little camper and slept for two days" to "I wasso upset... Isaid I was going to the health unit. We had not one, not two, but three off down there so upset - crying you know. I'm a big woman but it's either talk back and get fired or cry.'' The stress is even worse for those many who care about the quality of the service provided for patients. As one aide put itfc * Well personally... I appreciate to see the patient get good fresh fruits... with a muffin and piece of cheese.. .but they want all this extra work done with less staff.'' Choice comes at the expense of the dietary staff, but this staff is not always able to ensure that these choices prevail because the workers are already working at top speed and each different choice means more work.

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Choice is also limited by the reduced hours for the dietary department introduced in some hospitals. In one, the kitchen had been open until 8 p.m. and "you could get something... you would call down. And they have all the cards, too, on the information on the patient. So they'd say ' 1200 calories' or whatever. 'Let's give so and so.' So we would call and get something. Now you get nothing.'' Although there is supposed to be some food on each floor, this is not always the case. And this can be uncomfortableforapersonwho has retumedfrom surgery after dinner or even dangerous for those, such as diabetics, who need to eat regularly. Although much of the preparation is done on a line, it requires skill and training to work at the speed required and to take the care that is necessary to fill the trays appropriately. One of the most common problems these workers identified was the replacement of experienced full-time workers with inexperienced part-time ones. The interviewees were quick to say that the problem was not with the people who take the jobs but rather with the lack of training and with the conditions of their work. Part-timers and temporary workers often do not know the routines, they often have odd split-shifts that increase stress, and they are often temporary transfers who have less attachment to the job and fellow workers. For example, one worker explained that" "There's a temp on nourishment now and they just don't do a good job.... They are students filling in.' * Even trained people have difficulties if they are shifted around to different work areas.' 'Not everyone is used to workingthe same stations. Like we have part-time people... [they] might get trained on that number and not get back there for a month or so." This movement of workers around the hospital reflects that aspect of continuous quality improvement that stresses developing core competencies or multi-tasking. It is intended to ensure people have less "down-time" or time that is not used to it's maximum. It sounds likea reasonable approach to cost cutting. But these workers indicate that there can be problems for both patients and employees with a system that aims to make constant near-maximum demands on labour, especially when it is not accompanied by adequate training. This system usually means taking on extra tasks without relief from the old ones. According to one dietary aide,'' Where I' m working now we make sandwiches.... Cooks [used] to cut your meat... now ...I have to come in and cut my own meat." While taking on additional tasks, the worker is also supposed to be watching carefully because' 'we have what they call reverse isolation diets... we have to make sure that whatever we're doingis sanitized" for thoseon such diets. Doing multi-tasks can increase the risks of error, especially if those doing the work have not received adequate training. In addition to taking on extra tasks within the kitchen, some dietary aides are drafted regularly to do jobs outside the kitchens. For example, * There's nobody over there

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to check outside and see that everything' s alright on the property... that the entrance is clean and that nobody broke any. windows in the basement.'' So the kitchen staff are asked to take on the job. The checking of property may seem odd but rather nonconsequential . However, taking on multi-tasks can have an impact on quality, as one dietary aide explained. "Toseea [food] porter empty a garbage can and all of sudden he is working with clean trays and clean food... that turns my stomach... the porter has no choice." While some aspects of continuous quality improvement approaches are being introduced, the notions of employee empowerment and innovation that are central to this managerial strategy seem to be ignored. Indeed, when it comes to food preparation and delivery, the old scientific management technique, of Taylorism', which advocated close measurement and control of people's work, seems to be the practice. The aim of scientific management is to increase the speed of work by taking away decision-making from employees and pushing them to accept management methods without question. But, as the advocates of continuous quality improvement point out, this managerial strategy too often leads to poor products and both worker resistance and burnout. In the hospital, close supervision and the pressure to work at high speeds not only increase the stress levels of the workers but also mean important tasks do not getdone. For example, onedietary aidesaiditis "Nouseeventryingtowashproduce .. .you work like a bugger... then they call you a dummy.'' According to another, ' 'Every job we do is timed. We have a time limit on everything. The slower you are the more you get behind. Theyjust load extrajobs on top of what you have to do and expect you to do it but it cannot be done.'' The stress created by the pressure to work faster affects more than those preparing and serving the food. Management personnel in supervisory roles are also being negatively affected. Many of those interviewed reported that stressed supervisors often do a poor job. The supervisors are unable to deal with the pressure to cut or with the added pressure that running a lean operation entails. Many workers say that supervisors are more irritable and their capacity to problem-solve has been seriously reduced. The policy of not replacing absent workers means managers have to find staff, do their work themselves or force an already stressed group of workers to work harder. The whole atmosphere has changed, many workers report. "If they [supervisors] make a mistake it's not their fault. It's our fault. We don't mind helping, but theyjust scream and say,c Get your butt out there'. If I was a supervisor I'd at least use my please and thank-yous." As aresult, trust breaksdown while tensionrises. "It'sdogeatdog. Everybody is nervous, everybody is tense. Whatwegetfromthebossisscaretactics. Supervisors

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are ev en saying that [fellow workers] are going to watch and report back.'' More and more managers are unable to create the conditions for the work to get done, let alone for people to do their best at the job. The continuous quality improvement strategies promoted by the Premier's Council reports are based on the assumption that the productivity of people is influenced by intra-employee relations. If conflicts abound, workers get less done and patients suffer. And, according to these workers, conflicts are growing. Employees say that the pressure created by current managerial styles leads increasingly to fights among workers. "Staff members start to yell and scream at one another. It's because of the amount of stress that's been put onto the employee's back." The kind of team-work advocated in the total quality approach has to be based on trust and mutual respect. The changes in the hospital are leading to distrust and infighting. In the process they are destroying workers' morale. All of these changes have an impact on the quality of food patients receive. Some of the changes have been for the better, the employees say. Patients have more food choices today than they had in the past. People can request specific foods.' 'They have a choice of muffin or toast or waffles; then they can have a cold plate and eveiy kind of cereal.'' More fruit and fresh vegetables have been added to the menu. And more of the food is selected to match patients' age and culture. However, employees also say that too many changes have a negative impact on the quality of care. Although the quality of food in hospitals had been improving, the trend is being reversed. Worker after worker said that now the cooks have no time to concentrate on taste. More and more of the food is frozen, pre-packaged or prepared from a mix. Themovetopreparedfoodsis seenasawaytolay offwoikers,butitalso serves to downgrade the quality' of the meals and reduce patients' choices. As one worker put it,' 'there are more prepared foods... that comes in a patty and looks horrible and tastes just as bad.'' Another explained that' "There was a quality in service at one time... they don't even get puddings anymore... jello, jello, jello, jello. It's cheap. [They're] jelloed out. Even we are jelloed out!'' Many of these cuts not only reduce choice and quality; they may also risk patient health. In one hospital at least ' 'patients on clear diets don't get honey anymore. Honey is vital. It's good for their well-being.'' And ' 'those on full-fluids do not get two milks anymore. They are down to one. They don't even get instant breakfasts." Tang has replaced real juice, except for diabetics, and some employees fear that diabetics too could end up with Tang. The food, these workers say, looks less appetizing and has less food value, making it difficult for patients to recover their health. Onelessobvious way the cutbacks affect food qualityisthe move to temporary

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and part-time workers. At worst the inexperience of such workers can lead to dangerous and costly errors. At best, it can mean patients do not get what they want. For example, one aide said, "I've noticed a lot of snacks coming back. Yogurt coming back three days past date. The young girl didn't realize and was too rushed to think about it." Another equally invisible way cutbacks can influence food quality is through changing cleaning practices. According to many workers, cleaning in the kitchens is below standard and some of it gets left undone.' 'The floor is clean in the middle areasbutdamnedifwestartcleaningthecorners." Inonecase.abrokendishwasher was not repaired, and workers feared bacteria could spread through the dishes. That the new lower standards are recognized as inadequate is demonstrated by the extra work done when inspections occur. If there is to be an inspection,'" 'they will have a massive clean-up." The inspections are intended to ensure that standards are met, and to catch many of the problems raised repeatedly by the workers.fc 'I wish it [the inspection] would be unexpected, then they would find out how things are really run. We don't clean our fridges often or the counter" [so things get]' 'spiffed up when the inspector phones to announce a visit. They send the part-timer to clean your area or have porters go in and clean the fridges. [It] happens once a month." In cases where private management firms run the dietary services, those who have experience under the old system say the situation is often worse. Under private management, these workers say, the focus is even more on money and on making each employee work harder, rather than on service and quality improvement. In one hospital, it was reported that the private firm has ' 'a food club. [They] sell food to people. [They have] sidewalk sales. They order cases of things [to sell] but they are not ordering some things for patients. Patients are third class here, if you need something for them, they [management] say, "No, that's for the food club. They have three priorities here, and patients are last - food club, cafeteria because it makes money, and then patients.'' Despite important differences among the practices in various hospitals, there are many similarities in the comments made in the different focus groups. The work intensification experienced by those in dietary services is increasing stress levels. The stress leads to sickness, accidents, errors, and what they perceive as a growing inability to do the kind of job that is critical for patient health. The drive for efficiency is, in their opinion, pushing the patient to a lower priority and, in some instances, creating conditions that may jeopardize the patient's health and wellbeing. Lower level managers are also feeling the pressure and are not escaping the stress that these new measures are bringing. Instead of encouraging team-work, employee empow-

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erment and innovation, the methods being employed by management are fostering conflicts and preventing the development of any cooperative attempt to seek workable solutions to the current problems.

Cleanliness Housekeeping is the term usually used for the employees who clean in hospitals. However, the kinds of standards and the methods of cleaning in hospitals are necessarily very different from those required in most homes and public places. Not only do more people have dangerous germs that might be spread but also many of the patients are in a weakened state that makes them particularly vulnerable to germs. Moreover, many of the waste products and other materials found in hospitals constitute additional dangers seldom found outside the institution. Yet many of the workers in the focus groups said that practices developed in the private for-profit sector are being employed in hospitals. As a result, hospitals are no longer as clean as they used to be. And, less-than-clean hospitals can be a risk to people's health. In every hospital, the employees reported that there are fewer people to do the cleaning. A labour reduction is particularly problematic in housekeeping because it is very difficult to use technology to decrease the workload. It is hard to use machines to wash beds, empty waste-baskets, clean toilets, showers or bathtubs or scrub the sinks. Nevertheless, hospitalshave been reducingtheir housekeeping staff. Some hospitals have laid off workers; others have used attrition and most do not replace workers who are sick or temporarily disabled. In some hospitals, this change has been dramatic. For example, in one hospital where there were once fifteen workers in an area, * w we only have seven now.'' In another, '4We haven't really had layoffs, but the people with long-term sickness, they're off and will not be replaced." Various strategies are employed to get by with fewer workers. Some hospitals have simplymade each worker coveralargerarea. As one worker explained, "lused to do one floor and two bathrooms along with two corridors. Now I am doing three full floors and three bathrooms. [This happened] just since last year.'' No longer is there one housekeeping person per floor. Now, "Some people have two to four floors/' In order to get the work done, workers are more closely supervised and pressured to work faster. According to one housekeeper, the supervisor has been * ^pushing the people... past the limit. I have never refused to do anything but'' there is a limit on how much one person can do. Although most hospitals seem to have employed this strategyto someextent, theworkers already haveworkloadsthat make it difficult to take on additional cleaning. They cope by doing the job less well and

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less often. Working at high speed means more accidents, such as the housekeeping staff getting pricked by needles left in the bed. Close supervision that accompanies the speed-up means' * You are watched too much. You do not take your time. You don't have time to watch, so accidents happen more frequently. Long-term sick time has increased" \ further reducing the number of employees available to do the wo In order to address a part of the problem, some hospitals have changed what is done and how it is done. What is necessary is redefined. The most common strategy is to move to 'cycle-cleaning'. Instead of cleaning everything, every day, areas and objects are cleaned at regular intervals. One worker offered the following illustration of cycle-cleaning: * 'Well, it used to be done on a daily basis, and now an area or an office... specifically non-patient areas, get a full cleaning once a week.'' But dust, dirt and bacteria accumulates on a daily basis. As one worker graphically put it, '' there are no longer dust bunnies; there are dust cougars all over.'' Already. many workers say. necessary work is not being done.' In theory, by the end of the week I did everything but I have a floor and a half which cannot be done except... in theory." ' 'I went like hell. And I did mostly all of them, except four [rooms] didn't get scrubbed." By working harder, the employees do not necessarily ensure that patients or other workers will be protected.' The scaiy part is, when they do cycle cleaning, the whole goal is to add more areas and eliminate jobs.'' One answer to workers' concerns about the accumulation of dirt is to redefine what constitutes dirt.Anumber of employees report that supervisors now say,' It's the grey dust you have to worry about. The white dust is okay. It's clean dust." This cycle-cleaning approach does not always work smoothly, especially when there is constant restructuring. "What happens is they do a major reorganization with this cyclical cleaning. They say,'' Okay, we have fifty people and fifty areas. Now we have forty people, for fifty areas and bounce them around and stuff gets lost in the shuffle. And then, a month later, people are like 'What about me?' And then you scream. They fix it and then they forget about it. And it goes on and on. And that's the problem.'' Even when cycle-cleaning is firmly in place, it creates problems because it is based 6n the notion of a fixed routine that can be divided into minutes of work. But hospitals are only partially routine workplaces. Discharges, deaths, accidents and dangerous or offensive spills create disruptions in the best laid plans. As one housekeeper explained, t4I could never go by those minutes [assigned for a job] because in between all this, too, you'll have a mess over there. Like you can never go by this minutes baloney. And let's say you go to do a discharge and you have to

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go phone. I have to go phone down and tell them how many beds or I have to phone somebody to come and help me.'' Every minute must be accounted for but too few minutes are allotted to the tasks, especially given the interruptions that are routine in a hospital. Only a few minutes are credited for cleaning a desk beside a patient's bed. Yet, it may well be that the' 'person has spilled pop all over it or there's vomit or pee on it, for all you know. And it* s not just an empty desk that you have to wipe off.'' Unable to do the work, the only solution for some workers seems to be to say they did cleaning that they could not do.' c Yeah, like I got half a room done. I'll put a line in the circle but some will he. They're scared. That's why they are doing it." Some managers seem to recognize that the work cannot be done according to plan. Their solution, some say, is to tell employees to cut corners until there is a complaint. One supervisor kept' 'pointing to the standards. He was saying 'You've got to sign these standards. They've got to be kept up 100 per cent of the time'. But then he's telling you, Just do it when it's dirty. [When] dusting, just go around the outside, you don't move nothing'. And then ifhe gets a complaint about one of these standards, then he posts a notice saying' This is a standard. Why haven't you been keeping it up?'" Some managers seem to make promises they cannot fulfil. "The hospital turns around and hires a department head for housekeeping that sells them a bill of goods and he can't produce. He goes in and says, 'Look, I can run this department with half the staff. It's going to cost you half the money it normally costs, so they buy it. He gets in there and he can't do it. So instead of saying 'I can't do it It's not feasible', he blames it on the staff. Yet he's got the same staff he had before." Another solution managers offer to the problem, according to a number of employees, is to stop doing some kinds of cleaning. "They've eliminated the high dusting off of lamps and pipes that are above your head.'' ' 'The ventilation system is just filled with dust.'' ' 'We've had one experience with our chutes, wrhere we actually pick up the linen that they throw down the chutes. And in one particular chute, we had blood, urine, stool, coffee grinds and papers all stuck to it. It's like, it'd make very decorative wallpaper!" As a result of these practices, worker after worker claimed, "everything, under the toilets, sinks, around the bottom of the toilets, the floors, the baseboards are filthy.'' Some hospitals have also introduced multi-tasking into housekeeping, just as they have in dietary, and often with similar consequences. Some people are not well prepared for the tasks they are asked to do. Speaking from experience with such a system, one worker said "Imean, ifyoucan'tdo the job or you haven't been trained

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for thejob, then you shouldn't be doing it.'' When sick employees are not replaced, others are expected to do the job, but they cannot keep up the quality of the work. '' The person who was covering was only doing face value. So when you come back, you have to get back in all the creases and then they'll say * You didn't wash this'.'' Many workers fear that the changes may put patient health at risk. After discharges, beds used to be brushed thoroughly. Now the job takes' 'five minutes [at] the most. Five minutes because we no longer use brushes. We don't have time to use brushes.'' Employees fear that, without more thorough cleaning, infections will spread. As one housekeeper explained, "you can't get your rooms done, so obviously there's going to be more germs in it. The infection is going to go up. I believe it's gone up. The infection is up because we haven't got time to clean.'' According to another, "itsfilthy. Percentage-wise, infections are going up." Yet another felt, "Youdon't get upset. You just wait cause we're going to have a damn good inter-hospital infection." Referring to an area left out of the cycle, one worker said, "It's been let go for six months.. .so you're obviously going to get more infection.'' The fear is shared by others outside housekeeping. "The infection nurse is very concerned about it. And she thinks... a lot of it has to do with housekeeping because she sees the staffs been cut in half and they are expected to do even more than they were doing before."" Patients, too, have noticed the dirt. "There is a lot of complaints going in about the dirt."" Sometimes, there is a response to the complaint. In one case at least, the supervisor has c 'five or six people clean it top to bottom when he starts getting too many complaints.'' But new staff and new methods are not introduced in response to complaints and very little changes in terms of daily practice. As a result, many workers say,' fc Our hospital has never been so dirty as now. There's no way of faulting housekeeping, because you can't. I've never seen it so dirty, ever in my life." The continuous quality improvement approach supported by the Premier's Council is based on the assumption that employees will do extra work when they see it is necessary and when they have been part of the process that generates the plans for the workplace. Most of the workers interviewed said they had enjoyed their work in the past and had often done extra work because they felt they were helping the patients. But none of the employees interviewed for this study felt they were part of the current planning process and all said it was increasingly difficult to do a good job, to take pride in their work or feel their old commitment to the job. Indeed, they suggest that new strategies are moving them farther from the kind of goals set by thePremiers Council. Thereare widespread signs of rapidly deteriorating ortotally extinguished commitment to the organizations. According to one housekeeper,fc" It was a nice place to work. I started in the 80ns. You got along, you did your work, you

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had enough people. Then there was this transition where they expected more but gaveyou less; over-supervise andloadyouto death." Another said, in "somekind of way I don't care any more how it is done. I nearly had a nervous breakdown." In many ways, housekeepers see the hospital from a patient's view and these housekeepers often played a role, in the past, in the care process. However, this part of their job has become more and more limited by the speed-up and new rules.4' If someone is asking for something you can't just say no! You stop and give them their drink or whatever. The way I see it the patient is [first]." They once had "a relationship with the patients" but now that relationship is broken. And they no longer canfeel pride in their work. "ThishospitaTsso dirty. Itmakes us look terrible [you] almost have to be ashamed to mention you're in housekeeping." The cleanliness of hospitals is under assault due to increasing workloads, layoffs, the non-replacement of sick staff and multi-tasking. The effects of these processes vary widely but the commentaries reported above are typical of what we heardineveiyr institution. Instead ofensuring thehealthyemironmentthePremier's Council says is critical to health, managements are redefining standards, cyclecleaning and introducing other strategies designed to cut costs. In a hospital, these new approaches can lead to increasing infections, slower recovery and lower morale for both patients and workers.

Employee Empowerment According to the Premier's Council, what is required to realize its vision of health is a care system based on'' a fresh, new approach to human resources planning and implementation which is driven by health goals, needs-based planning and a flexible and dynamic planning process."5 The report Achieving the Vision: Health Human Resources goes on to say that the "organization and management of the future health care system will change significantly based on the vision. The governanceand management of health care delivery settings will also change incorporating more consumer participation and improved equity among the various health providers' '6. To reach these goals, the report recommends a version of total quality management based on the concept of continuous quality improvement. This involves the "merging of productivity, quality and customer service into an integrated effort to use the creativity and discipline of all people.' '7 Central to this approach are team-work and worker empowerment as well as training in a range of basic skills that allow employees to take on multiple and interdependent tasks. According to the workers interviewed, however, few if any of these ideas have been put into practice.

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Instead of needs-based planning, almost all these workers say, there are more and more managers who have little knowledge of or experience with the work actually done on each floor. Without such knowledge, it is difficult to plan on the basis of needs. For example, in one hospital,' The Director of Nursing has said... [we] need to revamp our thinking. They don't need a bed bath every day. They don't need their linen changed every day. And you don't have to do the baths in the morning [between] 1 and 10. You can bath at two o'clock in the afternoon. [However] we cannot bath them at 2, that's our time to move patients and the surgery patients are coming back./' The problems that are evident with nurse-managers who no longer work on the floor are even more obvious with managers who have never worked in a hospital. According to one clerical worker,' They've gotten rid of the people who have been therefortenorfifteenyears, and they Vereplacedthemwithpeoplewho have worked in industries.'' Methods used in industries, these workers say, simply do not work when the job is caring for people. Moreover, it is difficult for such strategies to reflect needs-based planning in the health care system. Instead of the flattened hierarchies that are part of the total quality management approach, there are more and more managers. Many of those interviewed maintained there has been an in increase, rather than a decrease, in numbers and levels of administration. According to one clerical worker, "We used to have an administrator and an assistant administrator. We now have an administrator and three assistant administrators, directors to these assistant administrators and coordinators to these directors. They seem to have lots of budget for management. A nursing assistant said that in her case,' 'It's been three or four years [that] they have been actively getting more and more supervisors. In my department we used to have one supervisor, and an assistant manager and a manager who did everything in the department. Now... I've got seven or eight supervisors, a couple of dispatchers, part-time supervisors, an assistant manager, a corporate director." Instead of promoting team-work, new managerial strategies are undermining the team-work that has been a traditional part of health care institutions. One clerical worker explained that ''Before, where somebody would finish theworkand say, "Okay, What have you got to do? Andl'll help you with that'. They won't now. They don't want to get involved. Besides not having the time, if they did have the time, they won't [offer to help] in any case because it's their job and they can't afford to take any moreon. But in case something [the work that they help with] gets to be theirs, they don't want to take it on. And it's turning co-workers against each other. Whereas before they worked as a unit, now they' re turning against each

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other.'' In nursing work, fc ' it takes the NA, it takes the RNA, and it takes the RN to work as a team", but team-work is being made more, rather than less, difficult by new work organization. Nursing staff say they no longer have the time to do team reports that used to allow them to discuss patients. They do not even have time to organize a team to lift a patient, something they used to do regularly. Team work is also made difficult by the increasing use of part-time and temporary help, because it takes time to learn how to work in a team. Increasing tensions created by the fear of job loss, as well as by the speed of the work, further limit the possibilities for team-work, because the trust that is critical to working together in the interests of the institution is no longer there. One RNA described how management launched a campaign that would not only save linenbut save jobs. "Andwefeltreallybadbecausetheysaid... in one month, you've already saved a full position. But nobody's job was saved. All those people were laid off." In at least one case, the situation has been worsened by managers who have asked workers to report on other workers who do not seem to be doing their job. The manager is reported to have statedfc'4 When you see [the nurses] sit down, you marie down the timeandwhat they were doing, because sometimes' hesaid, 'they'redoing nothing'.'' But, as this worker pointed out, because nurses are sitting down6 "doesn't mean they' re not going to do their work. They' ve got a few minutes to relax or maybe talk about some of the patients.'' Moreover, when sick workers are not replaced, others become responsible for their load and resentment towards sick colleagues builds up, further undermining any team spirit that remains. According to those interviewed, teams no longer work and new ones are not being created in this atmosphere. Instead of employee empowerment, many of the institutions were attempting to control more stringently the working patterns of the remaining staff. Many management practices concerning sick time and shift changes were outlined that directly influence, in a negative way, the staffs ability to work. A clerical employee explained that' "Theirway ofcommunicatingisby lettersofreprimand. We'venever had letters of reprimand until the last two years. And now... its petty. Letters of reprimand for sick time, letters of reprimand for [being] late.'' Employee empowerment is not realized when letters of reprimand are the most frequent form communication from management. Many of the participants also complained about harassment around sick time. According to one dietary worker,' 'I was told at one evaluation I had missed three days in the whole year.... One girl missed one and that was brought up in her evaluation.'' Many reported calls to their homes when they were off sick, calls that were intended both to check to see if they really were home sick and to pressure them to

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return to work. Another dietary worker explained that "In... our contract, that is harassment, phoning people at home fto see] whether they are going to come to work or not. But they do it all the time... to weak people... they pick on them." One housekeeping worker said that "When I was off sick, I had to sign a letter saying that I would not take [any] more sick time, or I'm out the door.'' Another employee in the same unit maintained that' 'When us part-timers are off sick, you should see how we get harassed.... Wedon'tasktobesick. He [director of department] saysl'm getting close to stage six. Once I'm in stage six, I'm out the door/' Many of these part-time workers are not even paid when they are off sick, yet they are still harassed. The pressure exerted on these employees to work, even when sick, has consequences for the well-being of the workers and the patients with whom they are in direct or indirect contact. Workers also report having fewer choices about shifts and shift changes. According to one RNA, "if you workfed] evenings, one benefit was you got a weekend off. You don't do that anymore.'' Others claimed there is less warning about shift changes and maintained that, while their lunch breaks are carefully monitored, there is no pay for the overtime they put in regularly. Such treatment contradicts the notion of teamwork and employee empowerment. Rigid rules about the use of supplies also severely limit employee power and initiative. RNAs and NAs reported that their use of disposable diapers was being rationed. According to one worker, policies on diaper use no longer leave the decision up to them. The staff are told that "being damp is not enough reason to change attends.'' Other RNAs were ordered to leave diapers on for longer periods of time.' They toldus when we first started [using them] that those attends were good for eight hours... even after three hours, they're just drenched." Staff at several hospitals indicated that linen is also rationed. Managers are pressuring workers to change beds only when absolutely necessary.' "You're using too much linen. Why are you using too much linen?... as though [we're] frivolously using laundry.'' RNAs and NAs in several hospitals have been told to use one bib per patient per day, rather than use their judgement about what is required. Such practices not only mean that employees have less power, they also mean there is little consideration of patient needs. As a result of these policies, it is often those patients in greatest need of linen supplies and diapers who are given the least. Instead of a flexible and dynamic planning process, the idea that care can be standardized for all patients in all settings seems to be experiencing a resurgence. Management based on time-motion studies has reappeared. Housekeeping aides in one hospital relate how the floor space for which they are responsible is carefully measured. And from this calculation, the supervisor assesses the exact number of minutes it takes to clean the space. These same workers then describe how

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impossible their tasks are because these calculations do not include working around patients, varying states and kinds of dirt or the everyday interruptions that are part of the hospital 'routine'. This process of breaking work down into minutes does not happen only in housekeeping. A Physio assistant describes how her workday is divided into fifteenminute segments, and she has to account, in writing, for her activities during each of these time segments. ' "Every fifteen minutes is counted a unit and you have to have eighty-four units a day. It's ninety units but six are coffee. You're allowed two fifteen minute coffee breaks, so eighty-four units I have to make sure I have every day. So I have to keep track if I'm fifteen minutes doing this or fifteen minutes doing that.*' These diaries are kept and her supervisor reminds her if she has forgotten to account for any fifteen minute slot. Yet at the same time as work is being divided into equal slots, there is a much greater variety in patients and a greater need for longer care periods As an O.T. assistant explained, "I find a lot more of the people that are admitted to the floors now7... are sicker because of the minor surgeries that... aredone in emergency... Soyouget bigger surgeries, more complicatedand these people need more care. But they count heads not workload/' Even nursing worktime is being allocated on the basis of time-motion studies developed initially for use in private industry. The RN As and NAs raise a range of criticisms based on their experiences with patient classification systems. In these systems, patients are assessed daily according to their diagnostic, medical and other treatment and emotional needs. The average time to deliver the particular level and type of care has been previously assessed and standardized. The application of this technology in the unit setting produces a number which represents the care needs of each patient. The sum of all patient numbers is intended to translate directly into nursing staff needs. In most hospitals, managers justified the introduction of the system to the staff by arguing that now there would be proof of how hard they are working. Now there w;ould be actual numbers or 'hard data" resulting from the application of a scientific instrument which was value-free and which would demonstrate their work load. One RNA's comment is typical: '"They told us that if we do the numbers properly, they could say... according to these numbers, you do need an extra half person and you can have it because it says so in the numbers. And so I was actually quite pleased at first. Finally its going to show what we do in a day. But it didn't happen/' When the hard data based on the time-motion principles did indeed demonstrate that the nursing staff was overworked, management responded by simply changing the numbers used to make the calculations. The system no longer seemed so value-free and scientific.

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According to another RNA, the system fc 'was shoeing that we needed an extra full nurse on our floor which we didn't get. Also, it says we need an extra person from three to eleven [shift]. And all of a sudden they were going to revamp the numbers, and a lot of our numbers got cut almost in half. It still showed. .we need an extra half person which we very seldom get." Yet another RNA reported that the patient classification system showed'c we' re working at 120 per cent which is saying maybe we need a little more staff to cover this workload. And suddenly, we're going to be on [another study] and they change all the numbers again. So, even though last week we were working at 120 per cent, that, in two weeks time is going to be brought down to 90 per cent." Differences between the actual time it takes to care for a patient and the time allowed by the instrument, and differences among patients, in terms of their needs, become problems to be managed. Too often, these differences are dismissed as resulting from patients who are too demanding, from workers providing unnecessary care or from employees not working hard enough at the job. Such practices do not encourage the kind of trust that is necessary for team-work, especially when the skill and complexity of nursing work is ignored by the system. Nor do they promote the kind of innovation and commitment that are central to the concept of continuous quality improvement. They do suggest that there is little that is scientific about the process, given that it is changed whenever the data do not match the number of workers hired. Although the patient classification systems do not seem to be used as promised, or even as designed, they consume an enormous amount of time. Employee after employee said they spend more and more time filling out forms and therefore have less and less time with patients. An RNA explained that "There are forms in all the rooms and there are days for the whole month. And each day, when you do something... you have to mark on this form whether you changed the complete bed or just part of the bed, or whether you gave him a complete bath or just a partial. It is supposed to be a method in order to minimize the amount of time that you spend doing something to the patient.... You can't look at a patient and tell whether their bed needs to be changed or not? I mean, what happened to our judgement along the way? That's what I feel... They're picking us to death." The forms are the basis of decisions and they take considerable time and effort to complete. Yet they are not used, most workers say, to provide even the minimum staff required according to the system. Moreover, the patient classification systems are based on assumptions that directly contradict other goals of the Premier's Council. They are neither flexible or client-centred. Little consideration is given to how the patient is situated socially, economically and culturally, or to the age and

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sex of the patient. Instead, the instrument assumes that the care provided during the hospital stay can be standardized, with each patient allowed a pre-determined amount of care. Furthermore, the system is based on a model of health that sees the body as a collection of parts that can be treated separately, and illness as primarily biological. Only with such assumptions can care be divided into discrete tasks and units of time and recovery be assigned a limited period Yet such an approach directly contradicts the findings of the Premier's Council that led it to advocate an emphasis on social, physiological and psychological factors as determinants of health, on the active participation of citizensand providers indecision-making, and on total patient care. In one area at least, strategies consistent with the philosophy of continuous quality improvement have been introduced. Multi-tasking has become increasingly common, with workers frequently moved from area to area or used to substitute for other workers. But this is often done, worker after worker said, without providing the necessary training and information. For example, the RNAs are increasingly responsible for the well-being of the patients but increasingly they do not have access to the full range of up-to-date information about the patients. Often, the RNA is given only part of the daily patient report because she is covering the call-bells on the unit while others are receiving the full report. Similarly, the RNA is usually not invited to patient conference sessions, or to the grand rounds where health care personnel discuss the care regimen of patients. Because the RNAs are rarely invited to attend these information exchanges, there is often new information that they do not hear until much later. Furthermore, the RNAs' up-to-date knowledge of the patients is not transmitted to the physician at a key point in the decision-making process. And it is the physician who makes the primary decisions about the patients. One RNA offered an example to explain the problem. This RNA was not in on the reporting stage but the RN "knew I was an RNA, so there were things she didn't write down. And one of them was [that] one of the doctors... was to see [my patient] on consult. Well... the doctor came around and... I didn't know who he wanted to see... it wasn't written on my paper.... And [they miss] things about your patient... why is this patient got this, that and the other thing, when it's not mentioned in report. [We] never get a second report." It is the RNs who make out the nursing care plans, even though administrative work often keeps the RNs from providing much nursing care. "So the RN, instead of helping more with the patients, she's sitting at the desk doing all the nursing care plans, which isn' t right because she doesn't give half the care. So how does she know what she's writing down?" Such practices not only frustrate the workers, they also make it difficult to provide continuity of care. In sum, according to these workers,

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there is little evidence that the strategies recommended for achieving the vision through new human resource policies are in place. Employees are less rather than more powerful. They have less say in the organization of their work, in patient care or even in their own schedules. Their work is more closely supervised and controlled. They are pushed to come in when they are sick, to work much harder when they are there and to do a quick rather than a good job. There are fewer people to do the job, at the same time as each patient requires more care. Moreover, the harder they work, the more they, or their friends, are likely to lose their jobs. More than one worker described the following kinds of consequences of these managerial strategies:fc 'with all that pressure, you're worn out. And you have to go into a patient's room and smile.... They expect it because who wants to see a sourpuss? But I tell you, lots of times it is very hard. Last week... eveiy night I come home. I had a couple of drinks. And finally my son said, 'Hey, where are you going with that?' I said, "Look, just leave me alone or Fll kill somebody'. And I asked my sister twice to bring me to the [hospital] and sign me in. She wouldn't do it. I said, "It's gotten to the point, Fm going to explode'." Under such conditions, it is harder to work as a team, because team-work requires trust, time, experience and choice. It is also harder to think in terms of the innovation that is critical to continuous quality improvement. As an RNA put it, "The bottom line is sometimes your work-related experience can certainly be an asset to them. But you wouldn't dare initiate, [say] let's try this, because right off the bat, their back is up against the wall.'' And it is harder to be flexible and dynamic, let alone respond to patient needs.

Achieving the Most Efficient, Flexible and Cost Effective Use of Resources In Achieving The Vision: Health Human Resources, the Premier's Council on Health Strategy points out that, over the last decade, health care expenditures have risen from a quarter to a third of the provincial budget and costs had been growing at twice the rate of inflation. It continues on to say that' fc if we do not change the way we use, organize, manage and plan for health human resources, we will be unable to realize our vision for the health care system.'' What is necessary to reduce costs, the Report maintains, is a collaborative process designedfc 'to achieve the most effective, flexible and cost-efficient use of our key asset-people.*' But according to the workers interviewed, many of the strategies introduced to cut costs are neither effective nor efficient and too many contradict the vision for the health care system.

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Hospitals have certainly introduced measures to reduce expenditures and they have reduced the rate of increase in costs. Most of the workers we interviewed agreed that new approaches are necessary to keep expenses down. Some employees pointed out that there had been wastage in the past, but this is no longer the case. One who works in finance said, "We weren't cautious. I say 'we'-the hospital-in spending. And now of course, they've gotten so tight that every bandaid is counted. Although a number of workers had suggestions for ways to cut costs further, in all of the interviews employees raised questions about the cost-effectiveness of the changes in work, management and care that have been implemented. Worker after worker described efforts to speedup work, to trim the size of staff, to cut down on the range of services offered, to reduce hospital stays, to economize on supplies and to saveormake money by privatizing services. When presentedtothe workers, these changes were justified as cost-cutting or efficiency-enhancing. The interviews suggest, however, that strategies designed to reduce staff and to provide services more efficiently and effectively might actually increase, rather than decrease worktime while limiting the likelihood of healthy outcomes. As a result, these strategies might prove more costly in the long term. In the interviews, employees offered a range of examples to demonstrate how cutbacks can serve to increase the risks for patients and for workers, with the result that work is not only less effectively done but also less efficiently done. They also offered examples of managerial strategies that were simply ineffective even in the short run, primarily because these methods developed in the industrial sector did not work when applied to the careofpeople. In the end, some part of the system will have to spend more as a consequence.

The Costs to Patients Fewer diapers, fewer walks and fewer bed changes can save money now. But for patients, staying longer in diapers, in wet linens and in bed is not simply uncomfortable. These practices lead to bedsores or ulcers and to embolisms that are life-threatening. They can cost the hospital more in the long run. Eventually, bedsores must be treated, often at considerable time and expense Patients who are not walked regularly and often, frequently become bed-ridden and thus even more dependant on the health care system. Some develop embolisms. According to one RNA, "they did a survey because they had a lot of people coming back with embolisms.... We had two people die from embolisms post-operatively.... Sotheydid a survey, and they're trying to find out, is it because we're not getting them up enough, or what is happening."

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At least one RNA in every hospital reported that infections were on the rise, with the result that people had to stay in the hospital longer than originally planned and had to receive more expensive treatment while they were there. In addition, more than one RNA said, "I found a lot of people coming back with infections", with infections they hadpicked up in the hospital because the hospitals are no longer clean and because too many very ill people are crowded together. Yet another RNA claimed that there were so many patients with infections in her section that the nurses were asking for data to be collected on return rates. People are also coming back, a number of the RNAs say, because they are sent home too soon after their operation, illness or birth. In their weakened state, patients can easily pick up infections present in the household. The loving but amateur care provided by relatives can be risky, given that relatives are more and more often asked to change dressings, attach and monitor equipment, do special feedings and take vital signs. Furthermore, many patients have no one to look after them at home, because they live alone, because everyone else is in the labour force or because their relatives are too elderly or disabled to cope. Newborns are sent home before signs of jaundice appear, then return to a nursery full of sick infants who pose a more significant risk than do other newborns. Mistakes that are more frequent as more people work at top speed and at tasks for which they have not been trained not only increase the risk to patients but also increase costs. Several employees reported that specimens were lost and thus had to be redone at extra cost. The three minutes allowed for cleaning the OR between operations, some feared, created costly infections. The policy of replacing equipment and parts "just-in-time" can create both costs and risks in a hospital environment. An inventory aide explained that he now only changes spotlights when they burn out. [Those]fc 'which they use over the patients when they operate. And a couple of times I Ve changed lightbulbs. And all kinds of surgery. I don't like doing it a lot because sometimes these bulbs burst inside the container where they' re kept. And can you imagine? I turn that thing upside down and all the glass will come down on someone's brain or open leg?'' A clerical worker who went from switch board to ward secretary without any training is worried she will make a costly mistake deciphering doctors' writing, costly bothin terms ofthe riskto patients and the expenditures involved in correcting errors. An RNA is worried that they often do not have time to stay and ensure that diebetics eat their snacks.4' Ifthey aren't with it enough to eat, lots of times they don't get it. And they should have it because it's part of what they're supposed to have, their daily intake.'' Without a snack, diabetics can have a insulin reaction that takes more time than the snack.

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In short, in the experience of these workers, cutbacks in cleaning, housekeeping, clerical services and nursing staff and in supplies are not only making patients uncomfortable; they are also making them sicker. The result can be an overall increase in costs to the system.

The Cost to Employees Managerial strategies designed to reorganize the work have a number of adverse effects on staff, many of which have cost implications. These cost implications are both human and monetary. Every group interviewed reported that the workload had increased during the past three years. There are fewer people to do the job but more work. Many workers are putting in longer hours and assuming responsibility for a greater number of different tasks. One RNA reported,' 'I work seven days in a row once a month and that's a killer.'' Another maintained that'* Some of these girls work all night, they may go home at 4 o'clock. And they have to come right back in the next day." With such schedules, no one can work efficiently or effectively. Similarly, without replacements for those who are sick and with fewer workers per ward, everyone is rushed, all day. The result is often less than effective use of time, because eveiyone is simply too tired. Jobs have to be redone or left undone and everyone is working slowly by the end of the shift. There are also cost implications of the additional tasks assigned to each worker. Although multi-tasking can reduce the number of workers required, it often leads to wasted time and thus money, especially when employees are not fully trained for the tasks. For example, the aide in OR has traditionally cleaned and prepared equipment. But now she is also called upon to run to the pharmacy orthebloodbankfor supplies. Then she has to get clean again before she handles equipment. One aide explained that she is expected to clean all the equipment.' 'But we have to wear the gloves when we go in. Everything is dirty. Everything was used on this last patient. So we have to wipe all those cords and monitors and everything down. Now, because the nurses are not there—they are doing their own jobs—I am expected to cover the OR table... with the clean sheet for the next patient. So this is where I told them 'This is not working out How can I [put on the clean sheet]. I don't have time to go and quickly take off my gloves in the soiled utility and come back and cover the bed." Similarly, another aide said, "by the end of the day we spend many hours going up and down, up and down, getting stretchers because the patients are there. Plus we have to operate elevators too and everything.'' The multi-tasking that may

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be useful in industry is difficult to adapt to the hospital, given the very specialized tasks and the need for sterilized equipment. The increasing use of part-time and casual staff also saves money on the payroll. But this strategy too can result in less effective and efficient work. More than one employee said,4 'the replacement can't keep up.'' Permanent employees spend more time teaching those who are new, and thus less time doing their own job. They also spend time correcting the errors made by the inexperienced part-timers and casuals, errors that can be costly indeed in terms of patient health. The rules introduced to limit the use of supplies often seem less than effective in cutting expenditures. New cost-efficient orders for bed changing provide a superb example of false economies and a failure to understand the nature of caring work. In several hospitals, workers have been instructed not to change an entire bed everyday. Instead, they are to change only that part of the bed that has been soiled Though justified as a way of reducing both labour time and laundry costs, the new requirements for bed changing actually entail considerably more time. Workers have to decide which parts to change and then set about removing and replacing those parts, a much more complicated procedure than simply changing all the linen, especially if there is an immobile person in the bed. Many workers also report that they spend a great deal of extra time running to other floors to find supplies because supplies on each floor are now kept so low. The rules introduced to cut labour time often seem to add to the labour, as well as to the sense of loss of control. As more and more work is timed, more and more time is spent filling in forms and calculating minutes per task. Worker after worker said the amount of labour that goes into reporting and into accounting for time has increased enormously. Moreover, because employees have to justify their time and because they fear for their jobs, some make sure that everything is written down in order to protect themselves. An RN A" "makes notes. I carry a book in my pocket and I have my own pen. And I write my daily assignment too, because there is a lot of nonsense too. So I make sure I buy my own little notebook and I put my patient assignment in there... and everything.'' Managers seem to spend a great deal of time and money monitoring sick time and having workers report on their sick time, rather than on addressing the causes of increases in sick time. These new work regimens and schedules, when combined with greater surveillance, loss of control and fear of job loss, lead to increased tensions in the workplace. Describing supervision on the belt line in the kitchen, a dietary aide said if there is a problem with the line' 'then they expect us to leave our area and go and help out. We don't mind helping out if they were nice about it, and

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say, 'Look,... I'm short this morning. Would you mind helping me out?' But they don't. They just scream... Some people deal with it; some people [get] upset; some people cry. If they're stressed out, you cry. [You're] so upset that maybe [they] have to send you home and such thing.'' Employees also report yelling more at each other and finding it more difficult not to ydl at patients and their relatives. This job stress has a physical and emotional impact that results in decreased productivity. Frustration and disaffection were constant themes of the focus groups. Many workers expressed a desire to quit or leave. Many said they simply could no longer do the job well and no longer felt a commitment to the work. ' 'Now, you wonder howyou would feel working in these conditions, [wondering] are they going to use you for the next two minutes, and then you're going to get dumped the third minute?.... When I first went to the hospital,... I found it was different. It was more friendly. It was more relaxed. And now it isn't. And I used to come in early and go real late. Nuts. I don't need this aggravation.'' Many say they can only cope with the stress by taking sick leave.' 'Last week I took two days of sick because I couldn't handle the situation so I stayed home sick. I couldn't do it.'' The psychological stresses of the workplace, compounded by the intensive physical requirements of long shifts and by the diversified work performed in an environment where infections are common, also make people physically sick. As one dietary worker explained,' 'your body can only take so much. Pretty soon, they are gonna start feeling sick or run down and when you're run down from overwork you start to get tension colds or whatever is going through different things that go through the hospital. We have had managers with chickenpox lately." Required to stand for extended periods, perform repetitious tasks, repeatedly lift heavy objects, and move at a very fast pace, workers report more on-the-job injuries. The expectation that employees will cover many different areas of the same hospital while on a single shift, combined with little training and speed-up, has also contributed to job-related injuries. An OR aide reported that "It's pressure, this running.. .this aide got knocked off on the floor, her head knocked the floor and she was unconscious. Shehadafractured...rib. It was months and months already [that she has been off] isn't it? She wears a brace. I went home with my back, my legs.'' The yelling and other manifestations of tension slow work down and ensure that everyone does less than their best. Even when sick and injured workers are not replaced, there are costs because less work gets done. Moreover, the extra work for those who remain on the job can lead to even more workers getting ill and to costly accidents. Part-time and casual employees may be less burnt-out, but they are also often less effective, and they consume time in terms of training and errors. Patients necessarily end up with less care.

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The Costs to the Hospital Employees offered example after example of management innovations that serve to increase costs. In order to reduce expenditures in the short run, many managements are not maintaining the infrastructure. Employees report waiting for long periods on elevators that are broken, in the process keeping expensive operating rooms empty and wasting labour time. Similarly, they say the vents are no longer regularly cleaned. As a result, dirt is blown throughout the hospital, dirt that not only creates a health risk but also increases cleaning time. In order to save money on supplies, hospitals have reduced the use of some materials and replaced others with disposables. For example, in one hospital the use of green soak pads was restricted when patients had diapers. But as a result "They were using a lot more linen because... if they didn 't put the green pad, the soaker that is, a patient had a diaper, but if he leaked, then you had to change the whole sheet the bottom sheet. So you end up having more stuff'' In one hospital,' 'they went from reusable linens to disposable linens. And the reason behind that they were saying, there was too many infections with reusable linens. They weren't being washed properly.'' A private company offered, at what was initially a good price, to provide disposables. 4iSo they got out the scissors and cut up all the linens that they had and they shredjed] them and use[d] them as rags.... And what started to happen shortly afterwards, the complaints started to come in with the disposable product. One complaint that I heard right off- and it makes me laugh -... [in the operating room] whenyou have the ventilation going and some one would open the door, you have this thing [sterile drape] flying up like a kite, cause it is not heavy [like] the linen.... Now they're talking about going back to the reusable because infections are still there. There hasn't been any improvement.'' Replacing the cut-up linens will be a enormous expense. And there is a huge disposal problem and expense with the current ones, especially as they become more expensive. There are problems too, with the disposable diapers. Accordingto one worker,fc 'they used to have these nice cushy things that you put under the patient' s butt. And when you turned it didn't stick to them. Like a patient gets a little hot and you are peeling these layers of plastic off, with the cotton stuck in crevices that you are not going to look for, right? And the cotton things were nice and flufiy. And people weren't allergic to it. And it didn't get them all upset. And when they did their business, you took it all and threw it into the laundry. Well here you have to pick through the linens, so people don't bother.''

The employees had other examples of things being ordered in large batches, before proper trials had been conducted. According to a clerical worker, "We'vegot

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IV bags, hundreds of them, that we give to veterinarians' offices, because some of them are out of date, some of them we don'tuse anyway. And we do this stupid thing where we 've got to tiy a certain syringe..'.The book work and the paper work that was involved in that. What was their trial period, something like three weeks? So they ship this stuff out to the floors and all the floors right back say'We want to go back to [the previous kind]. So we've got thousands and thousands of syringes and we have to restock with [the other one]. Like the stupidity of what they are ordering without proper trial is just overwhelming. And then the workload is increased." Employees had examples of waste,' 'even blood. Like I go to the blood bank sometimes to get some blood and after the doctors change their mind and the blood is there for like longer than the time it's supposed to be, or the patient doesn't need the blood... They waste. They want to cut the small things. And after... they open it, they don't use it. They think they're going to need it, but they don't need it. And it doesn't make sense, that's why they are wasting more money." They offer examples of equipment that is ordered and not used, like the case of the bathtub. According to the RNAs in one hospital, *' we said, don't bother bringing the bathtub. Let's keep the one we have and see what we can do. But it's no point. 'It's already budgeted for. I can't put the money anywhere else.' What happens with the tub, this is the problem. They go and purchase the things without consulting the people involved in these things. They never came to me and said, 'Listen we're going to buy a tub with this voltage'.... No. They just went ahead and bought it First thing,... it's not even CSA approved. You're not supposed to install it in Canada.... Three months ago, they were supposed to get an inspector to inspect it. The inspector will not inspect it until it is wired. It's wired up. The only problem is, when they read the instructions, the unit that sends the ultrasound to the tub has to be ten feet away from the tub. We don't have ten feet in that room. It's only eight feet. So they've got a problem. The unit has to be in another room so you can operate it. To top it off, there has to be a physician present.... So they are not using the tub.'' In some cases, new equipment designed to reduce labour is used in such a way that it actually increases labour. One hospital "went to computerization without training anybody. Brought in the computers and more or less said, 'Here you are. Go to it!'.... And all the work they thought they would save they haven't saved.'' Money has not been saved both because people lack training and because the system was not transformed to take advantage of the new technology. This clerical worker wenton theexplainthatthere is no permanent filekepton each patient. "We've had patients come in in the morning. They' ve been in an accident during the night. They have a broken leg.... We've taken all this information. We've entered it. He's assigned a chart number, etc. ThedoctortakeshimtoOR. While he'sinORhe needs

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an x-ray. That means we treat him just like we never saw him before. We give the name, the address, the OHIP number right from score one. Then after the patient has had his surgery, all of a sudden he's getting congested. He has to have a chest x-ray to make sure his lungs are clear. We have to enter his name, his address, his OHIP number, his doctor, everything from score one all over again, because our program was never programmed to maintain [the record]. We don't have a mainframe." The lack of a permanent file not only means that there is more work; it also means that it is difficult to track patients and tell whether or not they are re-admitted as the result of a problem created by the hospital. A number of employees also suggested that hospitals are spending extra money accommodating doctors. In one case, a clerical worker claimed that she has to do ' "all the orders from the doctors' offices. I totally disagree that we should be paying for and producing all the forms for the doctors' offices for free, all the doctors who do surgery or anything in our hospital. They all have their own forms, etc. The same as drug requisitions, we print them off for free.'' Others blamed doctors for special and expensive supplies that did not seem necessary and sometimes were not used. Many suggested that there is frequent overtesting, in part because doctors fear being sued. A number said doctors and managers did not co-ordinate their policies. For example, doctors may say on Friday that a patient can be released after receiving physiotherapy, but there is no physiotherapy on the weekend. As a result, the patient spends days in the hospital without treatment and at considerable expense. Finally, many said there was always money for new office furniture or other equipment that seemed unnecessary, but no money for new employee salaries or extradiapers. k4Theyspent$8,OOOforaspecialchakwitharmrests'',saidone, "for a chair that is kept in a corner.'' In sum, these workers saw the need for cutbacks in some areas but most were convinced that current strategies were not those that are required. They provided examples of waste and inefficiency. They also provided examples of strategies that not only increased long run costs but that also contradicted the vision set out by the Premier's Council.

Conclusion

One worker interviewed said 4Tve heard on television that the system is getting better because they' re trying to refine and.. rather than... having abuse of the system, they're trying to better it. I just hope it turns out for the best for patients.'' Another said' 4 I think that one thing Canada's got that we wanted is good health care. And we're losing it.'' Based on their many years of experience, they contend that what was once a good system and a good place to work is gone. According to an RNA,

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"We've been having... a lot of problems with families since the cutbacks because their parents are not getting the care... and they aren't... getting the care they used to get. But they don't understand that.and they expect to still get the same care." An employee spoke for many when she said "I'd take my family elsewhere. Maybe this is the point where ignorance is bliss. I know what happens in my hospital.'' They feel increasingly frustrated that they cannot do a goodjob under current conditions, increasingly ashamed of the hospital in its current state and increasingly frightened about the consequences of the changes, not only for themselves but also for the patients. According to the workers interviewed, the new managerial strategies threaten the health of employees as well as patients and contradict both the vision and the processes outlined by the Premier's Council. In short, they maintain, the entire system is being undermined. Increasingly, hospitals are money, rather than client centred; they treat people like machine parts rather than as whole people who require quality care; they offer a dangerous rather than a healthy environment, and they are neither efficient or effective. They may, in the long run, prove to be much too costly, even though there are alternative ways to save money.

Methodological Considerations The interview material in this study is based on 24 focus group sessions with 98 hospital workers, employed in nine different hospitals across Ontario. The participants and the hospitals were chosen to provide experiences, and therefore responses, that are as diverse as possible.

Protection of Participants The participants, although not necessarily union activists, were initially contacted by their local CUPE representative, and asked whether they wanted to take part in a focus group discussion of patient care and working conditions. The focus group sessions, each lasting between two and three hours, were held away from the institution in order to prevent those interviewed from suffering any repercussions as a result oftheir participation and inorder to avoid time lost on thejob. Those taking part were also informed, in writing and again verbally just prior to the session, that their participation was voluntary, and they could leave at any time. The sessions were tape-recorded, and the participants were also informed of this well in advance. Before the sessions started, participants were asked to give a first name only, and many chose to provide a pseudonym. Finally, the tapes were transcribed by an independent service that knew neither the identity of the worker nor the institution of employment.

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Reliability of Results Those interviewed represent work experiences in a variety of departments and ward settings, within urban and rural institutions of varying size, that are located in both northern and southern Ontario. Because of this diversity, the study manages to isolate those issues that are critical to many workers in diiferent settings, regardless of institutional size, or geographic location. Attempts were made to interview RNAs, NAs, Dietary, and Housekeeping workers in each institution, so that a central core of experiences could be more easily compared. In addition, other workers such as lab techs, clerical, therapy assistants, pharmacy assistants, maintenance, engineering, porters and attendants from one or more institutions were also included. As a final basis of comparison, one mixed group of workers, from the same department, was also included from each institution. The justification for this mixed session was to gather varied perspectives of the situation in the same department, unit or ward; thus providing a more comprehensive picture of the work setting. The researcher followed an interview schedule, with the same, open-ended questions included at every focus group session. However, there were different follow-up or clarification questions asked in each session; a factor of the very rich and detailed nature of the data, and also of the number of people present and the particular experiences that were shared. This kind of research instrument, more than other types of research, allows those issues to surface that are considered to be important by the participants at the same time as it permits the coverage of issues critical to researchers. In other words, the intrusion of the researcher is minimized precisely because the participants have more freedom to address issues as they choose. The focus group approach allows participants both to stimulate each other and to provide a check on each other. In the analysisofthese particular case-study results, commentsby participants fall into three categories. The typical comment is one that re-occurs and has no substantial refutation in other interviews. It isthiskindof response that is the primary focus here. The unusual or atypical remark is one that is not repeated widely enough to be considered undeniably reflective of the interviews. Very few of these have been included, and then only offered as examples of more typical patterns. The third type is the comment that is clearly outside the main response group. It is reported only on rare occasions and is identified as outside of, or contradictory to, the bulk of respondents. This kind of comment is similar to an outlier in quantitative data. Of course, the voices of these particular workers, in this particular study, do not necessarily represent all workers. And their views may be contradicted by those who manage the system. But there is so much consistency in their voices that they

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provide strong evidence to support a claim that, at the very least, further research needs to be done in order to evaluate the impact of current cutbacks on health care.

Notes 1

Premier's Council on Health Strategy, Nurturing Health; A Framework on the Determinants of Health. Toronto, 1991, p. 1.. 2 Premier's Council on Health Strategy, A Vision of Health; Health Goals for Ontario. Toronto, 1991, unpaginated. 3 Premier's Council on Health Strategy, Achieving the Vision: Health Human Resources. 1991, p.4. 4 Sara Dimers, "Total Quality Management - A Strategy for Success" Housecall, Women's College Hospital, 1992, p. 11. 5 Premier's Council on Health Strategy, Achieving the Vision: Health Human Resources, Report of the Health Care System Committee, Toronto, 1991, p. 1. 6 Ibid, p.4. 7 Ibid, p.5.

Closer to Home; More Work for Women In the report New Directions For A Healthy British Columbia, the Provincial government sets out a commitment both' 'to provide opportunities for good health on an equitable basis for all citizens in the province''* and to provide health service at home or close to home,' 'with the support of family members and friends.' '2 Most provinces have produced veiy similar reports.3 But under current conditions, these two objectives are incompatible. They are incompatiblebecause care in the home, the family and the community usually means unpaid care provided by women. Such care is often provided at great personal cost to women, and may not offer the best care for those requiring the service. If these two priority commitments are to be reconciled, the following issues must be addressed: • There are already significant numbers of people cared for at home. And both demographic changes and new health care policies will increase their numbers enormously. • Much of the care and service work that is being sent home has never been done there. And many homes are not healthy places to be. • Women are the overwhelming majority of care-givers in the home . and in the community. • Most women are now in the labour force, and therefore have little timeorenergyfor additional caringwoik. Moreover, most are in the labour force because they need the money and therefore have little choice about doing paid work.

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The caring work in the home has an impact on women's health and on women's employment. It also has an impact on the way they do their paid jobs. Furthermore, the stress of doing more than one job often means women are providing less than optimum care for those in the home. And many of those requiring care find it stressful to be cared for by mother, daughter or daughter-in-law.

Who Needs Care? There are basically three groups of people who require care: the elderly, the disabled and those recovering from treatment or illness. The number of people in all three groups are growing. As people age, they usually require more and more assistance to meet thendaily needs as well as more and more health care services. But only a minority of the elderly have ever had these needs met in institutions.' "Many still believe that, in times past, an elderly person lived his or her final years withdrawing gradually from the family farm, contributing wisdom and experience to the end. A popular portrayal of today's elderly person is one of alienation from family, especially from children.' ' 4 However, in the past few people lived long enough to follow such a pattern, and many of those who did survive were not supported by their families. Moreover, there is plenty of evidence on the current situation'cto debunk the myth of abandonment by family in old age. "5 At the same time, there is little evidence to support the concern that the availability of formal care means that families abandon their responsibilities for their relatives.6 Today, between 85 and 90 per cent of the care the elderly receive is provided informally in the home.7 There are lots of people who need this care. About four out of every ten Canadians over 65 have long-term disabilities and many of these disabilities are severe.8 While today only about one in ten Canadians is over 65, by 2021 it is more likely to be one in five.9 Many people are also disabled before they reach age 65. In 1986, there were more than three and a quarter million people with disabilities in Canada and many of them were young. Only a minority lived in institutions.10 Indeed, nearly 93 per cent of the disabled lived in households. Of course, not all these people require a great deal of assistance. However," Tor every one person living in an institution, we know there are two people with the same level of disability who are living in the community'';11 for every severely disabled adult living in an institution, there were three such adults living in the household population."12

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Moreover, the number of people with disabilities is growing. According to the 1991 Health and Activity Limitation Survey (HALS), the proportion of Canadian children under age 15 with disabilities grew to 7 per cent in 1991 (3 89,400 children) from 5 per cent in 1986."13 Part of this increase may be attributable to better diagnoses but part of it is also attributable to new techniques. As medical science increases the chance of survival, it does not necessarily increase the chance of recovery to a former level of capacity. '" 'Many infants and children who previously would have died now survive the acute effects of extreme prematurity, life threatening diseases, congenital abnormalities, and severe trauma. Unfortunately, some of these children survive with chronic disabilities and require complex, high-cost, long-term, labour-intensive health care."14 One study indicates that about thirty-five in every 1,000 children between the ages of 4 and 16 have a chronic illness and functional limitation.15 Another indicated that 56 per cent of the children with disabilities had chronic health conditions.16 Yet less than one per cent of the disabled Canadian children under 14 lived in an institution in 198617. Indeed, because ikso few children were living in institutions in 1986, this population was not surveyed in 1991."1S In addition to the people who require long-term care, there have also long been people who require short-term care. Most people who get sick do not enter a hospital or even visit a doctor. Most simply stay home, even though many of them need, and receive, assistance.19 Some of the elderly, the disabled and those with short-term health problems have traditionally found care in the home. But the growing numbers cared for in households do not simply reflect demographic changes. They also reflect changes in health care provision and in health. Today's health care problems and practices threaten to increase significantly the numbers seeking care outside institutions. AIDS offers an obvious example of a new health problem that is primarily dealt with in the community.20 By 1990, nearly four thousand AIDS cases had been reported in Canada21. And many more people may be carrying the virus. For example, in British Columbia, as of 1991 * 'there have been approximately 480 peoplediagnosed with AIDS, halfofwhomarealivetoday. There is also an estimated six to seven thousand seropositive individuals in our province/'22 Alzheimer's offers another example of a newly diagnosed health problem that has increased the burden on the community. At the same time as some debilitating diseases are increasing the care required for those outside institutions, health care policies such as shortened hospitals stays, day surgery and out-patient care are sending people home wiio still require a great deal of treatment and care. De-institutionalization of the elderly and the disabled is

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also increasing the community and household load And, unlike many of those sent out early after medical treatment, those who are de-institutionalized usually require long-term care. In sum, the numbers cared for in the home have been, and will continue to, grow significantly. When those with new health problems and those released from institutions are added, the amount of caring work required in the household will be tremendous.

What Services do they Need? The problem is not simply one of growing numbers requiring care in the home. It is also a question of the range of services required. Most research suggests that many ' 'family relationships have traditionally provided, and continue to provide, a major source of interpersonal support, warmth and commitment for people of all ages.' '23 Most still do so today, and often for more dependants than families cared for in the past. However, this does not simply indicate a return to traditional family care. Today" s health problems and practices are assigning many care services to the home that have never been provided there in the past. In addition to washing, bathing, dressing, lifting, turning, feeding, walking, toileting and changing, many of those who are now sent home require such services as the "monitoring of vital signs, apnoea and heart monitors; assessing the chest; performing or supervising renal dialysis; providing tracheotomy care; giving tube feedings; administering total parental nutrition; physiotherapy; cardiac pulmonary resuscitation and injections; and supervising the use of ventilators and oxygen administration."24 In a large number of cases, the work involves' 'caregiving tasks that often require a degree of physical intimacy, and contact that would not normally exist in family relationships."25 Such tasks have not traditionally been done in the home. Many are recent inventions and even the older ones have traditionally been performed by trained health care workers. One woman interviewed by Heller for her study of health guardians explained that "We (my sister and I) changed dressings night and day for two years. We gave injections...We spent whole evenings cutting dressings for our mother who had an open wound.'?26 This is not work sent' 'back home'' but new woik that is being ' 'devolved." It is complicated health care work that has been moved out of institutions and into the home.

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Much of this caring work requires considerable skill, and involves considerable risk to the patient if done inappropriately. Those receiving care may not want their mothers or daughters performing such intimate tasks and those giving the care may be unable to do the work properly. Caring about someone does not automatically give women the skills or capacity to care for someone they love.

Who Cares? When reports such as the Ontario Ministry of Health's Building Partnerships in Long-Term Care talk about supporting' "consumers who choose to remain as long as possible in the familiar surroundings of their homes or with family", the impression is left that a large group of people are around to do the work.27 But study after study in Canada and abroad has demonstrated that care by family members and community is really another way of saying care by women. Women are the overwhelming majority of caregivers and they provide the overwhelming majority of care.28 A review of the research in Canada, Britain and the United States found that in most studies,"' 70 per cent or more of the caregivers are women. "29 A variety of time-budget studies indicate that it is women who regularly prepare meals, do laundry, clean the house and maintain the social contacts. While there are some variations across class, cultural and regional groups, the overall pattern in the division of labour in the home is remarkably similar in all groups from coast to coast.30 Women still do such work even if they have another job in the labour force. When they take on said work, they simply reduce or eliminate their leisure time and do some tasks less often. In dual-earner households with small children, women contribute almost 30 hours a week more than fathers to household demands.31 It is mainly women's cooking, laundry, cleaning and emotional support work that increases when people are sent closer to home; not primarily the men's yard and car work or their repair tasks. When the work involved in the care of the elderly, the disabled or those who are temporarily incapable of providingfor their own needs is added to the household, women take on this labour as well. A study by the Conference Board of Canada found that women were "almost four times more likely than their male counterparts to report they stayed home when their children were ill.' '32 And it is women who give up their lunch hours and vacations inorder to care for sick children. Both women and men agreed that women provided the majority of caregiving for other dependents as well.33 When men did help, they often shared a task with a spouse, so women were still involved in the work. When men do work on their own, it usually involves financial assistance, transportation or yard work. Most of the

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personal care work, the meal preparation, the emotional support and the doctors' appointments are done by women. And this, of course, is precisely the kind of work that is to be sent closer to home. A U. S. study found that' 'husbands rarely gave direct help to their wives with the care of the dependent relative living with them, even when the wife was also employed."34 There is every reason to believe the same holds true in Canada. A woman interviewed by Heller reported, "I do everything by my self (for my 7-year old son, a spastic quadriplegic). My husband has just started to help me. He doesn't even take him to the toilet. When we take the boy to emergency, my husband drives but he only goes in when I tell him to.' "35 Women provide the care at home, whether or not they also have paid jobs. A U. S. study of parent-care found that there was little significant difference between the kinds of caring sendees provided by women with and without paid employment. However, employed women on average contributed an hour less personal care work per week and 5 hours less emotional support for those requiring care than did those without paid jobs. They also did less housework, shopping and laundry for their mothers, although they did as much money management as women without paid work.36 In other words, employed women still didthebasic and obvious tasks related to health but had little time for the caring parts of the job. Many of the women who care for disabled children and adults or for elderly parents are single, widowed or divorced. The high proportion of widows is largely explained by the facts that, on average, women live longer than men and many at a younger age. The high proportion of divorced women may be explained by the pressure caring work places on the family.37 Pressures from caring work can not only lead to family breakup but can also prevent women from forming new relationships. Single and married women also find that their caring work prevents them from developing relationships with those outside the household.38 Many of the women who provide care are immigrants, who may not know how to access the services that areavaOableandmayfinditdifficulttocommunicatewithothersw'hopro\idec^re.39 In all households, there are fewer people around to help with the caring load. A similar division of labour appears among the volunteers who form much of what is often referred to as the community. Among those over age 55, women are twice as likely as men to do volunteer work.40 Younger women are also more likely than men to do volunteer work. According to a Statistics Canada survey, 57 per cent of all 1989 volunteers were women. Women accounted for two-thirds of those providing care or companionship and collecting or distributing food or other items. They also constituted three-quarters of those preparing and serving food.

Closer to Home / ]Q1

Indeed, well over half of the women who do volunteer work prepare and serve food or provide personal care while half of the men volunteers promote ideas and do research. The only areas where men form the majority of volunteers is in professional consulting, sitting as a board member, repairing, maintaining and building facilities, fire-fighting, search and rescue, and protecting the environment.41 Such jobs are unlikely to increase much when people are sent home from institutions. Heller found that many women, in addition to providing full -time care for those who live with them, "also provide part-time care to aged friends and relatives elsewhere."42 This work will increase with de-institutionalization, given that women already account for more than three-quarters of those who do volunteer work in the health sector.43 Women also make up the overwhelming majority of those who are paid to provide health care services. In 1991,95 per cent of the registered nurses, 92 per cent of the registered nursing assistants, 83 per cent of the nursing attendants, 88 percent of the occupational therapists and 83 per cent of the physiotherapists in Canada were women. Overall, women made up more than three-quarters of all those in occupations in medicine and health. Nine per cent of all women employed in Canada are in health care occupations and these figures do not include the many who cook, clean, do laundry andsew in the health care sector.44 Overall, 16percentofCanadian women work in health and social service industries, while this is the case for only 3 per cent of the men.45 When the caring work is sent closer to home, it is primarily women who lose paid jobs, and they often lose them to women who are expected to do them in the home without pay and without formal training. Caring work is women's work. Given the division of labourthat exists at home and in the community, it is clear that closer to home will mean more work for women.

Can Women Care?

In 1993, women accounted for 45 per cent of the Canadian labour force,46 and 58 per cent of women over the age of 15 participated in the paid labour market.47 But participation rates were much higher for women in the middle age groups. Seventysevenpercentof those between theagesof25and44,and72percentofthose between 44 and 54 were in the labour force that year.48 More than three-quarters of employed women over age 25 had full-time jobs.49 It is the women between the ages of 25 and 54 who would have to take on most of the additional caring work but only a small minority of them are at home to do the job. Many of those who are not in the labour force are sick or in school, and therefore are unlikely to be able to take on significant amounts of extra work.

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Moreover, most of the women who have paid jobs have little choice about participating in the labour force. Most women work outside the home, not primarily because they want to fulfil themselves or because they can find stimulating and highpaying jobs or because they have changed their ideas about women's place. Most women do clerical, sales and service work, much of which is dull, repetitious and boring and most of which pays wages that are significantly below those of men.50 Indeed, women dominate the ten lowest paid occupations and account for only 20 per cent of those in the ten highest paid occupations.51 Most women take this paid work because they need the income. The proportion of families with both spouses employed in the market is highest for households in which the husbands earned between $10,000 and $20,000 in 1989. Fully 80 per cent of the wives in these households had paid work.52 One woman we interviewed clearly explained why she had a paid job.' 'If I didn 't work, we wouldn' t eat."53 Even with two incomes, 9 per cent of families were poor in 1986 and the proportionof families with twoincomes that are poorhasbeenincreasing.54 Without the income of women, many more households would have dropped below the poverty line. Indeed, even with two incomes, disparity among households has been increasing. Between 1973 and 1991,60percentofhouseholdsreceivedadecreasing share of total market income and this is even the case if all transfer payments from the government are included.55 Women are working in the labour force not just to maintain household income but also to prevent it from declining further. Few women work for 4 "extras.'' Among households with 1990 income of $25,000 or less, dual earner households were less likely than single earner households to have air conditioners, gas barbecues and cable television. Similarly, among households with incomes between $25,000 and $49,999, dual earners were less likely to own dishwashers, freezers and air conditioners.56 When women are asked about why they have paid jobs, the overwhelming majority say financial need.57 When compared to women with part-time paid work, somewhat more women employed fiill-time in the labour force give economic need as the primary reason for taking paid work. But a growing number of women are working part-time only because they cannot find full-time jobs and a majority of those employed part-time say they work for financial reasons.58 And a growing number of women not in the labour force are at home primarily because they cannot find paid employment. Their economic need is increasing as men's real wages fall and male unemployment rises.

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Paid work limits the timeand energy womenhave to take oncaring work in the home and in the community. The majority of women have full-time jobs and a growing proportion work more than 50 hours a week in the labour force. In 1990,6 per cent of employed women did 50 hours or more of paid work regularly.59 Such w7omenhave little time left to take on additional caring responsibilities. Moreover, many women who have paid jobs have irregular hours that make caring for others difficult. More than one in five women with a labour force job does shift work and more than a third of them have irregular schedules.60 Part-time employment does not necessarily solve the problem of scheduling time to provide care either, because many of these workers do not know their schedules ahead of time. Furthermore, many women who are counted as employed part-time have more than one part-time job. Almost half of those holding more than one labour force job were women and the number of women multiple job holders is increasing rapidly.61 Today, there are few women at home to take up additional caring work. Not only do the overwhelming majority of adult women have paid work, most of those with paid work have little choice about contributing to household finances. Most already do far more than a full day's work because they have two jobs. If proposals to make women on welfare seek paid employment are put in place, even fewer women will be available to provide such care.

At What Costs? To Women Caring work too often costs women in terms of their health, their social relationships and both their current and future employment possibilities. It usually costs them financially as well. Caring for the elderly and the disabled frequently means a 24-hour commitment.62 A U. S. study found that,4 'Of the overall caregiving population, 80 per cent provided unpaid assistance seven days a week.' "63 Three-quarters of these caregivers averaged at least four hours a day specifically devoted to caregiving tasks. Other research indicates that those who care for severely mentally handicapped children spend more than seven hours a day working directly with that child.64 Sleep is regularly disturbed and other chores around the house increase, especially if the person requiring care suffers from incontinence or vomits regularly. This work not only costs women a great deal of time and physical effort, it costs them emotionally as well. It is often more difficult to provide such intimate care to a close relative than it would be to a stranger, and the provision of such care often conflicts directly with past relationships. Many of those who are cared for are violent

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or abusive, subject to frequent mood changes and irritability. "Diminished emotional health is the most persistent finding of the caregiver experience. According to investigators, the level of depression in caregivers is higher than those found in normal populations.' '65 The stress may be particularly heavy for the many women whoalsohavelabourforcejobs. AConferenceBoardof Canada surveyfound that almost 40 per cent of those who combined paid employment with dual caregiving responsibilities experienced moderate to severe levels of stress and anxiety.66 The stress of caring often leads to physical illness as well. A variety of studies indicate that caregivers suffer from fatigue, headaches, inability to concentrate, hypertension, chronic obstructive lung disease, and an overall decline in physical health.67 A stud}' of mothers providing constant care concluded that the "greater vulnerability of the maternal caretaker to sickness because of the burden of caring fora chronically mentally ill adult child threatens both the functioning of the mother and the adult child."68 The stress also has an impact on relationships both in and out of the family. In an Ontario study of caregivers, a large proportion felt that the work limited their time alone with their spouses, prevented them from spending time with other family members and restricted their family vacation time.69 Although caring for others may bring a family closer together, it may also lead to ' 'marital discord, dissatisfaction or conflict.' '70 Caring for a chronically ill spouse can disrupt or destroy the marital relationship and caring for another family member disrupts usual family relations, increasing the tensions in the household.71 Caring can also isolate the caregiver from the outside world. The need for constant care may make it impossible to leave the person needing care alone. The abusive or assaultive behaviour of some dependents, mood swings and socially unacceptable behaviour in public places often make it difficult for women to leave the house.72 Other kinds of illness can mean that friends do not want to visit. At least 40 per cent of an Ontario sample said that caregiving interfered with their social life and prevented them from being involved in volunteer work or community organizations.73 Caring can also cost women jobs. This same Ontario study found that a significant proportion of caregivers had to take time away from their jobs in order to provide care. In 1993, more than eight times as many women as men lost an entire weekattheir paidjobs due to fc 'personal responsibilities.' '74 Women werealmost five times as likely as men to leave their jobs for this reason and thirty times as many women worked part-time because of "personal responsibilities.' '75 Moreover, in the Conference Board study,4 'Women were twice as likely as men to perceive that their

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advancement had been affected by their dependant-care responsibilities, and they were over three times as likely to say that their role in dependent care had affected theirjob advancement 'somewhat' or 'a lot V '76 When women leave the labour force in order to provide care, they severely limit their prospects for jobs in the future and reduce their access to pension funds as well. Caring also involves direct financial costs. It can involve the purchase of extra clothing, protective padding and linens; transportation costs and extra equipment; increased utilities costs and expensive foods.77 These costs may be rising just as family income decreases as a result of a man's illness and/or a woman' s withdrawal from the labour force in order to provide care. The high financial costs of giving care may help explain why the "rate of severe disability for every 1,000 children and youth was five times higher for those from families with the lowest incomes (3.0 per 1,000) than for those from families with the highest incomes (0.6 per 1,000).78 A Montreal study concluded that'4 maintaining the elderly in the community at all costs might in fact be at the expense of their caregivers.' '79 The same might be said of all caregiving in the community. Caring is expensive for women and may end up being expensive for the system if it results in women themselves becoming ill.

To Patients The forced intimacy' of care not only affects the caregiver, it also affects the care receiver. The dependency relationship itself can raise levels of tension and encourage depression that can inhibit recovery.80 Moreover, care by an amateur, no matter how much they care, may be dangerous toapatient'shealth. Today, informal caregivers are increasingly expected to handle complex equipment and procedures without receiving much formal training. The risk of causing temporary or permanent damage to the patient rises along with the skills required. If patients survive, they may end up back in the institution, increasing the costs of the system. While lack of training can lead to inappropriate treatment, the stress of caring work can lead to neglect or even abuse.81 Home care does not necessarily mean tender loving care, a "haven in a heartless world.'' Itmay simply mean basicneedsareprovidedfor. A study of elderly Canadian immigrants concluded that "Living with family may represent economic care, but not necessarily extensive social-emotional care. Largely custodial caregiving appears especially likely when the new immigrant elderly are in family settings in which all adults members are in the labor force.' '82 With most women now in the labour force, this is likely to be the case in most households, whatever their origin. Indeed, research indicates that there are very few differences among cultural groups in terms of the social support provided for the elderly.83

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Closer to home may at best mean minimum needs are met; at worst, it may be dangerous to the health of the elderly and the disabled.

To Employers

Caregiving can cost employers as well. In a Conference Board study of employers 6 'more than half of the respondents attribute one-quarter or more of their absenteeism and employee stress problems to work and family conflicts", although the majority "indicated that employees have the primary responsibility for finding solutions to work and family conflicts.'184 Another study by the Conference Board found that "In keeping with the earlier findings that women have the primary responsibilityfor dependents and home maintenance, agreaterproportionofwomen than m&i reported experiencing some problems during the previous year in meeting job demands...Furthermore, in terms of degree of difficulty encountered, women wereconsiderably more likely tosay thatthey had experienced 'major' or 'moderate' problems.' '85 Women were more likely to be absent or to leave their jobs as a result of their responsibility for dependents and this had an impact on employer costs in terms of time lost, training and the disruption to co-workers.

Conclusion Caring work is women's work and many women already do a great deal of this work outside the labour force, without pay. Given that most women have little choice about taking on paid work and that most have a range of domestic responsibilities, few have the time, energy or resources to take on the additional work implied by sending health care closer to home. Sending patients closer to home is justified in terms of better care and lower costs. It is the case that many people would rather be at home and some women would like to care for them. However, people do not necessarily receive even decent care in the home, in part because women are already so overburdened. Moreover, there are a whole range of hidden costs which may, in the end, serve to increase both the social and economic expense, especially for women. Under current conditions, closer to home conflicts with a commitment to equity in access to health.

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Notes Province of British Columbia, Ministry of Health and Ministry Responsible for Seniors, New Directions for a Healthy British Columbia, 1993, p. 11. 2 Ibid,p.l4. 3 See Douglas Angus,c 'A Great Canadian Prescription: Take Two Commissions and Call Me In the Morning", Pp. 49-62 in Raisa Deber and Gail Thompson (eds.) Restructuring Canada's Health Services System. (Toronto: University of Toronto Press), 1992. 4 Neena Chappell, Laurel Strain and Audrey Blandford, Aging and Health Care, (Toronto: Holt Rinehart and Winston, 1986), p.67. 5 Anne Martin Mathews, "Response to Papers" in Family and Community Supports Division, Statistics Canada, Caring Communities (Cat. no. 89-514E), (Ottawa: Supply and Services Canada, 1991), p. 232. 6 Elaine Brody and Claire Schoonover, "Patterns of Parent-Care When Adult Daughters Work and When They Do Not", The Gerontologist 26(4), 1986, p.372. 7 Chappell et al. ^Statistics Canada, Highlights: Disabled Persons in Canada/Health and Activity Limitation Survey (Cat. no. 82-602). (Ottawa: Supply and Services Canada, 1990). 9 Judith Dowler, Deborah Jordon-Simpson and Owen Adams, "Gender Inequalities in Care-giving in Canada'' Health Reports 4(2, October): 133. See also Janet Hagey,' 'Help Aroundthe House: Support for Older Canadians ",Canadian Social Trends, Autumn, 1989. ^Statistics Canada, The Health and Activity Limitation Survey, Subprovincial Data (Cat. no.82-608), 1989, Tables 1 and 2. "Mathews. 12 Dowleretal.,p.l33. 13 JillianOderkirk,"Disabilities Among Children.'' Canadian Social Trends, Winter 1993, p.23. 14 Ruth Gallop, Patricia McKeever, Ann Mohide and Donna Wells, Family Care and Chronic Illness: The Caregiving Experience. A Review of the Literature. Mimeo. Health and Welfare Canada, n.d., p.2. 15 See Ibid, p.2. 16 Oderkirk, p.24. 17 Statistics Canada, The Daily, May 31,1988, p.5. 18 0derkirk, p.23. 19 Each year, in my 75 member Sociology of Health and Illness class, I ask my students to interview family members about what they do when they are sick. Each year, the overwhelming maj ority indicates that they see doctors as a last resort, and this is particularly the case for those in the younger age groups. 20 See Richard Burzynski, "AIDS: A Community-based Response" in Caring Communities, Perspectives on AIDS, eds. Christine Overall and William Zion (Toronto: Oxford University Press, 1991) p. 50. 21 Christine Overall and William Zion,''Introduction", in Christine Overall and William

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Zion (eds.) Perspectives on AIDS, (Toronto: Oxford University Press, 1991), p.v. 22 Judy Krueckl, t4 A Comparison of Psychosocial Needs of Persons with AIDS and Canada's Aging Population" in Caring Communities, op cit., p. 108. *Chappell,etai.,p.67. 24 Gallopetal.,p.l2-13. ^Ibid^.lO 26 Anita Fochs Heller, Health and Home: Women as Health Guardians. (Ottawa: Canadian Advisory Council on the Status of Women, 1986), p.43. 27 Ontario Ministry of Health, Building Partnerships in Long Term Care; A New Way to Plan, Manage, and Deliver Services and Community Support, (Ontario: Queen's Printer for Ontario, May 1993):7. ^See, for example, Haya Ascher-Svanum and Ten Sobel, "Caregiving of Mentally Dl Adults; A Woman's Agenda' ' Hospital and Community Psychiatry 40(8, Autumn):843845,1989; Joan Anderson and Helen Elfert, "Managing Chronic Illness in the Family: Women as Caretakers", Journal of Advanced Nursing 14:13 5-743, 1989; Carol Baines, Patricia Evans and Sheila Neysmith (eds.), Women 's Caring. (Toronto: McClelland and Stewart, 1991); Gallop, op cit; Karen Whalley Hammell, "The Caring Wife: The Experience of Caring for a Severely Disabled Husband in the Community'', Disability, Handicap and Society 7(4)349-362, 1992; Heller, Judith MacBride, Work and Family: Employment Challenge of the '90s. (Ottawa: The Conference Board of Canada, 1990); H. PizurskL A. Butter and L. Ewart, Women as Providers of Health Care, (Geneva: World Health Organization, 1 988); Robyn Stone, Gail Lee Cafferata and Judith Sangi, c ' Caregivers of the Frail Elderly: A National Profile" TheGerontologist21(5):6\6-626, 1987. Parnel Wickham-Searl, c 'Careers in Caring: Mothers of Children With Disabilities", Disability, Handicap and Society 7( 1 ):5-l 7, 1 992. 29 Gallop, op cit., p.9. 30 See, for example, Susan Clark and Andrew Harvey, c ' The Sexual Division of Labour: The Use of Time" Atlantis 2(1, Fall):46-65, 1976; Tony Haddad and Lawrence Lam, "Canadian Families—Men's Involvement in Family Work; A Case Study of Immigrant Men in Toronto ' ' , InternationalJournal ofComparative Sociology 1 989\ Meg Luxton, More Than a Labour of Love, (Toronto: Women's Press, 1 980); Andrew Harvey, Katherine Marshall and Judith Frederick, Where Time Goes (Cat. no. 1 1-612E) (Ottawa: Supply and Services Canada, 1 991 ); Martin Meissner, Elizabeth Humphreys, Scott Meiss and William Scheu, "No Exit for Wives: Sexual Division of Labour and the Culmination of Household Demands", The Canadian Review of Sociology and Anthropology 12(4, Part 1, November):424-439, 1975; William Michelson, From Sun to Sun: Daily Obligations and Community Structure in the Lives Employed Women and Their Families, (Ottawa: Rowman and Allenheld, 1 985); Roxanna Ng and Judith Ramirez, Immigrant Housewives in Canada, (Toronto: Immigrant Women's Center, 1981); Peter Sinclair and Lawrence Felt, " Separate Worlds; Gender and Domestic Labour in an Isolated Fishing Region' ' Canadian Re\>iew of Sociology and Anthropology 29(1, February):55-71, 1992. 31 Eugen Lupi, "Fathers in Transition; The Case of Dual-Earner Families in Canada" in

Closer to Home / ]Q9 Jean Veevers (ed.) Continuity and Change in Marriage and Family, (Toronto: Holt, Rinehart and Winston, 1991). 32 MacBride, op cit., p. 9. 33 Ibid,p.l3. ^Claire Goodman,c" Research on the Informal Carer, A Review of the Literature'', Journal of Advanced Nursing 11:705-712, 1986. 35 Heller op cit. p. 59. 36 Brody and Schoonover op cit. p.375. 37 See Harriet Lefley, "Family Burden and Family Stigma", American Psychologist 44(3):556-560, 1989. 3S Ben Gottlieb, The Family Support Project. Feedback Report, (Guelph: University of Guelph, Department of Psychology, 1990). 39 Heller, p.53. ^Leroy Stone, Family and Friendships; Ties Among Canada's Seniors (Cat. no.89-508) (Ottawa: Supply and Services Canada, 1988, p.46). 41 Doreen Duchesne, Giving Freely- Volunteers in Canada (Cat. no. 71-535) (Ottawa: Supply and Services Canada, 1989; Table 16). 42 Heller, p.43. 43 Henry Fold,' 'The Gift of Time", Perspectives on Labour and Income 2 (2, Summer): 44, 1990. "Calculated from Statistics Canada, 1991 Census, Occupation (Cat. no. 93-327) Ottawa: Supply and Service Canada, 1993, Table 1. 45 Statistics Canada, 1991 Census, Industry and Class of Worker (Cat. no. 93-326), (Ottawa: Minister of Industry, Science and Technology, 1993), Table 1. 46 Calculated from Statistics Canada, Labour Force Annual Averages (Cat. no.71-220) Ottawa'. Supply and Services Canada, 1994, Table 1. 47 Ibid, Table 1. 48 Ibid, Table 1. 49 Ibid,Table2. 50 See Pat Armstrong and Hugh Armstrong, The Double Ghetto: Canadian Women and Their Segregated Work Third Edition. (Toronto: McClelland and Stewart 1993). Statistics Canada, The Daily, April 13,1993. 52 Raj Chawla, "The Changing Profile of Dual-Earner Families." Perspective on Labour and Income 4(2, Summer):22, 1992. 53 Pat Armstrong and Hugh Armstrong,^ Working Majority: What Women A/fust Do For Pay. (Ottawa: Canadian Advisory Council on the Status of Women, 1990), pp.23 and 65. M Morley Gunderson, Leon Muszynski and Jennifer Keck, Women and Labour Market Poverty, (Ottawa: Canadian Advisory Council on the Status of Women, 1990), pp.23 and 65. 55 Social Planning Council of Metropolitan Toronto, Infopac 72(1, February) 1993. ^Statistics Canada, Characteristics of Dual-Earner Families 1990 (Cat. no. 13-215) (Ottawa: Supply and Services Canada, 1992), Table 16. 57 See, for example, Armstrong and Armstrong, 1983 op. cit.; Michelson op cit. 58 Ann Duffy and Norene Pupo, Part-time Paradox, (Toronto: McClelland and Stewart, 1992), p. 155.

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Gary Cohen,'' Hard at Work", Perspectives on Labour and Income 4(1, Spring):8,1992 ^Deborah Sunter,'' Working Shift", Perspectives on Labour and Income 5(1, Spring): 17, 1993. 61 Maryanne Webber, "Moonlighters", Perspective on Labour and Income, 1(3, Winter)^ and 25, 1989. 62 Hammel, op cit, p.352. 63 Stone, Cafferta and Sangl, op cit., p.621. ^in Gallop et al., op cit., p. 11. 65 Ibid,p.l7. ^MacBride, op cit., Table 26. 67 Ibid,p.l9. 68 John Belcher, "Mothers Alone and Supporting Chronically Mentally 111 Adult Children: A Greater Vulnerability to Illness", Women and Health 14(2):79, 1988. 69 Gottleib. 70 Anne Davis, "Disability, Home Care and the Care-Taking Role in Family Life'', Journal of Advanced Nursing 5:480, 1980. 71 Gallopetal.,p.20. 72 Lefley,p.557. 73 Gottlieb. 74 Calculated from Statistics Canada, Labour Force Annual Averages (71-220) (Ottawa: Minister of Industry, Science and Technology, 1994), Table 24. 75 Ibid, Tables 19 and 33. 76 MacBride, p.22. 77 MacBride, pp.11 and 22-23. 78 Oderkirk, p.25. 79 Sylvie Jutras and Frances Veilleux, ''Informal Caregiving: Correlates of Perceived Burden'', Canadian Journal on Aging, 10( 1), p. 50, 1991. ^See R.K.Goodstein "Inextricable Interaction: Social, Psychological and Biological Stresses Facing the Elderly" American Journal ofOrthopsychiatry 51:219-229,1981 for a discussion of this issue in relation to the elderly. 81 Benjamin Schlesinger andRachel SMesinger, Abuse of the Elderly, (Toronto: University of Toronto Press, 1989). ^Monica Boyd, "Immigration and Living Arrangements: Elderly Women in Canada", International Migration Review 25(Spring):24, 1991. ^Barbara Payne and Laurel Strain,' 'Ethnic Variations in Family Support of the Elderly'' in Caring Communities; Perspectives on Aids, pp. 125-131. ^Helene Paris, The Corporate Response to Workers With Family Responsibilities, (Ottawa: The Conference Board of Canada, 1989), p.ix. 85 MacBride,p.25.

Epilogue: Listening to the Voices from the Ward Voices from the Ward is a pilot study that set out to investigate stories that were raised at a conference in 1992. It was partnership funded research, designed to explore the understandings of a quota sampled group of hospital workers geographically and structurally representative of the types of institutions in Ontario's hospital sector. We believe strongly that the "Voices" we report have a unique and important contribution to make to the debate concerning the restructuring of hospital care. We must admit we have been overwhelmed by the degree of support our research has received. There have been dozens of newspaper articles, television and radio reports, editorials and public support statements. People working in the system including hospital workers in several unions, nurses, some physicians and other stakeholders have lent support through their commentaries. The breadth and depth of interest in the 4 ' Voices'' is understandable. The report touches on the personal. Citizens see health-care as a social good and feel attached to its preservation. Hospitals are a place where people go to receive a service used by their family and friends, and this also touches those who work in the system. Understanding this reality helps to account for the response that we have seen to Voices from the Ward. This epilogue, then, has a simple task. It is to introduce the readers to some issues pertaining to how we conducted the research leading to Voices from the Ward .

Who are the "Voices"? First, the ''Voices" are largely women. More than three quarters of all hospital workers are women. It is interesting that the caregivers and general hospital workers represent a segment of society who are not often listened to or heard. Women have

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in many circumstances been set aside as voices of protest, voices of concern and voices of change. The second characteristic of the people who were the ' 'Voices'' is their jobs. These are people who come from the' 'underside'' of the hospital, people whose opinions are not often sought out, and are sometimes even dismissed. Who understands best what it means to clean a hospital, or prepare the nourishment for the patients? Who could judge best if they have been given more say in the running of hospitals? Who are the experts? If you want to understand the reality of the hospitals that we examined, it is best to listen to those who do the work.

Choosing the Proper Research Approach Method, method- who's got the method? There are few i ssues that are of more importance to the scholar than the selection of methodologies for scientific investigation. We chose to use a.qualitative method to gather our data. That is significant because at this time in Canada there is a predisposition to believe that quantitative methodologies are "more accurate" or "more scientific". This is not correct. We may make many divisions or distinctions in the science of inquiry. There is a school of thought that says that there is a difference between appearance and essence, holding a priori that there are structures that may be unknowable and may be at least unmeasurable. This tradition may be said to include Kant and structuralists such as Levi-Strauss, and perhaps even Chomsky. There are many problems to be explored that require us to seek the perceptions, opinions and understandings of the human beings involved. There are traditions often labelled "empiricist" and "positivist" that operate scientifically with the view that there is an observable world separate and independent from the thoughts, understandings, perceptions and the consciousness of those who operate in it. A world that can be measured with little or no bias or subjectivity. Dewey and B. F. Skinner are part of this tradition. This is the quantitative/experimental approach. How does one choose which approach to use?

Qualitative and quantitative methods- what's at stake? The underlying assumptions about the nature of reality, the relationship of the knower to the known, the possibility of objectivity and the possibility of generalization inherent in each approach, are different. The debates over these

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issues and the exploration of their potential has preoccupied a proportion of the work of the academy for many decades (see Karl Mannheim 1975 and W. James 1947). "The adequacy of a research method depends on the purpose of the research and the questions being asked" (Seidman 1993:5). Bertaux(1981:39) argues that it is wrong to apply the methods of the natural sciences (ie. the experimental and quantitative) to all situations in the social sciences. He notes, "The subjects of inquiry in the social sciences can talk and think. If given a chance to talk freely, people appear to know a lot about what is going on'' (Ibid). When depth and richness in the research findings are the goal, or the purpose is to find the direction of the underlying processes, then qualitative methods such as those used in ' 'Voices'' are the most appropriate. (Marshall, C. and Rossman G., 1989.) We would argue that uncovering experiences is an important method for gaining data. The challenge is to get people to relate their experiences and to develop a method of analyzing the information.' * At the root of in-depth interviewing is an interest in understanding the experience of other people and unravelling the meaning of that experience. One first must believe that the stories and experiences are "of worth.'' (Ibid.) The issues we were exploring had an important social dimension and because they involved a wide range of '* 'variables'' which interact and change, we knew that it would be necessary to use some form of qualitative investigation. If we return to the "Voices" for a moment, the point can be made. The "Voices" say that food in the hospitals is of lower quality as the institutions move to prepackaged products (quality is a perception as well as an absolute). Examining rice pudding for example, you could measure the calories and assess the vitamin and mineral levels of a packaged pudding verses one that is home made. You might conclude that both are the same, but if the patients are telling the dietary aids or others that they do not like the packaged pudding and the packaged pudding is being returned uneaten, then what do we conclude? You have to investigate the problem with the deliverers of health care. We did not seek to measure precisely the amount of change, but rather to capture the trends and direction in which things were moving. Interviewing techniques were the most appropriate and among the techniques open to us, (see White 1990) we chose the focus group.

The Focus Group The focus group is essentially a group interview which has the added advantage of increased validity. Multiple informants interact, adding additional information, and they verify each others' claims. This method had a rather prestigious

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start in sociology when Robert Merton examined the effects of wartime propaganda (Morgan 1988). Merton continued to develop and defend this tool well into the 1980s (Merton 1987). For the social scientist, focus groups are useful either as' 'a self contained means of collecting data or as a supplement to both quantitative and other qualitative methods.'' (Morgan 1988). There are some who would feel obliged to critique the "Voices", .."many of the concerns appear to be anecdotal... We want not anecdotal [sic], we want quantifiable information" (Windsor Star Feb. 10: A2). Morgan (1988:10-11) articulates our social scientific understanding: " The discussions of focus groups in marketing research too often gives the impression that the focus group must always be used in conjunction with quantitative methods ... The validity of this argument rests solely on the purposes that one intends for one's research. In marketing these purposes are largely limited to making accurate projections of future sales for new or revised products; for this purpose representative sampling with standardized survey questionnaires is quite useful. Social science research is not, however, limited to such narrow goals, and there is no a priori reason to assume that focus groups, or any other qualitative techniques, require supplementation orvalidation with quantitative techniques.''

Exploring Subjectivity Are the Voices Subjective? As with any research we had to confront the issue of subjectivity. How do we ensure that we are, as faithfully as possible, avoiding subjective influences? Pyke and McKagnew (1991:134) note that "Some... decry the use of qualitative approaches because of their alleged sensitivity to subjective influence' ' Who qualifies to be a voice and speak and who qualifies to listen to the "Voices"? Does subjectivity contaminate the "Voices" research? The question is, are those who have direct on-going experience disqualified from being objective? We would say 'no'. We would not argue that personal experience in observing events is a guarantee of truth. We all have fallible senses and our interpretation of events is shaped by our experiences. The "Voices",for example, have experienced upheaval in their workplace anduncertainty due to fiscal pressures at their workplace, not to mention the technological, managerial and structural changes at work (see Armstrong, Choiniere and Day 1993; and White

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1993). This has had an effect on their perceptions. However, this is not a bad thing — it is a good thing. This is what we are trying to hear from the ' 'Voices'' — their understanding of the changing environments in their institutions. There are no objective observers. Patients stay a short time and they may have no previous experience in a hospital to act as a reference for comparison. Managers who make decisions on policy and rules, procedures and protocols often feel that they must stand by their decisions to avoid losing pride, power, credibility or rewards. We made the simple assumption that those who worked in the hospital environment for many years had a unique and important view of changes and the effect of those changes. It is our considered opinion that the sample was diverse and approximated the natural setting. Our team used a modified quota sampling method (see Krause and Miller 1974:36) seeking interviewees via local key informants (White 1990:136-140) that reflected the population characteristics we needed for breadth of experience and comparability across groups. We chose to use our groups in a range of hospitals that approximated the different pressures and structural constraints (ie; northern and southern, urban and rural, medium and large). The interview schedule (ie; questions asked) was pre-tested and carefully prepared in order to avoid the pitfalls of drawing out expected responses. The research method always limits the possible claims one can make. We have been careful to explain that these were workers' views, albeit very experienced workers who shared many experiences. We concluded after analyzing the data that "our major point is that we need to monitor the impacts of the cutbacks within the health sector keeping in mind what are the determinants of health... It is not a criticism of particular hospitals, but a warning..." (Hospital News, March 1994:1 and 7). We did not think there was a need for panic. Rather the trends we uncovered indicated that the situation should be monitored in order to avoid a very serious situation (Financial Post Feb. 10-94:55). The fact that the study was funded by the unions as well as the Ministry of Health and York University has raised some questions (Timbrell Interview Radio Noon CBC Radio, 11 Feb. 1994; Ontario Hospital Association quoted in Windsor Star Feb. 10-94: A2). The use of partnerships in funding is an approach that the Social Science and Humanities Research Council and the Ontario Government advocate. The test of credibility comes from the influence that the funding agencies have on how the research is done and how the data is analyzed. In the case of the ''Voices" research, no outside institutions participated in any way in the analysis

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of the transcribed focus group interviews. We remain pleased that the unions provided assistance when asked for potential hospitals and methods of contacting possible interviewees.

Conclusion The subject chosen by the research team is a direct reflection of the academic and social predispositions of the researchers. The results are the consequence of the topic of inquiry and that does reflect our social and humanist bias. Myrdal once said6" As social scientists we are deceiving ourselves if we believe that we are not as human as the people we study" (Myrdal 1969). We are scholars with a social conscience. That is why we chose to study what we did. As C. Wright Mills noted " there is a politics of truth" and the choice of what issues to do research on is a political act. As we noted. Voices from the Ward is a pilot study which has raised a tempest in a very important teapot. This pilot study was partnership funded research, designed to explore the understandings of hospital workers and give voice to their perceptions. We conclude that the "Voices" are warning us that the hospitals have suffered tremendous reductions in resources. These cuts in funding and new initiatives must be monitored in light of their effect on the people working in the institutions, the care delivered to the patients and the environments of those institutions. The trends identified in the focus groups are reflections of more systemic trends, and care must be given to evaluate the potential problems. Jerry P. White, April 1994.

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