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It is intriguing and disheartening to review this book at a time when the management of human resources and industrial relations in British Columbia health care has been thrown into utter turmoil by the Gordon Campbell Liberal government. The book, a probing critique of the former NDP government’s health care reform policy, has been overtaken by events.
The new government has torn up collective agreements and accords between management and labour, destroying the most advanced labour adjustment program in Canada. And what domain in the work world cries out more for effective adjustment? The government is in the process of sending collective bargaining and labour standards legislation back almost to industrial prehistory. It has closed health care facilities and proposes to privatize others without union successor rights. Prospective private employers have been exposed endeavouring to eliminate the more militant unions from the new labour scene.
Certainly this plays havoc with the lives of health care workers. But it also makes life very difficult for researchers actively studying those lives. Such is the nature of health care reform in Canada that just when you think you have accurately described the situation, everything changes.
Veteran health care scholars Pat and Hugh Armstrong have become well-known for their attempts to investigate health care reform in a novel fashion, a method few others have even cared to employ: they speak directly to the workers delivering the care. In a series of publications in the last decade, the Armstrongs and several associates have sought out the opinions from those on the front line—patients, families of patients, nurses, LPNs and others. These are truly the (to use a phrase devised by these authors) “Voices from the Ward.” In their most recent book Heal Thyself, these researchers set out to investigate British Columbia nurses’ evaluation of the progress of the health care reform through the nineties. They take as their point of departure a series of seminal documents that began the process of reform in that province.
The 1991 report of the British Columbia Royal Commission on Health Care and Costs, Closer to Home provoked the Ministries of Health and Seniors to prepare a health reform strategy entitled “New Directions.” These documents mandated the integration of the separate subsectors of health care (acute care, long-term care, mental health, public health and home care) and the devolution of control downward from government and upward from institutions to new regional health authorities. In addition, the strategy identified five major components of reform: a focus on prevention; greater public participation and responsibility; a move away from institutions and toward the home and community; respect for the health care provider; and more effective management of the health care system. Heal Thyself holds those five directions up to scrutiny, both by the authors and by a group of British Columbia registered nurses working in several health subsectors. The reason for going after nurses’ opinions is straightforward, in the words of the authors: “Registered nurses make up the bulk of the health care labour force. In 1997, there were more than 200,000 registered nurses employed in Canada and three-quarters of them provided direct care in institutional settings. They not only experience the impact of reforms directly in their daily work, they are also often in a better position than doctors, policy makers or managers to see and assess the impact on the patients in their care. RNs have more regular and prolonged contact with patients and their families than do the physicians who direct the care or the managers who supervise the system. As a result, they are in a position to provide valuable assessments of management claims.” And the new health care system is nothing if not a management-driven system, insist the authors, where more and more institutions and providers come from the private sector, and public institutions are increasingly run on a private sector model, with an emphasis on efficiency.
Despite the change of government, the book’s main thrust may still be extremely relevant as the Liberals have altered the intensity of change, but perhaps not its direction. One of the most valuable features of the book is its careful concentration on how health reform affects women: women as workers, women as patients, women as the “voluntary” (read unpaid) caregivers of last resort out in the community. This is partly because the two introductory chapters first appeared as a paper for the Working Group on Women and Health Reform. On the other hand, this also gives the book a disjointed feel. It jumps from a discussion of the international and national context of health reform right into the results of interviews with nurses’ focus groups. Compact as the book is, it has the feel of two different books, moving peremptorily from very broad to very narrow. Although the authors take pains to present advantages as well as disadvantages of health reform, in some cases they do not give enough information to justify either, but especially the latter. For instance, their critique of “evidence-based medicine” is too brusque for a challenge so provocative of a notion so seemingly reasonable. It may well be true that “evidence may be used more to control and limit than it is to improve quality...”, but the critical reader yearns for more, well, evidence, of this assertion. Likewise, though the comments of the nurse interviewees are cogent, one wishes that the authors had done even limited verification to solidify the analysis. For example, the authors report “nurse after nurse” stating that infection rates in hospitals are rising because of cutbacks in housekeeping. While most readers would be ready to believe this assertion, both the statistics and the causation could easily have been corroborated.
Parenthetically, it would be remiss not to reproach both the authors and the publisher for the absence of an index, a complaint that is not exclusive to this book and this publisher. If one is producing serious social science publications, to which readers might wish to make further reference, the absence of an index is inexcusable. Notwithstanding these complaints, there is more than enough in this book to worry a reader about the consequences of health care reform on workers, patients and their families, even before the change of government.