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PREFACE The findings in this report are the outgrowths of a study commissioned by the Health Resources Administration of the Department of Health, Education, and Welfare. The Health Resources Administration, which is charged with the responsibility for administering the health planning program, asked the Institute of Medicine to examine the process by which national health planning guidelines--defined in the planning Act as health planning goals and resource standards--might be developed and to make recommendations for improving the process. The importance and breadth of these questions led the Institute of Medicine to set up a multidisciplinary committee to consider the issues. The committee began its deliberations with an open meeting at the National Academy of Sciences on March 1, 1979. This report contains the committee's findings at this stage of its examination. Recognizing that many important areas of inquiry could not be touched upon, let alone carefully reviewed, in the short period of time available since March 1, the Health Resources Administration and the Institute of Medicine have agreed to continue the study in a second phase. This report should not be read as a complete examination of all important planning issues. Rather it represents a "first cut," the report of the first phase of the committee's worke It represents the conceptual framework for our examination of the health planning program, examines some of the issues within the health planning program, offers a series of recommendations that are designed to increase the effective- ness of the planning and national guidelines efforts, and lays the foundation for the work of the second year. A major aim of this committee has been to understand and try to describe the role of health planning in the United States, and to underscore both its promise and its problems. Programs with the type of intergovernmental relations as found in health planning are particularly hard to evaluate and judgments concerning their effectiveness are difficult to make on the basis of quantitative information and in the absence of scientific evidence. That is certainly the case in the early years of program activity, years in which major efforts are undertaken to develop the necessary infra-structure and to strengthen processes. For a period of time, judgment by informed observers and scholars must substitute for formal quantitative evaluations. Similarly, for a period of time, while programs are taking root, there is a danger that expectations will be unrealistic. Rome was not built in a day; vii
diseases are not cured with the first dose of penicillin; planning is not accomplished with a single stroke. On the basis of its examination it is the committeets judgment that health planning can play an important role in ensuring a balanced, equitable, and cost conserving allocation of health resources at local and state levels. It is in that spirit that this report has been prepared. The committee did not formally evaluate the program, but after examining its history and the policy problems that helped to spawn the program, it is the committee's judgment that health planning of this type is a plausible approach that should be sustained at this time. This does not mean that the planning program in the field and in Washington cannot be improved. While endorsing the overall approach as promising, the committee recognizes that in its operation it does not always function smoothly. Changes will undoubtedly be warranted in the future but should be made on the basis of knowledge--not specula- tion. This committee believes that the availability of solid information and good research are essential ingredients in the effectiveness of any health planning activity and the committee urges increased attention to the development and funding of studies that will expand the knowledge base for planning and accelerate the dissemination of such knowledge. This report is not written primarily for individuals heavily involved in the planning program at state and local levels. A major audience is the group of health policymakers in Washington. While the activities of planning take place at local and state levels, many decisions about the character and structure of the program are still made in Washington. It is hoped, however, that others in state and local communities who are not directly involved in the program will also find parts of this report informative. The health planning Act attempted to accommodate federal needs into planning activities that would take place at a local level. Guide- lines can make manifest the goals and objectives of the health system that Americans want, but their development uncovers the lack of consen- sus about the specific direction that reformation should take. The development of guidelines, then, is not predominantly a simple technical process; guidelines may instead reveal our national policy ambivalences and ambiguities. The report that follows is the product of the committee. This preface, however, is written by the Chairman. It provides me with a welcome opportunity to express my deep appreciation to all members of the committee for their diligence, sustained effort, and thoughtful and rapid response to inquiries, drafts, and other written documents. They were willing to adjust their schedules in order to accomplish this first phase within the prescribed time limits. Clearly, this willingness stemmed from their recognition of the importance of · . . vet Il
the inquiry. But to have done all of this in a manner that made the life of the Chairman pleasant and the committee meetings stimulating and enjoyable--that speaks to the personal characteristics of each of my colleagues. All of this, however, would have come to naught had staff support under the leadership of Helen Darling not been superb. I particularly want to thank Helen Darling. Only the Chairman and committee members can fully appreciate her strengths, which include substantive knowledge, organizational ability, and general unflappability. I know I write for all committee members when I express my thanks. In addition, appreciation is due to other members of the staff who provided valuable background papers for the deliberations of the committee. Carolyn Kohn prepared a paper on Access to Health Care. Jeanne Holzgrefe wrote a paper on Long-Term Care for the Elderly. Sunny Yoder prepared a paper on the Configuration of Hospital Services. Jana Surdi produced papers on Selected International Experiences with Health Planning Guidelines and on Selected Activities of Planning Agencies. Each of the papers was helpful to the committee's understanding of the com- plexities of developing national guidelines a The papers gave consid- erable substance to the discussion in Chapter III, on national guidelines. Bradford Gray prepared a paper on process issues that contributed substantially to the committee's work on Chapter V. On behalf of the committee, I want to express sincere appreciation for their efforts and support. Rashi Fein 1X