nui
ONE COORDINATOR'S VIEW

In view of the foregoing budget discussion, why do we submit these
new projects at this time?

Much has been said prior to the recent cuts about the need to create
an overall consistent program for each region that meets its unique needs,
involves its resources to the fullest extent, defines objectives and sets
priorities, implements solutions, and evaluates results. Originally,
this program was to be built upon cooperative arrangements which would
lead eventually to regionalization of services that in turn would lead
ultimately to the availability of equally high quality medical services
to all citizens, no matter where they might reside. It was an admirable
and ambitious goal.

Further, we believe that the first, second, and part of the third
year development of our programs aimed directly at this goal. The major
thrust of our early proposals was to focus on a medical center or other
facility that provided high quality care, and through cooperative arrange-
ments, provide a system for the higher skills to radiate out, essentially
through training experiences, first to the closer-in facilities and
personnel, and eventually to all in the region who could profitably bene-
fit from such arrangements.

Although we received some mild criticism for this approach, that is
for not beginning projects on a regionwide basis, we still believe that
in most cases it was appropriate to begin in a center of high quality
and expand out geographically in stages to the regional boundaries. Like
the radiating out of ripples caused by dropping a stone in placid water,
it provides a more effective way of disturbing the calm of the water than
does the attempt to blow up waves over the entire pond all at once. This
is especially true since manpower has been more difficult to acquire at

_the beginning of the projects; but as time passed, generally more became
available, thus permitting gradual but effective expansion.

Most of our early projects were capable of this type of expansion.
Less than three years ago, when there was still hope that the program
would eventualiy be funded at near the $500 million level, we talked of
expanding our CCU training efforts into a regionwide coronary care system,
of greatly expanding ICU training for small hospitals, of training stroke
teams first in the larger Central Valley hospitals and then in the Coastal
and Sierra area. Although projects to accomplish these goals originated
in separate CCRMP areas, regional project coordinating committees were
later established. They developed regional goals For their categorical
problem, as well as shared their project experience among themselves and
with the areas lacking funded categorical projects.

We hoped that dosimetry linkages, tumor board activities and related
referrals eventually could be developed in a uniform pattern from our
“Ra

bases‘in the Bay Area and the Los Angeles metropolitan area. After the
Area I dosimetry planning and consultation project was funded, project
‘staff helped Area III with its planning for a similar project with the
intent that the San Francisco and Palo Alto centers could blanket the
outer areas of Northern California. The Area III project for the other
part of this plan was approved, but funds are not available to initiate
it. Similar planning for Southern California developed much further
than will ever be realized by persons not involved. Those who had worked
on these plans decided that it would be a waste of their time to write
their plans into an application when potential for funding seemed non-
existent. We saw, in essence, a series of systems, each relating to
specific disease areas, that would eventually expand throughout the
region.

Circumstances, however, never allowed these plans to mature. As
the possibility of support for an appropriation adequate to fund this
kind of planning and development faded, our hopes of developing systems
devoted to quality care along disease categories began to falter. As
the national health priorities became more of a factor, as the argument
over “primary care" developed and peaked, as the argument ensued over
how to extend and administer RMP, CHP and Health Services R and D, as
the enforced and ill-timed carryovers of funding were announced, it
became abundantly clear that support for the development of quality care
as we had perceived the intent of RMP would receive less than enthusias~
tic support from HEW health policy makers.

We were always acutely aware that the National Advisory Council
wanted each Region to develop an overall program to which each project
could be related. Part of the approval process was based on each project's
relation to the overall program,which in our case is described in our
first set of objectives. But we also perceived, with some misgiving, that
to pursue this course exclusively would be futile and further, we had an
obligation to attempt to implement certain of the national priorities,
although they might not be consistent with the overall thrust of our re-
gional objectives.

By the time we had come to these conclusions, the need to develop
objectives for the Developmental Component had become apparent. ‘Thus,
in drawing these objectives, we had the opportunity to mold them in the
image of the national priorities. This created a document, and a program,
quite different from that created by the original objectives. Since you
cannot turn planning efforts and funded projects on and off like a water
spigot, and since some in the program resented deeply this change in
emphasis, we begin to develop not an extension of the past consistent
program but instead a bifurcated program going down two paths at once.
The main difference was that one program was accelerating; the other de-
celerating. To be sure, we had pieces in our older program that could
be classified under the new objectives, but there was a very definite
change in emphasis. Later a site visit team reviewed both sets of objectives
and the National Advisory Council approved them.

- 10 -
It does, however, create a situation comparable to two artists
painting a picture on the same canvas. If they are both painting the
same picture, which is unlikely, or if they are cubists, it might work
out. Ordinarily though, it would have a sad effect on symmetry and
you would probably end up with Whistler's Mother rocking on the Sea of
Galilee.

To mix up the metaphors a bit further, it's like the pieces of two
jigsaw puzzles all mixed together in the same box, and with a few pieces
for each puzzle missing. Some of the pieces are even distorted, because
of the cuts they have taken. And so it is with our program in the
California Region. You have to work a little bit harder to relate the
pieces, but above all, you have to be aware of the fact that there is
more than one puzzle in the box.

Had all this not happened, had we been able to utilize the entirety
of our funds, our people, and our planning momentum for the original
objectives, we were near the time when our initial diverse project and
core efforts could be collected to form this overall regional program
which the National Advisory Council always urged us to develop. Not
only had some of our specific categorical activities neared this stage,
but so had our decision-making capacity.

As stated above, the Region had first prepared categorical objec-
tives. The early experience in some of the projects and project
coordinating comnittees and other experienced planning groups provided
capacity in this Region to take the categorical objectives and write
down activity plans to achieve the objectives. The Region's evaluation
personnel had developed a system for reporting data about progress and
achievement in the funded projects. The Region's review process had
reached maturity to judge the technical merits of proposals. The inevi-
table coming together of these factors was the capacity for achievement
of what RMP was all about. The CCRMP could have evaluated experience,
applied the results to decisions about the plans (no longer isolated
projects), then closely monitored the progress.

Since ail this was never allowed to reach its logical conclusion,
this submission represents at least three, and perhaps four, separate
thrusts. Prior to the beginning of the current CCRMP review cycle, there
were twenty-one proposals for consideration. After the review process,
the enclosed twelve emerged as approved by CCRMP. This round of reviews
was the most thorough to date. Those involved in them felt that the
process had matured and was producing adequate, consistent results. But
what has to be noted is that there appears to be more of a heterogeneity
than a homogeneity about the pieces of our program now. Although it may
be temporary, at this time we seem to be going in at least two different
directions, at different levels and different speeds, and apparently
serving different masters.

We feel certain that any site visit team will want to inquire about
this. It has concerned us to no lesser degree, but in all honesty, the

-11-
reasons relate to the fact that we have attempted to anticipate and to
meet changes in direction of the program, the national priorities at
the HEW level, and at the same time provide a response to the Congres-
sional intent. OO

One proposal is a response both to Congressional intent and direc-
tion from the National Advisory Council. This project was referred to
in the foregoing "Budget Narrative'' as the Comprehensive Plan for Renal
Disease. The National Advisory Council had requested a regionwide plan
in response to our earlier renal proposal. Outstanding professionals
in the field responded by working many hours on this proposal; and we
believe we have met the legislative intent of the Kidney disease amend-
ments.

But, as pointed out in the "Budget Narrative", not all of the
proposals in this submission were recommended for’ funding by the Priori-
ties Committee and the renal proposal is recommended for only partial
funding. The reason is simple: although the proposals were judged to
be of high quality, there just were not enough funds to go around. As
indicated previously, the Priorities Committee made a hard choice, but
it did so on certain described criteria, and in so doing, did not wish
to prejudice the unfunded proposals from receiving funds from other
‘federal programs or private sources. It was believed that approval by
CCRMP and the National Advisory Council might be helpful in obtaining
funds from other sources. Therefore, although a proposal may not be in
line for immediate funding from RMP sources, we respectively request
NAC review in order that we can keep the hope alive that our planning
efforts have not been in vain.

Some of these proposals have been in the planning stage for at
least eighteen months, others are more recent, but all have been
thoroughly reviewed and CCRMP has set the priorities for funding.

We realize, all too well, that there appears to be a multiplicity
of programs, not a single program to which each proposal in this submis-
sion relates, but we request your understanding during this period of
transition. We are shifting to placing emphasis on the national priori-
ties, the developmental component objectives, and the directions indicated
in the memorandum to Secretary Richardson which emerged from the National
Meeting of Coordinators in’Atlanta on March 24, 1971.

- 12 -