Finally, through a formal Approval Procedure, hospital capital proposals are endorsed by the Association board of directors, using criteria focussed primarily on the planning processes that produce the proposals.

The Association's criteria require that each hospital be established or expanded solely in terms of community need rather than the needs of the institution. Definition of community need requires a determination of what people the hospital is planning to serve, and what services it is planning for these people. Whether its programs are geared to primary health services or to specialized services, this requires that the hospital do its planning for a geographically defined community. The criteria require each hospital to delineate a geographic service area.

No one is suggesting that the hospital cannot serve patients from outside of its defined geographic area. There is no implication that the hospital should erect a Berlin Wall around its service area to try to prevent residents of the area from going to unrelated hospitals. Freedom of choice is preserved. But successful implementation of the hospital's plans should result in a higher and higher percentage of the hospital's patients coming from the defined service area, as more and more residents of the area identify with the hospital, its medical staff, and the inter-hospital relationships which develop.

What services should the hospital plan to meet the needs of the people in its defined service area? Here the Association's criteria provide a very simple and clear guide. The hospital should plan for comprehensive services. This includes all services: not only general medical and surgical, but also psychiatric, rehabilitative, social service, home care, extended care, preventive, diagnostic, emergency, other ambulatory, etc.

No hospital can provide comprehensive services. But each can plan in terms of the comprehensive health needs of its service area, both by direct provision and by making arrangements with other institutions. Effective and efficient arrangements to make available comprehensive care for the population of the hospital's service area is the ultimate goal. This requires that, in developing its plans, the hospital should give at least as much attention to the service it will not provide as to the services that it will provide. Only in this way can orderly systems for comprehensive care be assured for the people.

The Hospital Planning Association places greater emphasis on planning process than on planning content. Building programs and staffing patterns are treated as elements of implementation which flow out of the functional plans that emerge from efforts to meet the Association's basic criteria. If a hospital is organized to plan effectively, and if its plans are demonstrably couched in terms of meeting the comprehensive health needs of a defined population, the criteria have essentially been met.

A major challenge to the Association is the fact that most hospitals are not organized for a systematic planning process related to community needs. Active involvement and interaction of the entire hospital family, especially the medical staff, are required if the hospital is going to be able to carry on corporate planning which is responsibe to medical progress and which is based on viable goals.

Therefore, the key step is to achieve a viable organization of the planning process at each hospital. In Allegheny County, the hospital and medical leadership have decided that responsibility for the planning process at each hospital should be assigned to a new committee, called the Long-Range Planning Committee. This mechanism has since been picked up by many areawide planning agencies in the United States.

The Long-Range Planning Committee consists of representatives of the hospital's board of trustees, medical staff, and administration. Its task is very difficult and time-consuming, and requires staff support. In most hospitals, staffing can be provided by the hospital's regular administrative team, but three of our larger hospitals have now employed full-time planning directors to staff this committee. A fourth has sub-contracted with one of these large hospitals for planning staff services. Others have employed professional consultants to help. Candor forces me to admit that progress has been very slow. Some hospital officials have had great difficulty applying the Association's concepts to their own institutions. There have been those who have rejected the Association's approach, or who haven't really believed that the Association was seriously committed to what it said. In seven years, two building programs have gone ahead without the Association's participation. The process of disseminating the

agency's viewpoint is a continuous one, requiring endless hours of meetings, conferences, and other forms of communications. Hospital Long-Range Planning Committees have tended to be preoccupied, understandably enough, with their own institutions' pressing building needs. They have frequently put off discussion of comprehensive care and the difficult issues involved in relating medical practice to institutional service in meeting community needs. It continues to be difficult for many hospital officials to understand why an institution with high occupancy, high standards of patient care, and a worn-out building cannot proceed to replace the old building without a lot of frustrating talk about goals and comprehensive care.

Moreover, an infrequently mentioned but widely recognized fact is that hospitals, in developing the instutional pride that underlies the pursuit of excellence, have tended to develop deep-seated distrust of their neighboring, "competing" hospitals. With a long history of competition for self-sufficiency among autonomous institutions, there is a legacy of misinformation, a lack of trust, and memories about apparent past immorality and double-dealing which cannot be overcome overnight.

The only answer to this problem is better communications within institutions and between institutions. Open communications can create conditions of mutual understanding and trust which will permit much more effective planning.

The Association's approach requires a great deal of patience and fortitude. When carried out aggressively, it is deeply disturbing to the community, the institutions, the medical profession, and the staff and directors of the Planning Association. Over time, however, ignorance, apathy, disbelief, and opposition have receded. The Association's Administrators' Advisory Committee has recently re-affirmed the planning criteria. Its Medical Advisory Committee has become deeply committed to and involved in the Association's activities. Both committees are currently working on more detailed recommended guidelines for use in applying the planning criteria. Some hospitals still want to build first and plan later, but they can expect little support from the two advisory committees.

Specific results are beginning to appear. One community hospital, for example, which had had difficulty in accepting the service area concept, is now working closely with its immediate community-a poverty area—and has just received a $1,800,000 federal grant for a neighborhood health center to be operated jointly with community representatives. A large center city hospital has shelved its plans to compete in providing specialty services with all hospitals in the area. It has recast its program to become a coordinated specialty resource to the commuity hospitals in a section of the region as well as a primary resource to a nearby poverty community. It is working to strengthen its neighboring hospitals through joint programs in specialty services. Other examples can be cited. Two hospitals have grouped their maternity services at one location. Four hospitals have formed a joint corporation which is now operating a central pharmacy service, a central clinical chemistry laboratory, and a joint laundry, each of which serves hospitals not in the corporation. Seven other hospitals serving another section of the region have recognized their community of interest and have formed a joint corporation for coordinated policy making, and for operating joint programs. In both of these corporations, the participating hospitals have not surrendered legal autonomy. But as they work together on common problems, they tend increasingly to adopt common or interrelated positions. The Hospital Planning Association assisted in the creation of a Regional Medical Program which is beginning to function to promote and fund cooperative arrangements in the fight against heart disease, cancer, stroke and related diseases. Countywide approaches to emergency care, to home health services, to rehabilitation services, and to mental health services are in planning. Several hospitals are developing innovative joint approaches to ambulatory services, social service, and radiation therapy. Physicians are becoming more deeply involved in planning at their own hospitals. Discussions concerning comprehensive care are becoming more common and less charged with emotion within hospital staffs and among groups of hospitals.

Implications of the Allegheny County experience

The Allegheny County experience suggests that delivery systems can be improved-with reduced costs for comparable service, or better yet, improved service for less than it would have had to cost-by concentrating attention on

improving the corporate planning processes of all health agencies. By holding each hospital and other health agency responsible for developing a viable and defensible community oriented planning process, the health care system can become more effective, more systematic, and more responsive to community needs and demands. Reduced costs and improved effectiveness will flow from strengthened planning at each level of operation.

Under Public Law 89-749, the Comprehensive Health Planning Act of 1966, every area can have a regional comprehensive health planning agency-backed up by a state comprehensive planning agency and by a strong federal commitment to stimulate improved planning processes in every health agency and institution. This new law can have the most profound impact on the cost of delivering quality health care to people. The Allegheny County experience suggests some guidelines for this planning program.

(1) Emphasize planning process rather than plans

The comprehensive planning agency should not make plans for hospitals and other agencies. Rather, it should help operating health agencies to improve their planning processes.

A planning agency which attempts to plan for the health agencies risks the same reactions as parents who attempt to plan their children's lives: healthy but destructive rebellion, or unhealthy loss of capacity to change. Officials of operating health agencies are not children; they are mature, independent responsible people who have demonstrated great capability in achieving institutional objectives. With appropriate incentives and assistance in formulating broader goals and objectives, they are quite capable of planning sound programs in relation to community needs. The complex and delicate interpersonal and interagency relationships involved in implementing comprehensive planning require a commitment that can be obtained only if those responsible for the implementation are also responsible for the planning.

A comprehensive planning agency which concentrates its effort on review of building plans developed by operating agencies will also be of limited value. After an operating health agency has carried out the difficult and extremely time consuming process of developing a building plan, there is a sense of emotional involvement and commitment that permits very little outside influence. Unless the plans are patently absurd-they hardly ever are-it is too late to do much good.

Planning on a more or less systematic basis is a continuous process at each health agency. These processes-especially formulation of goals and objectivesmust be strengthened. The primary job of the comprehensive planning agency is to help improve planning processes.

(2) Require All Health Agencies to Plan Comprehensively

Comprehensive planning agencies should attempt to improve the planning processes of all health agencies, not just the hospitals. While the hospitals are the key agencies in health care delivery systems, they must interact with a wide variety of other agencies which must also be engaged in planning in relation to comprehensive health services.

Especially important is attention to the planning processes of health agencies which are not directly responsible for patient care. Accrediting agencies, licensing agencies, financing agencies, educational institutions-all of these need improved planning processes that reflect a commitment to comprehensive care. A health care provider agency has difficulty planning in terms of comprehensive care if those agencies which supply it with capital and operating funds, with license, prestige and trained personnel do not reflect the same commitment. A hospital which can meet all the standards of license, accreditation, Blue Cross, Title XIX and Medicare participation has difficulty understanding why it must recast its goals and programs. Delivery of comprehensive health care as a goal must permeate the entire health establishment.

(3) Make appropriate use of sanctions and incentives

A comprehensive health planning agency will function most effectively if it does not exercise direct controls. The health establishment already has a great many agencies which exercise and respond to formal and informal sanctions and incentives. Many agencies which exercise sanctions on health agencies are in turn influenced by sanctions of other health agencies. For example, the hospital's power to grant or withhold staff privileges is a strong potential in

centive and sanction on the practicing physician; the hospital, in turn, is subject to strong incentives and sanctions exercised by a wide variety of agencies such as the state Hill-Burton agency. All agencies should be guided by sound planning in exercising their sanction power-planning related to delivery of comprehensive health care. The comprehensive health planning agencies should strive to improve the planning processes of sanction and incentive agencies to help them to make maximum impact on improved delivery of health care services. Planning agencies should not usurp the operating responsibilities of these sanction agencies; rather sanction agencies must become involved in comprehensive planning themselves.

The greatest conceptual fallacy about areawide health planning today is that one form of sanction-control of capital funds-by itself can create more systematic planning. It hasn't worked anywhere.

Why should a hospital or health agency which has not planned its future in terms of the comprehensive health needs of people be entitled to accreditation? to licensure? to tax exemption? to all medicare funds (not just depreciation funds)? to public welfare payments? to Blue Cross membership?

All agencies which exercise sanction or incentive in the health field need to re-examine their programs and be guided to a strong commitment to comprehensive health care.

(4) Determine priorities on the basis of innovation in delivering care

Establishment of priorities is an inherent part of the planning process of any health agency. As planning processes of individual health agencies become more coordinated in relation to comprehensive health needs of the same people, many priority decisions will become products of inter-agency agreement. Agencies with operational responsibility for disbursing limited funds among different institutions will need to develop priority criteria relating to their own role in promoting improved delivery systems.

In the long run, determination of priorities will be one of the most difficult areas of planning and decision-making, because ethical considerations will be involved. In the short-run, and for a good number of years, most health agencies will have sufficient difficulty in re-focussing goals and objectives that priorities can be assigned to acceptable programs on a "first-come, first-served" basis. Innovative response to comprehensive health care needs of people can be the primary priority consideration. Overstructuring of objective priority considerations can be a stultifying force.

As with sanctions and incentives, a comprehensive planning agency without operational responsibility should not assume responsibility for determining priorities. It can advise on priorities. Even more important, it can help all health agencies and institutions to build into their planning processes priority considerations related to improved delivery of health care for people.

(5) Avoid Overemphasis on Precision

Health planning must be increasingly based on proven facts, and on ideas and programs that can be qualified, tested, and evaluated. But there is danger in over-reliance on precision. The current problem is not as much lack of exact knowledge about delivery systems as lack of commitment.

Precise quantification in the health field is difficult, expensive, and slow. Most basic concepts in the health field-for example, quality-have not yet been adequately defined or quantified. Yet, quality of care can be and has been improved, because of the deep commitment to it. Quality could probably be improved more efficiently if better concepts, definitions, measurements, and data were available. But we cannot and should not wait.

The same approach applies to planning for improved delivery systems of comprehensive care. We cannot wait for precision. The basic direction is clear enough to proceed simultaneously with efforts to improve delivery systems and to develop measurement techniques in a mutual feed-back process.

(6) Coordinate Health Planning and Community Planning

In the long run, the greatest potential for reduction of medical care costs probably lies in recognition that investment in other forms of conservation and development of human resources may frequently contribute more to human health than direct investment in health services. Investment in neighborhood development, housing, education, recreation, and welfare services are examples. P. L. 89-749 goes a long way towards making the comprehensive health plan

ning agency look beyond the limits of medical care, and on to environmental health, public health, and so on. It may be too soon to hope for, but we also need to relate comprehensive health planning to the planning which is directed at the total community. Close coordination of community planning and health planning—almost unknown today-may create a planning environment which will produce health care statesmen capable of deciding that application of all medical advances are not always in the community interest.

A FINAL WORD: PROGRESS WILL BE SLOW

Systematic planning by each institution and agency holds the answers to rising medical care costs. But patience and perseverance are required. Dramatic results may be hoped for, but should not be anticipated in short order. Systematic development must deal with the weight of tradition, custom, and vested interests, and with the special type of momentum and vitality of established institutions. The health field harbors an unusual mixture of sentiment, prejudice, and authoritative knowledge. There will be progress in the reorganization of medical care, but decades of development are not likely to be telescoped in one year. Everyone in the system is to some extent a prisoner of his education and experience. Everyone in the system can be expected to initiate or adapt to some change, but Great Leaps Forward are not to be expected. An entire system of health care will not be quickly converted to conform to models designed by the best planners. Facts and logic are not enough. To improve health care delivery systems requires a special logic that considers the stubbornness of men and policies and institutions, as well as the logic of rational thought.

I-PATTERNS OF UTILIZATION OF HEALTH SERVICES BY OLDER PEOPLE*

(George A. Silver, M.D., Deputy Assistant Secretary for Health and Scientific Affairs, Department of Health, Education, and Welfare)

We are all aware of the dramatic strides which have been made in this country in the health picture of the entire population. It is the very success of modern medicine in preventing epidemics and curing or controlling diseases once usually fatal, that has brought chronic illness and the illnesses of old age to the fore as the major health problem of our time. Let me emphasize though that millions of older Americans enjoy relatively good health. Most of them can be almost as active as they were when they were many years younger and even large numbers of those with disabilities have learned to live with them, and accept their limitations.

Yet we must face the fact that the majority of the aged have become the prey of at least one disease in their lifetime that sticks with them as long as they live. About 15 million older Americans have at least one chronic condition, although it is true that less than one-half of those with a chronic ailment have some limitation on their activities. We all know that many of those with disabling illness might be in better health today if known preventive and restorative services had been promptly used. We do not know the causes and cures of all the diseases that come with old age. Until research efforts give us more information on the causes and cures of most chronic disease, we can only apply palliatives. Still, the most potent weapon against them is early detection and prompt treatment. However, too many of today's older people have not received treatment early enough.

Part of the problem may lie with the manner in which older people decide to seek medical care the evidence shows a tendency to delay going to a physician until the later stages of a disease. The National Health Survey indicated that during the year ending June 30, 1964, one out of 4 people 65 or older had not been to a physician. But the entire responsibility cannot be placed on the aged; they have not always been made aware of the need for regular check-ups or the dangers of self doctoring or ways to avoid accidents. And we know that there is a tendency among many to treat themselves when they really need to see a physician. People often use medications which have worked on similar symptoms of neighbors and friends. Sometimes they wanted to avoid the cost-sometimes they were just afraid of treatment and hospitals. A large proportion of older

*Delivered at the 12th Annual Conference on Aging of the Western Gerontological Society, Monday, Sept. 19, 1966, San Francisco, Calif.