A New Organization of Health Services The federal mechanisms for care are disjointed and fragmented. Covering the broad range of needs at the local level is not possible because resources are so often tied to tightly defined purposes that do not include total population groups or community needs. Indeed, mechanisms for redirecting available money into broad coverage of services are lacking.Most of the energy in this medical nonsystem, as in so many other areas, seems to be directed toward nonclient, yet presumably relevant, activities such as internal agency concerns, relations with other agencies, traffic flow, managing of money, and measures of efficiency. Only a small proportion of total resources (governmental and private) actually goes into direct services.4 Much energy is spent in working out how that small proportion of activities directed to clients will be paid for and managed; much less is spent in finding ways to increase the percentage of resources channeled into real rather than support services.The people most capable of organization for both medical and other care are often the ones most capable of obtaining funds and developing new programs, and they thus take a larger and larger share of the funds and the responsibility. The organizations with experience are the ones that are ex­panding, while those communities most in need of help have difficulty in obtaining money. The rich get richer and the poor get relatively poorer. New types of developments are extremely difficult to get started. Their propo­nents have neither the ability to deal with issues on an appropriate scale nor the funds to do so.It is still unusual for all the people in health and related fields to come together for common decision making. When they do, the participants rarely act together; most often they fight. Indeed, there is no process of governance that permits the integration and working together collegially of the various groups. A “ family” integrating mechanism does not exist for any problem solving.It is now worth turning to one alternative answer to the problems. Clearly, there is need within a metropolitan region for the delivery of care on a more rational basis. Clearly, too, pluralistic alternative plans for giving care must be open to all community groups. The models of neighborhood ambulatory health centers that have emerged suggest not a pattern of government medi­cine but new forms of group practice, small enough in scale to maintain the personal level of care that patients desire and yet part of a larger network

involving hospitals and medical schools. These connections are required so that when complex problems arise in primary care, there are resources availa­ble.This concept of care leads to a search for some form of central linking organization-perhaps a public-private authority5-o n a variety of levels. “Linking” is used rather than “coordinating” because coordination implies that one is forcing separate programs to function as one, and that is not the objective. Rather, the need is for programs to be able to link when their objectives intersect but to exist otherwise as separate entities. It is the differ­ence between a confederation of states and the United States. Such a central linking organization should include representatives of all programs, regulatory agencies, and consumers.Some form of this organization should exist in the local neighborhood, and also in the citywide and the metropolitan regional levels. These various levels of organization should be able to provide for the provision of planning assistance to member programs; the assessment of community wide needs and the creation or stimulation of new programs where deficiencies exist; the support of new program development; the provision of central services (for example, the training and supervision of professionals and paraprofessionals and the administration of such matters as personnel, budgeting, and book­keeping for individual groups); the provision of specialist services; the inter­pretation of the system to the consumers; and negotiation with state and federal regulators.A major challenge is to get the organization to come together and to design itself on its own initiative and its own terms. The potential for this happening exists in the commonly felt needs of the constituent actors, but the problem of providing a “catalyst” is a difficult one. Yet a solution to this problem is highly critical; a coordination organization that is imposed from outside is bound to fail. The organization must come together on the basis of its members’ commonly felt needs, and these members must not feel that they are losing autonomy by participating.The authority must receive its power, and thus its viability, through ena­bling actions on the part of those outside agents who now control resources and regulatory powers. The difficulties of catalyzing such a linking organiza­tion and of devising ways to judge its viability and the effectiveness of its use of resources are enormous. Multiple-Level “Authorities” In an immediate neighborhood, public-private “ authorities” could be devel­oped in which all bodies concerned with any problems, such as health care

delivery, could participate. In the first stage of development there should be a voluntary “ forum” in which all the participants play a role in discussing and dealing with the issues involved. As the “ forum”6 begins to share ideas about problems, it could gradually incorporate itself into a locally governed public-private body to control the development of that issue. This local “authority” would be a new form of “congress,” containing all participants in the system, including the consumer, and backed up by a staff. In the health field, the participants would include everybody in the medical network from the in­surers to the pharmacists, other practitioners, and community representatives.Each local area would participate by selecting representatives to send to a citywide area “authority.” In no instance should the “ forum” or “authority” take over the responsibility for running individual group programs or local activities. It should, however, reserve the right to develop new programs where needed by subcommunities and the community at large, and it should encourage others to increase their activities. Ideally these citywide and neigh­borhood “authorities” would have funds allocated to them for their activities.But neighborhood or citywide “authorities” cannot deal with those prob­lems that are metropolitan or areawide in scale, so yet another level would be required. Allocation of funds that will be increasingly available from federal and state sources could either go through, or be forced to “ touch base” at, regional or areawide “authorities.” 7This multiple level of governance by different levels of “authorities” has the major advantage that it involves all participants. Further “congresses” on each level would serve to interpret the separate problem areas to each other. Some of this can be done by existing governmental groups in the city or state. However, new integrative and collaborative groups must continue to evolve.One of the continuing dilemmas will be the relationship between the vari­ous levels and forms of “ authority.” Clearly, those local and problem areas with the most competent participants would normally continue to get the best allocation of funds. Thus the authority on the metropolitan level would have to be responsible for seeing that funds were allocated to various problem needs and that those groups without skills or resources were given assistance to raise their levels of competence.The function of the “metropolitan authorities” will be to catalyze and facilitate the development of programs on all levels and to connect to other “authorities”—not to control programs. Controls descending from the state or

the federal government will be unacceptable. However, when local “authori­ties” create standards for themselves, these standards can gradually emerge into metropolitan, and ultimately statewide or national, performance specifi­cations. On the other hand, there must be national performance criteria, which the federal government must implement if we are to deal with inequi­ties in our society. Too often local standards have ignored federal directions, which come only from national debate, the actions of Congress, and adminis­trative leadership.This outline of a pattern of governance has arisen out of the complex problems of health, but is not limited to health. It is not offered as a panacea, and, indeed, it is currently facing serious difficulties. Clearly, though, unless mechanisms are developed that bring the disparate groups and views together, we will have a continuing sense of impotence.Any acceptable model of governance must involve the consumer and the public and private sector. It must be one that does not force compliance on local issues but demands compliance with national values and priorities, nor must it let ideological directives becloud pragmatic changes. If anything, we must leave open to professionals, with consumers, the development and choice of alternative models of governance within the broader democratic framework. This process will be turbulent. The essential theme must be decentralization, pluralization, and the involvement of consumers and all those affected by the program in the planning of their own future. The key organizations for governance, albeit of low visability, will probably turn out to be the metropolitan ones. From the point of view of scale, that is the most relevant level of planning. But this will not arise de facto; one must accept the psychological need for subgroups to possess a feeling of territorial identify and one must work within the framework of this reality to design a low-profile, ad hoc, functionally alive network of govern­ment operations.These concepts of government may appear to be embarking on uncharted waters, but in fact prototypes do exist in the health field, which may have extremely broad implications. One case history is worth mentioning briefly.