0 I 0 -,!,@@j@@@4-L F@RM .01 -.0 $010-107 G. 'O. -@l N. 1'r-,D @NIH-OD-OPP /-,, ;Te c) 7 cj,, n cl q, @l r, rz Sur@@,@on General PHS DATL: Decei-@@@r 24, l@6" 'Lirector,- iN!H SUBJEC'!':. factors of importance in considering PHS plans in respect to the Pr@sident's Co=ission Report on Heart D@.sease, Cancer and Strolce We have discussed within the O'Lfi-cc- of Director, I\TIH, the broad iMT)I.ica- tio,r..., of --he '@Oreslac,@t s Co-r=ssion a-.id the specific problems of develo-oin- a concept of action to accon-.)'.@Lish -@ie primary recommendations at, -V re ig t-.e creation of th so-ca',-Ic;6 "national networ'-." The alternate e c@L action ifn4-ch have thus far blame developed, seem to cover the 1 4 o 'L broad -Dossib@L Lties in respect to t,-ie nianner in %@7h4ch -he Federal might undertone the of these maior -:ecorre-.i a--ions. !L SeC-,-rS c';ear that the is that which preserves to the -,iaxi@.u-,i the established relationships through which the Federal Govern- I-enL acts in pUb'L.--'-L purposes in the nonfeda@--al sec,.,,,;,-@. Such an approach would also seen to require the least legislative add-'-z:4@on -in terms of new authorities to support the necessary Federal ac t@- k)ii these alternatives constitute an a-2-@?-ro-pr4-ate set of "-@cirst cut" con- they,Dy no means, constitute ,@,.olly adequate solutions to all the DroD!er,s %.71,-7Lc.1 rr--co,=,.ei-idations of tp@ Con-,ussion -,Dose. Even the fifth alternative devised following -the meetirc, your office on Dece,-o,Der 22 has many unsatisfactory aspects. We have a.'Lc-r-:3teci a further variation of this fifth alternative (attached) to copE! certain of the -;-ncoa,--2lete aspects in the first version of this alternative, but even this lat-@er version leaves much to be desired. Even so, it is worthy of serious consideration as a ,rLean@ of refining our ideas about the ess--c.4--;e., @ramework throu'.7h which Fede,-al action can be taker to achieve objectives of the Peport. ,@ate,@er alternatives are considered, i@- is my very stron- feeling that we to have clearly @. mind certain prq-nc-.'Lrles which it is imperative not to violate, diminish or contravene. June exter-t to which these principles are recognized and preserved in the development of a plan of action should be our measure of its desirability a-.id supportability. As I see it, these imperatives are of -,he following nature: 1. Tne direct relationship be-@Weei Federal aaencies and institutions of research and education in -"he achievement of basic Federal objectives =st be sustained. Thus there should be no intervening of a-ay other agency or instrument between the Federal Government and these institutions in ac.-i--ev- ing the Federal purpose. Pii) ff @lii)ingc Rt)n,,-Zf Rei7mlarlv can the Pavroll Savii@,as Plan 2. Federal action to improve quality and quantity of health services available to t,ie population ought to the raa=ir,-cani extent possible De integrated with tae whole pattern of medical a-id health care services a-@.- the state and local level rather than in the form of discrete and separa---e actions or entities. 3. Federal support of the trainir,- a-,id educational pr ocesses and institutions of hi-he-r education our.-ht not to be subdivided or ot-ien\7ise partitioned when there is no basis for such differentiation in the educa- tior.al process in terms of the settin- and content in which the training takes place. 4. ne development of stron- centers of research and education ic dispersion their qualitative enhancement a-,id their ao@raph Pust be undertaken as an end in itself a-Lid not as a dependent consideration of their relationship to any particular categorical prouranL action. 'Znus creation of additional centers of excellence is a matter requiring direct a-,id @-arposeful effort .not in +,-he context of heart disease, cancer a-Lic stroke regional centers but in -,he interest of developing the most effective 'Lrarewor.,: of national resources for teaching and research. 5. The proole-,,i of manpower for acco:nnlishirent of national objectives -,nu s @L be viewed in two parts. The need 4Lo'.- prc)iessional and tecr,,n-'@cal ,7,a,,.-)o@qer by the substantive research tra-L;-iin- a-@id. service activities to be undertaken constitutes one essential requirement; the need for mana-e- -Land pro-ra:,- direction @anpower constitutes the other essential recu.rement. Failure to recognize -the dual nature of these manpower requirements be -Lcatal to the --@ec-@t-;-on of the Commission's objectives. I believe that if we kee-D these considerations in @".Id -Ln exaninin- the pros and cons of alternative approaches our sense of in respect to the preferable alternatives will be sharper and sound. Obviously there are other =-Lters of importance to be kept in L@,nc an connection with this and extraordinary effort in the interests of better,health as a whole and the control of heart disease, cancer and stroke problems-specifical 1,@. 'Ln many respects we will have to feel our way quite cautiously and in.this circumstance it is all the more important to have a clear sense of what we ought not yield in considering any course of- action. James A. Shannon, NIH Variations on Alternative Nuuber 5 'fnis alternative would provide a framework for the accomplishment. of -the recommendations of the Presideht's Corir,,ission concerning the establishment of a national network for dealing with heart disease, cancer and stroke in a manner which would seek to achieve the essential objectives of title Report but would also utilize the established relationships through which the Federal Government deals with the university, medical schools and research institutions on the one hand, and state and local agencies on the other. In essence, the first three recommendations of the Presidentis Co,@,cission Report deal with (1) the concept of-a national network of centers and stations, (2) the development of centers of strength in respect to research, teaching and specialized services 3- (3) an array of diagnostic and treatment stations enga@ed.primarily in the provision of services but serving also an educational and informational function at the local level. The Report e-.ivisages'a close working relationship between the centers and stations. T'ne accomplishment of these basic objectives could be brought about through the following arrangements: 1. The establishment of a national advisory group to the Public Health Service to undertake, in conjunction with the PHS and through appropriate consultation with the stated, the development of a framework of regions or service areas for the I\Tat4@on. This fran,.ewor,.-, of service areas would constitute the basic grid within which the efforts to establish regional centers and.diagnostic and treatment stations would 2 take place. Some such advisory group was envisaged in the Com-rission's Report in its discussion of recommendations I and 2. The re"ions of service areas developed through this mechanism would be individual states, parts of states, metropolitan areas or groups of two or more states, the basic determinant of the,grouping being existing teachin- and research C> facilities, population distribution and the pattern of normal economic, social, a-,id governmental relationships. 2. Given this national grid or framework of service areas,respo-,isi- bility then could be placed upon an appropriate state governmental agency in each state to (a) carry out the necessary state, interstate, and intrastate planning to deter,-nine the location of diagnostic and treatment stations in the state; (b) identify the most suitable and appropriate relationships between these stations and reg ional centers of research, teaching, and specialized services; and (c) to oversee the operations of the network as it relates to the provision of health services and the conduct of extension education. 3. The conduct of this state and local planning- activity would envisage the establishment of an advisory group or commission for each @gional area made up of representatives of the centers of research, training and service in the state, practicing phy sicians, and the public at large, to assist in t7ne determination and coordination of these activities. 3 4. The Federal Government would work directly with the major research teachin- and centers of medical activity in the enhancement and enlargement of these centers as an overall framework of national, resources in research, education, and high quality services as'an end in itself. In addition a special program of grants would be available to encourage and support the activities of those centers directed toward regional relationships with the framework of diagnostic and treatment facilities in the provision of specialized professional assistance and extension education services to such stations. In providing support for the regional service and educational activities of these institutions, a criteria of award would be the extent to which such proposals conform to and implement the regional plan devel oped under 2 and 3 above. Through these arrangements t'ne Fe@ral Government would undertake: 1. To provide for the development of an overall national plan for improving and extending the quantity and quality of services available for heart disease, cancer a-ad stroke and the regional framework within which this would be accomplished. 2. To utilize a framework of state, interstate, and intrastate mechanisms for regional planning relating to the establishment and operation of diagnostic treatment stations and the relationship of these stations in respect to health service and educational activities to centers of research and education 3. To provide support for the construction,, equipping and operation of diagnostic and treatment stations to the extent that such proposals are compatible with the regional plan. 4 4. To provide funds to major research, teaching and service institutions to serve a;centers in the provision of specialized services, educational functions, and to extend professional assistance and educa- tional services to the-regional framework of diagnostic and treatment stations, a criteria for such support beina the extent to which the activities proposed confo= with the regional plan.