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Ronald Reagan Presidential Library
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Collection: Reagan, Ronald: Gubernatorial Papers,
1966-74: Press Unit
Folder Title: [Health] - A Department of Health for
California, 02/01/1970 (1 of 2)
Box: P37
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PRESS
A
DEPARTMENT OF HEALTH
FOR
California
DEPARTMENT EUREKA OF CALIFORNIA
STATE OF
CALIFORNIA
REPORT TO THE SECRETARY OF THE HUMAN RELATIONS AGENCY
Feb. 1, 1970
State of California
Human Relations Agency
Memorandum
To
:
Honorable Ronald Reagan
Date
:
February 10, 1970
Governor
File No.:
Subject: A Department of
Health for California
From
:
Office of the Secretary
Transmitted herewith is the report, "A Department of Health for
California". The report was prepared by the Task Force on
Organization of Health Programs, appointed by the Secretary of
the Human Relations Agency. It represents the basis for my
recommendation to you that a Department of Health be established
in the Human Relations Agency.
I concur in all of the recommendations of the Task Force, except
those pertaining to the Veterans Home and Hospital of the
Department of Veterans Affairs and the meat, dairy and poultry
inspection programs of the Department of Agriculture. I feel
that these programs require further analysis and review, and I
am not prepared to recommend their inclusion in a Department of
Health at this time.
Establishment of a Department of Health, consolidating the health
and related functions now performed in several departments, will
permit us to do a more effective job of evaluating total health
needs and developing and implementing programs to meet them. It
is our intention to create the new department within the staffing
that is currently authorized for the functions being consolidated.
To the extent that reductions in staff are made possible as a
result of the reorganization without curtailing essential services,
they will be accomplished through attrition.
With the exceptions indicated, I recommend that you submit an
organization plan for a Department of Health, embodying the
recommendations of the report, to the 1970 session of the
Legislature.
Secretary
Attachment
A DEPARTMENT OF HEALTH
for
CALIFORNIA
Report to the Secretary of the Human Relations Agency
February 1, 1970
RONALD REAGAN
Governor of California
OF
THE
STATE OF CALIFORNIA
GREAT
HUMAN RELATIONS AGENCY
CALIFORNIA
February 1, 1970
LUCIAN B. VANDEGRIFT
Secretary
OFFICE OF THE
SECRETARY
The Honorable Lucian B. Vandegrift
915 Capitol Mall
Secretary
Sacramento 95814
Human Relations Agency
915 Capitol Mall
DEPARTMENTS OF
Sacramento, California 95814
THE AGENCY
Corrections
Health Care Services
Dear Mr. Vandegrift:
Human Resources Development
Industrial Relations
Pursuant to the Secretary's letter of July 24, 1969,
Mental Hygiene
the Task Force on Organization of Health Programs
Public Health
submits its report and recommendations for creation
Rehabilitation
of a Department of Health. In accordance with the
Social Welfare
Agency charge, the Task Force has developed an organi-
Youth Authority
zation plan that the Governor can submit to the Legis-
lature at the 1970 Session.
The proposal represents a major change in the organi-
zation of the State's health programs. The Task Force
recognizes that organizational change by itself is no
panacea for the many complex problems related to health
policies and programs. We believe, however, that a
unified Department of Health will be in a much better
position to deal with these problems than our present
fragmented organization. In recent years we have seen
tremendous expansion in health programs and services.
This has placed a severe strain on the existing admin-
istrative machinery. This expansion also underscores
the urgency of the State's acting now to develop an
improved system of managing its health programs.
The Task Force did not attempt, within the limited
time available, to carry out the detailed planning
that will be necessary for implementation of the pro-
posal. We have suggested a recommended structure for
the new Department but recognize that the Director of
Health, who hopefully will be selected as early as
possible, must have an opportunity to bring his own
ideas to bear on the organizational planning. If the
Governor and the Legislature support the proposal,
we recommend that the Department of Health be acti-
vated no later than July 1, 1971.
The Honorable Lucian B. Vandegrift
Page 2
Throughout the study, the Task Force has been assisted by two
advisory bodies. The Ad Hoc Advisory Committee was composed
of persons associated with State Government. It included rep-
resentatives of several legislative committees, the Commission
on California State Government Organization and Economy, the
Human Relations Agency, and the Department of Finance. The
second advisory group assisting the Task Force was the Health
Planning Council, consisting of a broadly representative group
of persons from outside State Government. The Task Force ex-
presses its appreciation to all of those who participated on
these advisory bodies. The two groups provided an effective
sounding board for testing various alternative approaches and
made a valuable contribution to the project. It should be
made clear, however, that the conclusions and recommendations
in the report are those of the Task Force and that the Task
Force assumes full responsibility for them.
The Task Force also acknowledges its appreciation for the
willingness of many persons, both within and outside State
Government, to discuss problems related to the present organi-
zation of the State's health programs. The Task Force met
with numerous individuals and groups and, in the process,
broadened its understanding of health programs and obtained
many useful ideas. Our one regret is that time did not permit
us to contact directly all of the many organizations and indi-
viduals that have a strong interest in health services.
In its charge to the Task Force, the Agency asked that we take a
broad approach in our analysis, be innovative in our approach,
give full consideration to the rapid changes that are occur-
ring in the health field, and offer interested groups and
individuals an opportunity to present their views. We have
made an earnest attempt to carry out this directive.
Very truly yours,
Lee D. Bomberger
LEE D. BOMBERGER, Chairman
Task Force on Organization
of Health Programs
ii
TASK FORCE MEMBERS
Lee D. Bomberger, Chairman
Kay Araki
Rose M. Nonini
Daniel A. Grabski, M.D.
Walter J. Pilgrim
John K. Harper
William D. Simmons
Robert C. James
Anne Davis, Research Associate
Carolyn Wilson, Secretary
iii
SUMMARY OF PROPOSAL
The Task Force on Organization of Health Programs recommends
that:
1. The State of California proceed with the establish-
ment of a Department of Health.
2. The new Department include the following components:
a. All of the functions of the Departments of Public
Health, Mental Hygiene, and Health Care Services,
except for the two Neuropsychiatric Institutes
now in the Department of Mental Hygiene. These
would be transferred to the University of Cali-
fornia.
b. Social Service functions of the Department of
Social Welfare.
C. Ten of the healing arts licensing boards in the
Department of Professional and Vocational
Standards.
d. Alcoholism functions of the Department of
Rehabilitation,
e. Meat, dairy, and poultry inspection functions
of the Department of Agriculture.
f. State Veterans Home and Hospital in the Depart-
ment of Veterans Affairs.
V
3. An Advisory Health Council be created to assume the
functions of the existing State Board of Public
Health, the Health Planning Council, and the Health
Review and Program Council, except that the regula-
tion and licensing responsibilities of the State
Board of Public Health would be assigned to the
Director of Health.
4. The Department of Health have the following organiza-
tional segments:
Director's Office
Advisory Boards and Commissions
Comprehensive Health Planning
Health Facilities
Health Manpower
Personal Health
Environmental Health
Comptroller
Staff Services
Hospitals
Laboratory Services
Program Management
vi
TABLE OF CONTENTS
PAGE
Transmittal Letter
i
Task Force Members
iii
Summary of Proposal
V
Table of Contents
vii
Introduction
1
An Overview of Health
7
The Consumer's View of Health Services
13
Trends in Health Care
19
The State's Responsibility for Health
25
Components of a Department of Health
33
Recommended Organization
65
Benefits of Recommended Organization
99
Appendix
A. Footnote References
109
B. Task Force Charge
111
C. Project Schedule
113
D. Program Structure for Health
115
E. Alternative Organization Structures
117
F. Annotated Bibliography
123
G. Bibliography
139
vii
- 1 -
INTRODUCTION
This report presents the results of a study by the Task Force
on Organization of Health Programs. The study was part of a
process initiated by the Human Relations Agency in November,
1968 to examine the feasibility of consolidating the State's
health programs into a new organization. The present study
is an extension of the preliminary work done by two earlier
task forces established by the Agency to deal with certain
aspects of the problem. The results of the earlier studies,
plus the present study, are summarized below.
First Task Force
The first Task Force was established in late 1968 to evaluate
a proposal that the Departments of Public Health, Mental
Hygiene, and Health Care Services be combined into one depart-
ment. That Task Force was charged with determining whether
the proposal had sufficient merit to warrant further study.
In carrying out its charge, the Task Force identified a
number of problems related to the existing organization of
the State's health programs and recommended that a more de-
1
tailed study be undertaken. The problems were described as
follows:
Note: All footnote references are listed under Appendix A.
- 2 -
1. The State lacks a coordinated health program planning
and resource allocation system capable of determining
the needs of all the people, establishing goals, set-
ting program priorities, and evaluating program effec-
tiveness.
2. There is no integrated research program capable of
assessing all the State's health research needs and
allocating funds on a priority basis.
3. The present organization is unable to adjust to basic
changes in medical knowledge, technology, or the
health care delivery system.
4. Fragmentation and overlap exist in the administration
of some of the State's health programs. This is most
evident in the fields of mental retardation, alcoho-
lism, and health facilities licensing.
5. There is a growing interrelationship between medical
and social services that has not been adequately
recognized within State Government.
6. In attempting to optimize Federal funding, the State
has, in some cases, resorted to cumbersome organiza-
tional arrangements.
7. There has been a proliferation of boards and commis-
sions related to health.
Second Task Force
The second Task Force was established in the spring of 1969 to
conduct a more intensive analysis of four problems identified
- 3 -
in the earlier effort. These problems related to alcoholism,
licensing, mental retardation, and research. The Task Force
prepared five reports -- one for each of the problem areas
2
and a summary report.
The second Task Force considered three major alternatives for
the State's organization of health services, as follows:
1. Create a number of independent departments to
assume responsibility for specified programs or
functions.
2. Retain the present departmental organization,
but establish a coordinating mechanism in the
office of the Human Relations Agency.
3. Consolidate all health-related departments into
one unified Department of Health.
In its summary report, the Task Force recommended that the
Administration consider adopting the third alternative. It
recommended further that a new Department of Health include
a program management system to assist the Director in man-
aging selected health programs.
After reviewing the second Task Force's findings, the Governor
requested the Human Relations Agency to prepare an organiza-
tion plan for a unified Department of Health, which he could
submit to the Legislature in 1970.
- 4 -
Third Task Force
The third, or present, Task Force was established by the
Agency in July, 1969 to develop the basic plan for a Depart-
ment of Health. The Agency Secretary instructed the Task
Force to take a broad approach in its analysis, to examine
health-related programs wherever they occur in State Govern-
ment, to consider several organizational alternatives before
recommending one for implementation, and to approach the task
with the idea of constructing a new Department, not remodel-
ing the old ones. (Appendix B)
In carrying out its charge, the Task Force reviewed the sig-
nificant trends in health, attempted to gain an understand-
ing of consumer attitudes toward health programs and services,
inventoried the State's health functions, developed a program
structure for health, defined the State's role in health,
analyzed a number of functions for possible inclusion in a
Department of Health, and developed an organization structure
for the proposed Department.
The Secretary for Human Relations requested the Task Force
to design the best organization possible, ignoring existing
or potential obstacles to implementation. If adjustments in
the proposal were required to obtain general acceptance,
these would be made by the Agency once the study was completed.
The Agency imposed only two constraints on the Task Force:
- 5 -
1. The plan should be capable of implementation
within available funds, and
2. The plan should not require a staff increase
at the Agency level.
The Task Force believes that the proposal set forth in the
report provides a sound basis for an organization plan that
the Governor can submit to the Legislature.
- 7 -
AN OVERVIEW OF HEALTH
In any attempt to develop an improved organization of health
programs, it is desirable at the outset to gain an overview
of health. Major changes are occurring in technology, methods
of providing services, and public attitudes toward the pro-
vision of health services.
For a number of years there has been a tendency to equate
health with the provision of medical services. Medical ser-
vices, in turn, have usually been considered to be of a diag-
nostic and treatment nature, provided directly by, or under
the supervision of, a physician who operated as a solo prac-
titioner on a fee-for-service basis. This view has prevailed
despite the fact that ancillary and paramedical personnel now
perform many health functions and that an increasing number
of physicians are employed on a salary basis or financial
arrangement other than fee-for-service.
Scientific and technological advances in medical care have
occurred at a rapid rate in the past several decades. These
advances have resulted in new and more complex procedures, the
creation and training of more health specialists, and more
costly and intricate equipment. With these advances, medical
services have become more effective, and this, in turn, has
created a greater demand for services.
- 8 -
These changes are creating new and difficult problems for
both government and the private sector in trying to meet
the public demand for health services. The Task Force has
attempted to identify the most important of these problems,
along with a number of solutions being proposed by health
authorities to deal with them.
Some Major Problems
1. Health care costs over the past ten years have
3
risen twice as fast as the Consumer Price Index.
There is, however, no conclusive evidence that
this cost increase has resulted in a propor-
tionately increased benefit to the general pub-
lic - the ultimate consumer of these services.
Consequently, more attention is being paid to
cost control and the reestablishment of a better
balance between the supply of, and demand for,
medical services.
2. There is growing dissatisfaction with the health
care delivery system. The consumer often com-
plains that he is being ignored and that medical
services are inadequate or unavailable. Whereas
the medical profession has traditionally empha-
sized quality of service, it must now devote in-
creasing attention to the availability, adequacy,
and appropriateness of medical services as well.
- 9 -
3. The concern with the diagnosis and treatment
(curative medicine) of sickness and disease has
tended to overshadow the prevention of disease.
This does not overlook the fact that preventive
health programs exist and, in many cases, are
effective. However, the identification of pre-
ventive programs as "sickness control" programs
is evolving and broadening into an ecological
concept of man being a biological entity, exis-
ting as a psychological self in a complex physi-
cal and social environment that has a great
effect on his health and well-being.
A Smorgasbord of Solutions
The solutions that attempt to deal with these problems are
many and varied. In an effort to gain a better perspective
on health, the Task Force classified a number of these
emerging concepts, program approaches, and innovations
under the three basic problems described above.
1. Some solutions aimed at controlling the rising cost
of medical services and alleviating the imbalance
between supply and demand are:
a. Prepaid medical insurance programs
b. Peer review
C. Utilization review
d. Consumer cooperation in cost reduction
- 10 -
e. Hospital planning
f. Manpower planning
g. Fee schedules
h. Capitation
2. Some of the solutions being offered in an effort
to deliver health services more effectively are:
a. The "campus concept" of medical service, under
which a number of operationally independent
facilities located close to each other share
some physical plant and services.
b. Group practice and, related to this, the devel-
opment of the professional corporation.
C. The establishment of hospital centers providing
a continuum of ambulatory as well as inpatient
services.
d. Various manpower innovations, including the
assistant physician, Medex, and nurse pediatric
practitioner.
e. Neighborhood or community health centers.
f. Financial and other incentives, encouraging the
provision of services on an ambulatory rather
than an inpatient basis.
3. Some solutions designed to make the citizen aware of,
and take action to correct, those factors in the
total environment that are detrimental to health are:
- 11 -
a. General health education programs to create an
increased health awareness.
b. Immunization programs.
C. Safety and accident prevention programs.
d. Awareness and concern for those substances taken
into or used on his body, including a variety of
foods and drugs.
e. Environmental control programs, including air,
water, solid waste, radiation, and noise.
- 13 -
THE CONSUMER'S VIEW OF HEALTH SERVICES
One of the Task Force's concerns related to consumer attitudes
toward health services. The difficulties in obtaining a cross
section of public opinion in a field as broad as health are
obvious. Within the time available for the study, the Task
Force could not carry out an exhaustive analysis of consumer
attitudes. However, by talking with a number of groups, in-
cluding users of private as well as public health services, it
was possible to gain some understanding of the way people feel
about these services.
Health As A Priority
It is apparent that health holds a high priority among the
American people. This is evident not only from the fact that
total expenditures for health services in the United States
are approaching $60 billion per year; it is also indicated by
the increasing public concern - expressed through organiza-
tions and news media - about the high cost of sickness, the
intolerable burden of social disease, and the continuing deter-
ioration of the environment. In a recent survey for Blue Cross,
Harris and Associates found that 51% of the population as a
whole gave good health a higher priority than possession of a
4
job.
- 14 -
What the Consumer is Saying
There is a growing awareness of the need for more consumer
participation in planning health services. One of the require-
ments imposed by the Federal Government on comprehensive health
planning activities carried out by the states is that advisory
councils must include a majority of consumers in their member-
ship. Similarly, consumer participation is an integral part
of the planning and operation of the federally-funded OEO
Neighborhood Health Centers.
The first question that usually arises in connection with con-
sumer participation in the planning and delivery of health
services is, "Does the consumer know what he wants?". Given
an opportunity, consumers of personal health services are
candid in their criticisms of "the system" and well aware of
their needs. Various groups pointed out that available ser-
vices are often not the needed ones, or they are inadequate.
Among personal health needs, for example, out-of-hospital
services (including home care) are insufficient; suitable
out-of-home facilities that could provide continuity of care
in the community are often not available; rehabilitative and
restorative services are limited; personal health services,
even if available, cannot be used because they are too costly
or too far away; transportation to service agencies is not
available or is too costly; no provision is made for child
care if parents require services away from the home; language
barriers add to the difficulty of providing care; and services
- 15 -
tend to be medically-oriented when the consumer often needs
a broader kind of assistance.
Consumers also criticize the quality of services. Some of
their more common complaints are long waits and poor facili-
ties; an impersonal atmosphere; no house calls; and an in-
adequate explanation by the health professional of what is
happening to and what is expected of the consumer.
An equally important consumer criticism is the fragmentation
of health services. Even a cursory review of directories of
health and welfare services available in medium-sized Cali-
fornia counties reveals that a person seeking assistance is
confronted by a confusing array of public and voluntary
agencies. As a result, he finds himself being shuffled
from one agency to the next during the course of what, for
him, should be a continuum of care linking together preven-
tive, diagnostic, treatment, and rehabilitative services.
The result in all too many instances is that coordination is
left to the consumer.
Coordinating services will not become easier for the con-
sumer. This is indicated by the large increase in the number
of programs providing services, facilities, and aid to commu-
nities, financed from Federal, State, and local government
sources. The need for coordination has never been greater.
In attempting to meet this need, public agencies have created
a number of types of local centers which have contributed to
- 16 -
the overlapping and fragmentation. Meanwhile, the already
slender resources of the multi-problem family are stretched
to the breaking point, as the family tries to find its way
through the maze.
Beyond the need for personal health services is a widespread
public concern for the quality of the environment as an even
more important determinant of man's physical and mental well-
being. It has been stated that "An individually acceptable
amount of water pollution added to a tolerable amount of air
pollution added to a bearable amount of noise and congestion
5
can produce a totally unacceptable health environment".
While this concern extends through all levels of society, the
effects of a deteriorating environment fall most harshly on
the underprivileged. For these people, lack of adequate en-
vironmental controls is real and close, taking the form of
inadequate housing, dirty neighborhoods, lack of open space,
overcrowding, and poor sanitary facilities.
Often, too, there is no single source of authoritative health
information available in the community, and the consumer sel-
dom has enough knowledge of the system to classify his needs
in terms of the providers' labels. Lacking information about
where help is available, the consumer does not know where to
go for assistance on his problems and frequently does not
even know that help is available. This is as true for gen-
eral health services as it is for special problems, such as
mental retardation, alcoholism, drug addiction, or family
planning.
- 17 -
Organizational Implications
Any organization providing health services, to be effective,
must be responsive to consumer needs. These needs are under-
going rapid and significant changes, and public programs must
be flexible enough to meet these changing needs. The State,
in administering health programs, must be prepared to listen
to the complaints and suggestions of consumers, to weigh
these against other competing demands, and to take appropriate
action. Participation on advisory boards and commissions re-
lated to health programs which, for a long time, has been
limited largely to providers of service, is now being opened
to consumers. The Task Force regards this as a desirable
change and feels that mechanisms should be built into any
proposed health organization to ensure that the consumer's
voice is heard by those responsible for planning and imple-
menting health programs.
- 19 -
TRENDS IN HEALTH CARE
Any new organization that is developed to administer the
State's health programs must meet the needs not only of
today, but also of the years ahead. It must be flexible
enough to change as public needs change. It is essential,
therefore, in developing the concept of a new organization,
to identify the significant trends in health care. The
Task Force regards the following as some of the more im-
6
portant trends and directions in this field.
Demand for Health Services
There is, and will continue to be, an increasing demand for
personal health services. This demand results from several
factors:
1. An over-all increase in population, from 76 million
in 1900 to 195 million in 1965, with a projection
of roughly 260 million by 1985,
2. An increasing ratio of older persons in the popu-
lation,
3. Increased urbanization, with potentially easier
access to health care,
4. A rising income level, and
5. A steady increase in education level.
- 20 -
Scientific and Technological Advances
In the past twenty or thirty years there have been rapid ad-
vances in both the science and technology of medical care.
These advances have resulted in new and more sophisticated
equipment, facilities, and medical and paramedical manpower.
The changes are transforming a highly individualized pro-
fession into a vast and intricately interdependent industry.
At least two major consequences have followed from these ad-
vances in medical science and technology. First, more medi-
cal manpower and facilities are involved, with the result
that medical procedures cost more money. Second, the health
services industry is able to offer better results, causing
a greater demand for these services.
The expansion of scientific and technical knowledge in the
health field brings with it the need for changes in the de-
livery system so that the advantages of these developments
can be enjoyed by persons requiring the services. This has
a tendency to obsolete facilities, equipment, and procedures.
An example of this type of change is the treatment of the
mentally ill in California, where the emphasis has shifted
from treatment in large State hospitals to treatment in
community facilities.
Growth of the Health Services Industry
There has been, and will continue to be, a substantial growth
- 21 -
in the health services industry. This is now the nation's
third largest industry, exceeded only by agriculture and
construction. Some three to four million people are engaged
in some aspect of health services.
An interesting feature of this growth is the declining ratio
of doctors to other health personnel. Whereas there was a
one-to-one ratio at the turn of the century, it is now one-
to-ten.
Specialization
Specialization has been increasing rapidly. In 1950, only
about a third of the physicians in private practice regarded
themselves as specialists. Today, the figure is closer to
two-thirds.
There are a number of obvious advantages to specialization,
but there are also several disadvantages. One of these is
described in the following statement:
"A major hurdle is the process of institutionalization
of paramedical personnel. Every new skill in the health
field tends to emulate the doctor. White coats are fol-
lowed by certification, awards, association, officer-
ships, and technical papers. More than fifty major
paramedical specialties are working side by side or
communicating across geographical gaps, on a downward
spiral of efficiency, insulated from one another and
preoccupied with the pursuit of skill, excellence, and
professionalism. Even strenuous efforts of institu-
tions cannot create enough horizontal pressure to
achieve suitable coordination, so that service is rele-
vant to the patient's total needs. 117
- 22 -
Specialization, both among physicans and paramedical per-
sonnel, is adding to the complexity and difficulty of man-
aging and utilizing health manpower. The physician is being
called upon to function as a team leader, drawing upon all
of the manpower resources available to him. Management
skills are becoming increasingly important to the medical
practitioner.
Combined Forms of Medical Practice
There is a distinct trend toward various kinds of combined
medical practice. These vary from informal relationships
of individual practitioners to formal incorporated groups.
8
Important legal decisions, such as the Kurzner decision,
and the legal authority to establish professional corpor-
ations have influenced this trend. Salaried employment of
physicians in government, hospitals, teaching, preventive
medicine, and research accounted for 17% of all doctors in
1963. If one adds to these groups the unknown but growing
number in partnerships, it appears that only about half the
nation's doctors are still in solo practice.
Institutionalization
There is increasing institutionalization of medical care.
Much of this centers around the modern hospital. These
organizations range from the "medical center of excellence"
9
visualized in the original DeBakey report to a gradually
evolving "campus concept". This institutionalization is
- 23 -
another outgrowth of the increasing complexity of medical
care, including the use of highly specialized personnel and
costly equipment.
Health Insurance
There has been a steady growth of mechanisms to cover expen-
ditures for medical care, through private health insurance
and expanded public medical care programs. Approximately
75% of the population now has some form of hospital expense
coverage, the most prevalent form of health insurance. While
there is a large portion of the population that is covered by
health insurance, less than one-third of total personal health
expenditures are now being met by such plans. With the passage
of legislation in 1965 establishing the Medicare and Medicaid
programs, additional millions of persons became eligible for
insured medical care.
Comprehensive Health Planning
In the past, health planning has centered around a categorical
approach. Programs have been developed to deal with such prob-
lems as tuberculosis, mental illness, alcoholism, heart disease,
or cancer. Recently, this fragmented approach to planning has
given way to comprehensive health planning. The Federal Govern-
ment has encouraged the change by providing financial support
for State, regional, and local comprehensive health planning
activities.
- 24 -
Community-Based Programming
There has been growing acceptance of the need for more commu-
nity-based health programs. At the State level, California's
Short-Doyle Act was a pioneer in this regard, followed by the
Federal Community Mental Health Center Program, the Mental
Retardation-Facility Program, and the Neighborhood Health
Centers established by the Office of Economic Opportunity.
- 25 -
THE STATE'S RESPONSIBILITY FOR HEALTH
The State's basic legal authority in matters of health resides
in its sovereign powers under the United States Constitution.
While the State of California, under its own Constitution, has
delegated certain powers to local units of government, it re-
tains ultimate responsibility and authority for the public's
health.
In its laws regarding health, the State has indicated a broad
intent regarding "preservation of the public health and safety,
including the health and safety of persons,
...
the safety and
10
protection of property; and matters incidental thereto". In
carrying out this intent, the State is responsible for organi-
zing, financing, and staffing those health activities which
the Legislature has authorized.
The State's Role in Meeting the Health Needs of the Public
In recent years, the entire field of health has undergone major
changes. This dynamic process is still underway. Most devel-
opments have revolved about concepts of public and private re-
sponsibility for health, health care delivery systems, the need
for more effective controls over the environment, health faci-
lities and manpower requirements, and the relative emphasis on
health programs competing for funds. One consequence of these
- 26 -
changes is that public jurisdictions have been compelled to
modify their roles significantly, and consequently, their
health organizations and programs. In addition, there has
been considerable discussion of the concept that health care
should be considered a right. It is essential, therefore,
that the State of California's role in meeting the health
needs of the public be redefined, giving full consideration
to the changes that have taken place in recent years and to
future trends and developments.
The State's role in health is changing in the following di-
rections:
1. The State is assuming greater responsibility for
assuring the availability of health care.
2. The State is becoming a major purchaser of health
services and reducing its role as a direct provider
of services.
3. The State is accepting greater responsibility for
the environment, especially in those areas detri-
mental to health.
4. The State is becoming increasingly concerned with
meeting the growing needs for health manpower.
5. The State is accepting greater responsibility for
comprehensive health planning.
6. The State is fostering community-based health
programs.
- 27 -
7. The State is entering more frequently into fiscal
and operating partnerships with the private sector
in meeting health needs.
In addition, the State has significantly broadened its health
authority by accepting responsibility for the implementation
of various Federal programs. It does this through comprehen-
sive health planning and policy determination; participation
in regional planning; allocation of funds for specified ser-
vices or facilities within the State (e.g., funds for local
public health services and hospital construction) ; review
and approval of health project proposals financed by Federal
agencies (e.g., health projects under Model Cities and
Housing and Urban Development programs) ; and certification
of agencies and facilities for participation in federally-
financed programs (e.g., Medicare and Medi-Cal).
The National Commission on Community Health Services (a pri-
vate corporation sponsored by the American Public Health
Association and the National Health Council) has provided a
clear indication of the important role of the states in meet-
ing health needs, as follows:
"In discussing new organizational patterns for health
services, the Commission arrived at the opinion that
the state is the jurisdictional entity on which atten-
tion must be primarily focused. For, despite the con-
tinuing demand for independence among smaller, local
communities, and despite a greatly increased partici-
pation by the federal government in matters pertain-
ing to health and welfare, the state still holds the
mandate stated in the Constitution of the United
States as the governmental center of all power not
- 28 -
specifically held by the federal government. In like
measure, all counties, townships, and cities are po-
litical creatures of the state and their powers have
been delegated to them by the state. Therefore, while
there is a definite tendency to develop regional ap-
proaches (interstate and intrastate) to health ser-
vices, by planning for them on the basis of geograph-
ical areas whose residents wish to secure common
community objectives, it still seems feasible to
consider the state as the filter, the arbiter, and
in many instances, the level 11 at which plans and pro-
grams are initiated.
"
The State's Health Goals and Functions
For the State to exercise such leadership, a set of broad
health goals must be enunciated. Functions essential to the
State's achieving its health goals must be identified also.
The Task Force recommends the following goals, along with
some related functions, most of which would be the responsi-
bility of a Department of Health:
GOAL
To identify health needs and develop programs to
meet them, giving consideration to relative priori-
ties and effectiveness.
Functions
Identify and evaluate health needs and problems
Develop policies, plans, and programs
Set program priorities and allocate resources
Evaluate program effectiveness
Encourage innovation
- 29 -
GOAL
To promote an environment that will contribute to
human health and well-being.
Functions
Identify factors that cause deterioration of a
healthful environment
Set and enforce standards to control such factors
Insure that consummable goods and other products
available to the public are not detrimental to
health
GOAL
To assure the availability of comprehensive health
services for all Californians, utilizing both public
and private health resources.
Functions
Develop plans to meet health manpower and faci-
lity requirements
Provide assistance in the development of health
facilities
Train a portion of the health manpower
Provide financial assistance to certain groups
of people who are unable to bear the cost of
medical care
Provide certain types of direct medical services
if private or local public treatment resources
are unavailable or unsuitable
Provide funds to cover some of the cost of local
health program development
- 30 -
GOAL
To assure that quality standards for health programs
and services are established and maintained.
Functions
Set standards for certain types of health man-
power and facilities
Ensure that standards are met
Set and enforce performance standards for local
subsidy programs
GOAL
To assist in coordinating the activities of health
agencies -- State and local, public and private --
along with medical schools, hospitals, and private
practitioners, in providing health services.
Functions
Ensure that the State's health programs are ad-
ministered in an integrated way and that program
fragmentation is avoided
Provide consultation and technical assistance
to public and private agencies in meeting health
manpower and facility needs and in designing
more effective systems for the delivery of health
services
GOAL
To promote the development of new knowledge on the
causes and cures of illness and on the means of de-
livering health services to the public.
- 31 -
Functions
Develop and maintain a health information system
Conduct basic research
Conduct research designed to deal with specific
health problems
Support the design and demonstration of more
effective systems for the delivery of services
GOAL
To help all the State's citizens understand the
essentials of positive personal health and the
effective use of available health services.
Functions
Assist the public school system in presenting
an effective health education program
Extend the general public knowledge of nutrition
Assist local public and private health agencies
in broadening understanding of health and the
use of available services
Build an education component into all health
programs
Need for a Unified Department of Health
One of the earlier task forces recommended consolidation of
"all health-related departments into one unified Department of
Health". Further consideration, including discussion at Cabi-
net level and the Agency charge to this Task Force, tended to
reinforce this view. However, the charge was sufficiently
- 32 -
flexible that had this Task Force found some other alternative,
including the status quo, to be clearly superior, it would
have been free to recommend it.
It is the Task Force's independent conclusion that a unified
Department is essential to the effective administration of
the State's health programs. It is also clear that sub-
stantial consolidation of health programs will be necessary
if the State is to fulfill its health goals. Accordingly,
the Task Force recommends that the State of California proceed
with the establishment of a Department of Health.
- 33 -
COMPONENTS OF A DEPARTMENT OF HEALTH
The Task Force was charged with responsibility for developing
an organization plan for a unified Department of Health.
Having identified the State's health goals and functions, most
of which would be the responsibility of a Department of Health,
it was then necessary to analyze the many health and health-
related programs in State Government to determine which of
these should be transferred into a Department of Health.
Some guidance was provided by the work of the National Commis-
sion on Community Health Services, mentioned earlier in this
report. The Commission conducted a four-year nationwide study
of community health needs, resources, and practices, out of
which it developed the following concept of a state health
agency:
"Every state should have a single, strong, well-
financed, professionally staffed, official health
agency with sufficient authority and funds to carry
out its responsibilities. The state should assure
every community of coverage by an official health
agency and access to the complete range of commu-
nity health services.
"This state agency must be able to work effectively
with federal agencies, to provide all the environ-
mental and personal health services for which it is
responsible, to stimulate and support the develop-
ment of local health units that will provide official
health agency services to local communities, to take
leadership in broadening the scope and quality of
health services available to its communities, and to
respond positively to the health needs of the public.
- 34 -
"This single agency, in which all the major health
programs of the state government should be concen-
trated, would be able to coordinate the various
environmental, preventive, curative, and rehabili-
tative components into a comprehensive health ser-
vice system. It should be responsible for setting
the health standards of other state programs even
though they may be a secondary activity of another
agency. "12
As a first step in determining which functions should be trans-
ferred to a Department of Health, the Task Force inventoried
the health-related programs in a number of State departments.
While the primary interest was in the Departments of Mental
Hygiene, Public Health, Health Care Services, Rehabilitation,
and Social Welfare, the Task Force also looked at programs in
several other departments. As an aid to understanding and
classifying these programs, the Task Force developed a pro-
gram structure for health, viewing State Government as a
whole. (Appendix D) The Task Force also established criteria
to assist in analyzing the desirability of including specific
functions in a new Department of Health, as follows:
1. The function is concerned primarily with health
preservation or restoration and is essential to
accomplishment of a key objective of a Department
of Health
or
2. The function is one which, because of close inter-
relationships with health, can be carried out most
effectively if combined with other programs in a
Department of Health.
- 35 -
If a function met one of the above criteria, the Task Force
also examined it from the standpoint of how its transfer to
a Department of Health from an existing department would
affect the remaining programs in that department.
Applying these criteria to a number of functions led to the
conclusions shown graphically on page 36. A discussion of
the specific components follows:
Department of Public Health
The Department of Public Health's program budget for the
1969-70 fiscal year describes its over-all objectives as
follows:
"The continuing mission of the State Department of
Public Health is to promote the highest level of health
attainable for every Californian in an environment which
contributes positively to healthful individual and family
living. This necessitates attention to all the complex
factors that influence health and that cause disease,
disability, and death. It also demands the technical
competence and resources to forestall potential threats
to health as well as to ameliorate adversity.
"Within this mission, departmental responsibility in-
cludes identifying those biological, physical, and social
conditions in working, living, and recreational environ-
ments that are detrimental to healthful living; planning
and coordinating the provision of high quality comprehen-
sive health services and facilities to all segments of
the population for the prevention and control of disease
and disability; and encouraging the full participation of
the people in recognizing their health concerns and in-
terests and in taking appropriate action in relation to
these. 13
The Department attempts to achieve these objectives through
three basic programs: Environmental Health and Consumer
COMPONENTS OF A DEPARTMENT OF HEALTH
DEPARTMENT OF
DEPARTMENT OF
DEPARTMENT OF
*
PUBLIC HEALTH
MENTAL HYGIENE
HEALTH CARE SERVICES
Staff: 1,185
Staff: 18,327
Staff: 295
Funds: $89,000,000
Funds: $269,830,000
Funds: $1,060,000,000
DEPARTMENT
OF
SOCIAL SERVICES
HEALTH
LICENSING OF HEALING
ARTS PROFESSIONS
(Dept of Social Welfare)
Staff: 22,103
(Dept of P&V Standards)
Staff: 1,085
Staff: 122
36 I I
Funds: $1,661,850,000
Funds: $225,600,000
Funds: $3,220,000
ALCOHOLISM PROGRAM
MEAT, DAIRY, AND POULTRY
VETERANS HOME
INSPECTION
(Dept of Rehabilitation)
(Dept of Agriculture)
(Dept of Veterans Affairs)
Staff: 54
Staff: 283
Staff: 752
Funds: $3,400,000
Funds: $3,800,000
Funds: $7,000,000
NOTE: "Staff" represents funded positions, 1969-70 F.Y.
"Funds" represents total dollars (Federal, State, and local)
controlled by the department, 1969-70 F.Y.
*
Neuropsychiatric Institutes (Staff: 1,055; Funds: $13,170,000)
to be transferred to University of California.
- 37 -
Protection Program, Preventive Medical Program, and Community
Health Services and Resources Program. The Task Force con-
cluded that all of the functions carried out under these pro-
grams are appropriate to a new Department of Health.
Department of Mental Hygiene
The Department of Mental Hygiene is responsible for providing
mental health services, including diagnosis, care and treat-
ment, and rehabilitation of mentally ill or mentally retarded
persons for whom no other treatment resources are available
or suitable. This responsibility is carried out through the
operation of 14 State hospitals. The Department administers
the Lanterman-Petris-Short Act, which provides funds for com-
munity programs for the mentally ill. The Department also
conducts research into the causes, treatment, and prevention
of mental illness and retardation; provides education for
the general public on mental health; and conducts training
for mental health specialties.
With one exception, the Task Force concluded that all of the
functions of the Department of Mental Hygiene should be trans-
ferred to a Department of Health. The exception is the two
Neuropsychiatric Institutes, one in San Francisco and the
other in Los Angeles. The Institutes are located on the cam-
puses of the University of California Medical Schools in those
cities and are jointly staffed by the Department of Mental
Hygiene and the University.
- 38 -
The programs for which the Neuropsychiatric Institutes are
responsible are academic instruction and basic and clinical
research. These are essentially university functions. More-
over, they appear to be incidental to the primary mission of
the Department of Mental Hygiene, which is to provide diag-
nosis, care, treatment, and rehabilitation of the mentally
ill and mentally retarded. This is not to ignore the con-
tinuing need of the State hospitals to conduct staff train-
ing in job-related knowledges and skills and to carry on
research that is an integral part of its basic programs.
Since the Neuropsychiatric Institutes are performing a pre-
dominantly university function in a university setting and
their transfer would have relatively little impact on the
other Department of Mental Hygiene programs, the Task Force
concluded that the Institutes should be transferred to the
University of California for integration within its total
educational system.
Department of Health Care Services
The Department of Health Care Services is responsible for
administering the California Medical Assistance Program
(Medi-Cal). The program was established by the California
Legislature in 1965, following passage by Congress of Title
XIX of the Social Security Act (Medicaid).
The objective of Medi-Cal is to provide for the purchase of
basic health care and related remedial or preventive services
- 39 -
for recipients of public assistance and for medically needy
persons. While the program is carried out under the over-all
direction of the Department of Health Care Services, it also
involves several other State and local government agencies.
Each county, through its welfare department, certifies program
eligibility for the applicants who meet established standards.
The providers of services send their bills to the State's fis-
cal intermediaries (Blue Cross and Blue Shield) for payment.
The fiscal intermediaries check the claims for program com-
pliance and make payments to the providers of services.
The projected Medi-Cal caseload for the 1969-70 fiscal year
is 1.8 million, which includes 1.6 million in the categorical
aid programs, 175,900 medically needy, and 7,000 mentally re-
tarded patients. Medi-Cal expenditures for the fiscal year,
as shown in the 1969-70 Governor's Budget, total $1,059,532,571.
This is made up of: State General Fund, $386,768,790; County
funds, $218,842,000; Federal funds, $453,921,781.
Obviously, the impact of a billion-dollar public expenditure
program on the existing health care delivery system is sub-
stantial. This raises a fundamental policy issue: Should
the State attempt to use this purchasing power to influence
the character of the total health care delivery system? There
is no question that the State, in spending this amount of money
for medical care, is influencing the system, even if only to
perpetuate the existing system. The issue revolves around the
question of whether this influence should be random or purposeful.
- 40 -
There is ample evidence to support the view that the health
care delivery system is inefficient, wasteful, and costly.
For example, Secretary of Health, Education, and Welfare,
Robert H. Finch, stated recently, "The Medicaid program,
which already is costing twice as much as originally pro-
jected, was instituted with an appalling lack of planning."
In calling upon the medical profession to join with govern-
ment to provide the people with an adequate health care sys-
tem, Secretary Finch added, "The crisis of which I speak is
many-sided. It is a crisis of escalating costs, of inade-
quate facilities, of flaws in resource distribution, and at
14
the very core it is a crisis of manpower. =
In 1967, the National Advisory Commission on Health Manpower
reported that "Medical care in the United States is more a
collection of bits and pieces (with overlapping, duplication,
great gaps, high costs, and wasted effort) than an integrated
15
system in which needs and efforts are closely related".
Walter J. McNerney, President of the Blue Cross Association,
stated recently:
II
it is essential to face the fact that the system
is fragmented, with gaps and overlaps in service, one
that is too difficult for too many patients to use
well when in need, or, at times, to afford. Bolder
strokes than those taken to date are needed to give
it greater effectiveness.
"The challenge is one of selective involvement in
providing discipline to the system without smothering
its initiative and vitality.
16
- 41 -
Last year the Federal Government spent $1.6 billion on bio-
medical research. During that same year it spent less than
$18 million for research on ways to improve the delivery of
17
health services.
Former Secretary of H.E.W., Wilbur J. Cohen, put the problem
in this way:
"American health care is not really a 'system' but is
essentially a mosaic of public and private health pro-
grams -- one that has grown piecemeal to meet needs as
they arose
"This dynamic, pluralistic arrangement has definite
advantages. It provides opportunities for innovation
and competition for quality development, and incentives
for organizational and quality improvements. And it
has produced amazing medical miracles.
"But out of it has evolved a number of serious problems
that are likely to continue to face us in the decade
ahead. Among the most serious, I would include the
fact that the supply of certain services, such as
those of physicians, dentists and nurses, is inadequate.
There is often an excess in supply - duplication -- of
some services and facilities for high-income individuals,
including some very expensive hospital services, and
health facility planning is not now performed adequately.
Also, children, the poor, the disadvantaged, the blacks,
and other minority groups, often have inadequate access
to medical care. There are often shortages in less
costly alternatives to hospital care such as outpatient
care, home health services, extended-care facilities
and nursing homes. Some costly services, especially
hospital services, are sometimes utilized unnecessarily.
Many private health-insurance plans produce undesirable
incentives to use the most expensive methods of care;
there are substantial gaps in the coverage of health
insurance. The cost of many drugs is too high. Many
possible hospital management improvements have not been
adopted. The growth of group practice has been retarded
by. legal bars and restrictive attitudes. Productivity
in the provision of medical care has not been defined
and measured. Insufficient attention is given to pre-
ventive care and health education. There are insuffi-
cient financial incentives to restrain mounting hospital
costs while maintaining high-quality medical care.
- 42 -
"Ignorance of quality comparisons or the failure to
undertake them have resulted in the purchase of high-
priced drugs or unnecessary services. There has been
unsatisfactory organization of activities at all lev-
els - public and private - in the health field. In
summary, there are serious deficiencies in the organi-
zation, financing and delivery of health care in the
United States.
"These problems create obstacles to the provision of
adequate health services for all Americans. Although
the poor suffer most from the inadequacies of the sys-
tem, American families of all income levels are exper-
iencing the consequences of our piece-meal system. "18
In discussing the role of a State health agency, the Advisory
Committee on H.E.W. Relationships with State Health Agencies
stated:
"
A revolution in health delivery systems is called
for; the situation demands innovation, wider use of
allied health personnel, new channels of cooperative
effort, and new partnerships. The state health depart-
ment should be the focal point for these changes. 19
The Task Force found these and similar arguments persuasive.
While State Government must be concerned with the cost of
Medi-Cal, there is an even larger concern, and that is the
increasing cost of medical care for all Californians. The
health services industry must be encouraged to find less ex-
pensive but equally effective forms of care. At present,
insurance coverage is directed primarily at expenses incurred
by patients while they are in a hospital, thus encouraging
patients and their doctors to choose hospitalization when
less costly outpatient facilities or services would be equally
satisfactory from a medical standpoint. This emphasis on hos-
pitalization in lieu of ambulatory care has been underscored
- 43 -
by Dr. Joseph P. English, Administrator of the Health Services
and Mental Health Administration, Department of Health, Educa-
tion, and Welfare, who said:
"
in recent years a great many conferences, commis-
sions, and task forces have pointed out the need for
relatively greater attention to ambulatory care vis-a-vis
institutional inpatient services
But when we look at
...
the total health care enterprise, we must admit that we
are not putting our money where our mouths are. As a re-
sult of the cumulative impact of our financing mechanisms
and the present patterns of care, the system is swinging
ever more strongly toward the institutional modalities of
care. "20
The Task Force concluded that the State of California has the
opportunity -- and the responsibility - to spend its Medi-Cal
dollars in such a way that it exerts a constructive influence
on the health care delivery system. Working in cooperation
with the private sector, it can encourage the development of
less expensive forms of medical care. It can stimulate and
provide incentives for innovation. One of the State's major
concerns in conducting comprehensive health planning should
be the health care delivery system. If major improvements are
to be realized in the system, it is essential that these plan-
ning decisions be reflected in program decisions related to
Medi-Cal.
One other argument for including the functions of the Depart-
ment of Health Care Services in a new Department of Health is
that, in assessing total health needs and setting priorities,
expenditures for the Medi-Cal program should be arrayed along-
side expenditures for other programs competing for the health
- 44 -
dollar. There are those who contend, for example, that the
State is spending too much on curative medicine and not
enough on preventive health services. These kinds of deci-
sions on resource allocation among competing programs can
be made most effectively if Medi-Cal is viewed in the con-
text of all the major health programs.
The main arguments presented to the Task Force against in-
cluding the functions of the Department of Health Care Ser-
vices in a Department of Health are (1) that Medi-Cal is a
welfare program and not a health program, and (2) that there
is more likelihood of the State's establishing effective cost
controls on the program if it continues to be administered as
a separate department. Advocates of this point of view con-
tend not only that Medi-Cal is a welfare program, but that it
is essential to maintain its identity as such. They point
out that roughly 90% of the beneficiaries of Medi-Cal are re-
cipients of some form of categorical assistance under the wel-
fare program. They are also concerned that the costs of Medi-
Cal would be submerged in a Department of Health and that
there would be less likelihood under that organizational
arrangement of establishing effective cost controls on the
program.
The Task Force is well aware of the concern over the cost of
Medi-Cal. However, the Task Force believes that in the long
run the best chance of holding down the cost of this program
is by improving the total health care delivery system through
- 45 -
the development of less costly alternative forms of care.
This can be accomplished most easily if the responsibility
for Medi-Cal is placed in a Department of Health, where it
can be related more closely to basic health planning policies
and decisions.
Social Services
The State Department of Social Welfare supervises the admin-
istration by the 58 counties of money payments to public
assistance recipients and the provision of social services.
The department reviews and licenses plans for the reception
and care of the aged and children, both directly and through
delegation to local agencies. It licenses public and private
adoption agencies and provides reports to the courts on inde-
pendent adoptions. It issues certificates of authorization
for certain institutions to enter into "life care" contracts
with aged persons. The department also provides directly cer-
tain social services, chiefly those related to adoptions, child
protection, and patients released from State hospitals.
Under supervision of the Department of Social Welfare, the
counties provide a broad range of social services to people -
most of whom are also recipients of cash or medical assistance.
These social services have varying degrees of relatedness to
health services. They range from the placement services for
mentally or physically handicapped patients discharged from
State hospitals to the supervision of county adoption programs;
- 46 -
from identification of medical treatment needs to promotion
of adequate child nutrition; and from family planning coun-
seling to the provision of a home health aide or homemaker.
It is becoming increasingly difficult to draw a clear line
between health services and social services. This is evident
when we examine some of the overlapping programs in this area.
For example, alcoholism clinics, local mental health clinics,
and diagnostic centers for the mentally retarded compete with
the county welfare department's protective services for budget
resources, qualified staff, and even clients. This fragmen-
tation is evident also in the home health aide services for
the temporarily ill, permanently disabled, or feeble aged.
These services are licensed by the Department of Public Health,
funded by the Department of Health Care Services, duplicated
in large measure by the Department of Social Welfare's atten-
dant care-homemaker program, and used by the same client group.
To cite still another example, a health visitor from the county
health department makes a post-partum call on almost every new
mother to identify health problems; the county welfare depart-
ment social service worker makes a routine call on each AFDC
mother with a new baby to make sure that both mother and child
are well and that the baby is not neglected.
Organizational separation of closely related services at the
State level is carried over to the local level, with the result
that the person seeking assistance is often shunted from one
agency to another in a frustrating effort to coordinate for
- 47 -
himself those services that government has failed to coordi-
nate. It is the Task Force's hope that the State, by placing
its own house in better order, will stimulate local government
to provide for better integration of its health and social ser-
vice programs, with a consequent improvement in the quality of
service to the public.
One of the social service functions for which the Department of
Social Welfare is responsible is licensing of institutions for
children and aged persons. The Departments of Public Health
and Mental Hygiene also have licensing functions with respect
to certain types of out-of-home care facilities. The adminis-
tration of these licensing functions by the State has been sub-
ject to considerable criticism in the past. All indications
are that the licensing of out-of-home care facilities will be
an expanding function as the State continues to move toward
more community-based programs. It is essential, therefore,
that the existing problems in relation to facility licensing
be solved as soon as possible.
The second health Task Force identified the following problems
resulting from this fragmentation of responsibility for faci-
lity licensing:
1. Multiple interpretation and application of licensing
laws, rules, and regulations by licensing departments.
2. Inconsistencies in enforcement through inspection by
several departments.
- 48 -
3. Enforcement and regulation by more than one depart-
ment for some facilities.
4. Duplication of consultative services within licensing
departments.
5. Lack of accountability for consistency in setting and
revising standards.
6. Lack of a comprehensive licensing program which em-
phasizes the common program elements of medical,
health, and social care instead of the distinctive
21
elements.
It is the present Task Force's opinion that consolidating the
facility licensing functions of the Departments of Mental Hy-
giene, Public Health, and Social Welfare in a Department of
Health will enable the State to overcome the problems indicated
above.
The Federal Department of Health, Education, and Welfare has
recommended organizational separation of social services from
cash payments in welfare programs. The State Department of
Social Welfare has already organized along these lines and has
directed county welfare departments to effect a similar organi-
zational separation by July 1, 1970. The Task Force agrees
with this separation and feels that the State should take the
additional step of effecting a closer integration of health
services and social services.
The value of social services to health programs has been recog-
nized for a long time. For example, each of the State hospitals
- 49 -
has a staff of social workers. The staff of the Community
Services Division of the Department of Social Welfare, which
assists in providing out-of-home placement for persons re-
leased from the State hospitals, was in the Department of
Mental Hygiene until a few years ago. (The staff was trans-
ferred to the Department of Social Welfare primarily to opti-
mize Federal funding.) In addition, both the Department of
Public Health and the Department of Health Care Services have
small social service staffs.
Social services are also recognized as an essential part of
various community health programs. In the local mental health
program, the diagnostic centers for the mentally retarded, and
the OEO Neighborhood Health Centers, social workers serve as a
valuable part of the total therapeutic team.
It was the Task Force's conclusion that:
1. Most of the social service functions of the Department
of Social Welfare are related in one way or another to
protective living,
2. The primary reason for providing protective social
services is to insure the health and well-being of
people requiring this kind of assistance,
3. It is becoming increasingly difficult to draw a work-
able dividing line between health services and social
services, and
4. The public will be served best by integrating these
services as fully as possible.
- 50 -
Licensing of Health Professionals
Within the Department of Professional and Vocational Standards,
there are ten licensing boards related to the healing arts.
They are responsible for issuing licenses to more than 310,000
persons. Their purpose is to protect the public by insuring
that persons practicing the healing arts possess the necessary
skill and proficiency. Some of the boards have the additional
responsibility of establishing and enforcing standards for
accreditation or approval of more than 500 schools in their
respective fields. The healing arts boards include:
Board of Chiropractic Examiners
Board of Dental Examiners
Board of Medical Examiners
Board of Nursing Education and Nurse Registration
Board of Optometry
Board of Osteopathic Examiners
Board of Pharmacy
Board of Examiners in Veterinarian Medicine
Board of Vocational Nurse and Psychiatric Technician
Examiners
Social Worker and Marriage Counselor Qualifications Board
The boards have broad statutory powers to set standards, con-
duct examinations, investigate complaints, and take disciplinary
action against erring licensees. The number of members on a
board varies from five to twelve. The staff assigned to each
- 51 -
board varies from one to thirty-one. Board members are
appointed for three or four-year terms by the Governor and
are selected from the professions licensed, except for one
non-licensed public member on six of the boards.
The Department of Public Health also licenses or certifies
a number of types of health personnel. These include clini-
cal laboratory technologists and trainees, bioanalysts, home
health aides, public health microbiologists, public health
nurses, public health sanitarians, radiologic technicians,
and school audiometrists.
Providing sufficient health manpower is becoming an increas-
ingly serious problem. The problem has been aggravated by
the fact that Medicare and Medicaid have made health care
services available to many persons who did not have access
to them before. The State has an obligation to assess the
need for health manpower and take steps to meet the need.
This includes such things as working with public and private
training institutions to provide the necessary curricula,
stimulation of new approaches to meeting manpower needs, and
encouraging those responsible for licensing the health pro-
fessions to tailor their credentialing requirements so that
they are truly relevant to the tasks to be performed.
This is consistent with steps being taken by the United States
Department of Health, Education, and Welfare to support inno-
vative programs aimed at shortening physician training
- 52 -
curriculums, increasing the number of family physicians,
and training physicians in the efficient and effective use
of auxiliaries. In line with its announced intention of
integrating returning medical corpsmen into the health care
team, the Department of Health, Education, and Welfare plans
to work for revisions of State licensing practices and edu-
cational standard setting to permit greater mobility within
health occupations and greater access to such occupations
22
by those who can substitute experience for education.
The healing arts boards in the Department of Professional
and Vocational Standards are limited in their capacity to
provide this kind of leadership in meeting the total need
for health manpower. The autonomy of the individual boards,
along with the small size of their staffs, inhibit them from
viewing the problem in terms other than that of a relatively
narrow occupational specialty. The present organization, in
some cases, has also led to a series of exclusive and rigid
requirements for licensing in particular fields. Upgrading
from one field to another may require repetition of the edu-
cation required for the lower level.
The Task Force sees several advantages in placing the li-
censing of healing arts professions in a Department of Health.
It will facilitate the coordination of the licensing function
with health manpower planning. It will provide a better cli-
mate for innovation in meeting the rapidly expanding demand
for health manpower. It will be better able to eliminate the
- 53 -
artificial barriers that exist among professional classifi-
cations. It will provide a better framework within which
to evaluate the need for new professional boards when new
specialties emerge with a request for licensure. And a
Department of Health will be in a position to encourage the
educational institutions to develop new and improved courses
of instruction.
Alcoholism Program
The State's alcoholism program started with the establish-
ment of an Alcoholic Rehabilitation Commission in 1954. The
program was transferred to the Department of Public Health
in 1957. In 1967, legislation was passed directing the De-
partment of Public Health to contract for services with the
Department of Rehabilitation, followed by legislation in
1969 which designated the Department of Rehabilitation as
the State department responsible for the alcoholism program.
The primary reason for transferring the function to the De-
partment of Rehabilitation was to take advantage of the more
favorable Federal funding. However, recent Federal legis-
lation (Section 204, PL 90-577) appears to have removed the
necessity for locating the program in the Department of Re-
habilitation in order to assure maximum Federal participation.
Under the provisions of the McAteer Alcoholism Act, the De-
partment of Rehabilitation operates one clinic directly and
contracts with cities and counties to operate ten others.
- 54 -
A similar program exists within the Department of Mental
Hygiene, which administers the Lanterman-Petris-Short pro-
gram. This program provides treatment and care through
local clinics, purchased services, and State hospitals. The
Task Force is unable to identify any concerted effort to
coordinate the activities of the two programs.
Transfer of the alcoholism clinic program from the Department
of Rehabilitation to a Department of Health will reduce the
fragmentation in this program area and will facilitate a sys-
tematic approach to the prevention of alcoholism and to the
identification, treatment, and rehabilitation of alcoholics.
Meat, Dairy, and Poultry Inspection
All meat, poultry, and dairy products sold in California are
subject to inspection. The principal agency responsible for
these programs is the State Department of Agriculture.
Inspections made of milk, milk products, and products resem-
bling milk products start at the dairy ranch, or other pro-
duction facility, and continue through processing to the con-
sumer. The objectives of the inspection program are to in-
sure that the products are nutritionally adequate, that they
are not hazardous to health, and that they are unadulterated
and properly labeled. The inspection includes physical faci-
lities, equipment, operational procedures at producer and pro-
cessor levels, and serving of both milk products and products
resembling milk products at restaurants. The conduct of these
- 55 -
-
inspections is divided approximately equally among three
groups: State Department of Agriculture field staff,
local milk inspection districts, and county health depart-
ments.
The objective of the State Department of Agriculture's meat
inspection program is to insure that only wholesome, clean,
and truthfully labeled meat products are sold to the con-
sumer. Inspections are conducted in slaughtering and pro-
cessing establishments. Meat food labels are approved.
The department maintains quality standards through chemi-
cal laboratory analysis for biological residues, pesticides,
permitted and non-permitted additives, contaminants, adul-
terants, and preservatives.
The poultry inspection program attempts to assure the sale
of wholesome, unadulterated, and correctly labeled poultry
products. The Department of Agriculture carries out this
responsibility by enforcing sanitary building and proces-
sing procedure requirements in plants licensed to process
poultry and rabbit meat for human consumption.
The Department of Public Health conducts several related
functions. Its food protection program attempts to elimi-
nate or reduce chemical, bacterial, or physical adultera-
tion; misbranding; false advertising; and substandard food
products. Its cannery control program attempts to elimi-
nate the risk of botulism.
- 56 -
The primary purpose of the meat, dairy, and poultry inspec-
tion functions of the Department of Agriculture is to pro-
tect the consumer public from human and animal diseases
capable of being transmitted through these food products.
The Task Force regards this as basically a health purpose
and believes that the functions should be made the responsi-
bility of a Department of Health.
State Veterans Home and Hospital
The Department of Veterans Affairs is currently responsible
for administering the State Veterans Home and Hospital. The
facility is supported by both Federal and State funds. It
provides not only hospital care, but also nursing home and
domiciliary care. The average age of the residents is 72
years.
Since 1957, use of the domiciliary wards has declined SO that
less than half of the 1,558 beds are now utilized. The hos-
pital and nursing home wards, on the other hand, are utilized
at over 90% of capacity. Further evidence of the medical
orientation of the facility is the fact that approximately
56% of all civilian employees are medical, ancillary, or
paramedical personnel.
The Task Force concluded that the Veterans Home and Hospital
program is primarily medical and that the facility should be
made the responsibility of a Department of Health. Bringing
the facility into the same organization with other health
- 57 -
programs will make possible the sharing of technical and
management knowledge, better utilization of staff, improved
professional contacts, and better care for the resident
veterans.
Programs Reviewed but Not Included in a Department of Health
In addition to the functions described above, the Task Force
examined a number of other health-related programs to deter-
mine the feasibility of including them in a Department of
Health. For various reasons, the Task Force decided not to
recommend their inclusion at this time. Several of these
programs merit special comment, as follows:
1. Pesticide residue and agricultural chemical programs.
The State Department of Agriculture carries out several
functions relating to agricultural chemicals and pesti-
cides. It requires agricultural chemicals to be properly
labeled and provides for inspection and enforcement of
quality requirements. It licenses agricultural pest
control operators, regulates the use of pesticides, the
sale of pesticides, and the issuance of licenses to
qualified pest control operators and pilots operating
aircraft used in pest control. It establishes standards
for pesticide residues and conducts inspections to see
that the standards are not violated.
- 58 -
While these functions have a health relationship, the
Department of Agriculture is also concerned about the
effectiveness of pesticides in eliminating plant pests.
The Task Force concluded that the Department of Agri-
culture should retain its present responsibilities in
this field. It concluded further that a Department of
Health should conduct and support research activities
in the field of pesticide residue, make recommendations
regarding standards for residue, and maintain an over-
all surveillance on the use of agricultural chemicals
as they affect the health of the people of California.
2. Air Resources Board
The extent to which air pollution is a health problem
is an issue subject to considerable debate. This adds
immensely to the difficulty of defining the responsi-
bility of a Department of Health in controlling air
pollution. Does it involve only questions of whether
air pollution clearly contributes to morbidity or dis-
ease, or does it extend to eye irritation which may
affect comfort but is not a serious illness? Does it
extend to increased stress, which may be the primary
"health" effect of limitation of visibility? A good
case could be developed that almost any aspect of air
pollution has some health connection and should be
within the sphere of a Department of Health. On the
- 59 -
other hand, there are other interests besides health
that are concerned with air pollution. For example,
concern with hydrocarbons in California's air stems
primarily from its adverse affect on vegetation and
agricultural crops rather than on human health.
The Task Force concluded that no action should be taken
to transfer the functions of the Air Resources Board to
a Department of Health. In addition to the fact that
there are other interests besides health that are con-
cerned with air pollution, the Task Force noted that
the Air Resources Board is a relatively new organiza-
tion that has not yet had an adequate opportunity to
prove its effectiveness.
The Task Force believes, however, that a Department of
Health has a valid concern with the problem of air pol-
lution and its impact on human health. The proposed
Department should conduct research to determine more
precisely what that impact is; it should continue to
recommend minimum standards for air quality; and it
should exercise surveillance as to the current status
of air quality and its effect on human health.
3. Water Quality Control.
The State Water Resources Control Board and the nine
Regional Water Quality Control Boards are charged with
providing coordinated, statewide control of water
- 60 -
quality and water rights so that the water resources
of the State are beneficially utilized to the maximum
extent, and to prevent water pollution by unreasonable
waste disposal practices.
The State Water Resources Board, established in 1967,
is the successor to the State Water Quality Control
Board. The Regional Water Quality Control Boards (and
the previous State Water Quality Control Board) date
back to 1949, when the responsibility for water pollu-
tion control was shifted to them from the Department
of Public Health. These boards have been part of the
Resources Agency since its establishment in 1961.
Following the establishment of a stronger organization
in 1967, the State Water Resources Control Board, at
the request of the Assembly Committee on Water, created
an independent panel to study the water quality program.
The results were enacted in 1969 as the Porter-Cologne
Water Quality Control Act. This act materially strength-
ened the authority of both the State and regional boards.
It also declared the intent of the Legislature for a
stronger water quality control program and strengthened
the existing law and enforcement procedures.
A number of other departments in State Government, such
as Public Health, Fish and Game, Agriculture, and Water
Resources, are also concerned about maintaining water
- 61 -
quality. The Department of Public Health, for example,
maintains surveillance and exercises preventive and
control measures relative to providing safe, wholesome,
and potable water supplies; to treatment and reuse of
sewage without hazards of disease or adverse effects
upon water supplies; to assuring that shellfish are
grown and processed in water such that the product will
be free of disease organisms, hazardous chemicals, and
toxins; and to achieving sanitation and safety for
bathers at public swimming pools, beaches, and other
recreation areas. The staff works closely with staff
of the State Water Resources Control Board and the
regional boards.
The Task Force concluded that no action should be taken
to transfer any of the water quality functions of the
State Water Resources Control Board or the nine Regional
Water Quality Control Boards to a Department of Health.
One reason for this is that health is just one of a
number of interests concerned with water quality.
Another reason why no change is being considered at this
time is the recent reorganization in 1967, followed by
the significantly strengthened program adopted in 1969.
Prior to 1967, the State and Regional Boards admittedly
represented a weak administrative structure, with limited
power and authority to deal with the problems of water
pollution and water quality. The new organization, with
- 62 -
stronger laws and enforcement procedures, reflects pub-
lic demand for more effective water quality control.
The Task Force concluded that these developments should
be allowed time to demonstrate their effectiveness be-
fore any further changes are considered.
The Task Force believes, however, that the present powers
and responsibilities of the Department of Public Health
relating to water quality are appropriate for a Depart-
ment of Health. The new Department should carry out
research on the impact of water quality on human health.
It should exercise general surveillance over the status
of water quality. It should have summary abatement
powers when water contamination represents a threat to
human health. It should formulate and recommend mini-
mum standards of water quality necessary for human health.
And it should be a strong spokesman for health concerns
relating to water quality.
4. Division of Industrial Safety.
The Task Force examined the functions of the Division
of Industrial Safety of the Department of Industrial
Relations for possible inclusion in a Department of
Health. The Division's program is aimed at preventing
industrial injuries and deaths to California workers.
The Department of Public Health has two related func-
tions, namely, occupational health and radiological
- 63 -
health, as part of its Environmental Health and Con-
sumer Protection Program. The Division of Industrial
Safety has a staff of about 300, most of whom are safety
engineers. The Department of Public Health, in its occu-
pational and radiological health functions, employs a
staff of 55, most of whom are physicians, chemists, stat-
isticians, nurses, and other health-related specialists.
While there is some similarity in these functions, the
Task Force concluded that:
a. The responsibilities of the two departments'
programs in this area are delineated,
b. The programs appear to be coordinated, so
that there is a minimum of duplication,
C. The roles of the two departments are estab-
lished and understood by their respective
"publics", and
d. There would be little advantage in trans-
ferring the entire Division of Industrial
Safety to a Department of Health.
The programs of both departments are clearly directed
toward the safety and health of employees in work sit-
uations. There may well be a need for a more extensive
program of safety for the general public, not limited
to industrial working conditions. If such a program
were established, the skills of both groups would be
- 64 -
extremely useful in this broader approach to safety
and accident prevention. At that point, consideration
might be given to consolidation of the two functions
in a Department of Health.
If there is no immediate action taken along the lines
suggested in the previous paragraph, it would, however,
be in order to analyze further the responsibilities and
staffing of the two organizations in the radiological
and occupational health areas. The Task Force felt
that a more intensive review than was possible during
this study would suggest consideration of nominal trans-
fers of specific activities and related personnel to
clarify the responsibilities and consolidate health-
related activities. Since this is not a major organi-
zational or program change, it could be accomplished
administratively within the Human Relations Agency.
- 65 -
RECOMMENDED ORGANIZATION
Having reached certain conclusions with regard to the com-
ponents of a Department of Health, the Task Force then de-
veloped an organization structure for the new Department.
The Task Force, before deciding on a recommended organiza-
tion, examined several alternatives, including proposals
developed by groups outside State Government. (Appendix E)
The recommended organization structure is not intended as
a detailed blueprint. Rather, it is a concept of what the
Task Force considered to be a logical grouping of functions
in a Department of Health. Once the Director of Health is
appointed, he and the staff assisting him with the imple-
mentation planning should have the flexibility to modify
the structure as necessary.
Criteria for Recommended Organization
In evaluating various organizational alternatives, the Task
Force was guided by a number of criteria which should be met
by a new Department of Health. The Task Force felt that the
new Department should be capable of
conducting comprehensive health planning, giving
consideration to the needs of all Californians.
establishing goals and setting program priorities.
- 66 -
making a rational allocation of health resources
among programs competing for these resources.
consolidating or coordinating programs that are
now fragmented.
fixing responsibility and accountability for
program results.
evaluating program effectiveness in accomplish-
ing stated goals.
exerting a major impact on environmental issues
that affect people's health.
fostering better service to the public through
the integration of health services and social
services.
influencing constructively the nature of the
health care delivery system.
moving toward a continuum of care, embracing
both preventive and curative services.
making effective use of advisory boards and
commissions.
demonstrating a concern for people's health,
in the broadest sense, and moving away from
the archaic dichotomy between the physically
ill and the mentally ill.
maintaining sufficient flexibility to modify
programs and organization structure in response
to changing public needs.
- 67 -
placing more responsibility for health-related
services at the local level, with a gradual re-
duction in the State's role as a provider of
direct services.
making optimum use of Federal funding without
resorting to cumbersome organizational arrange-
ments in order to meet Federal requirements.
It is the Task Force's view that the recommended organization
is capable of meeting these criteria.
Director of Health
Selection of a director for the Department of Health is a
matter of utmost importance. He will be responsible for ad-
ministering the largest department in State Government, ex-
cluding the University and State Colleges, with approximately
22,000 employees. He will be responsible for the annual ex-
penditure of $1.7 billion in Federal, State, and local funds.
He must organize and manage a broad range of programs with
numerous public and private groups with an interest in health
services.
To carry out these responsibilities, the Director should be
a person with proven managerial skills. In molding the De-
partment of Health into an effective organization, it will be
most important to have a director who is able to deal with a
broad range of programs, to select capable subordinates, to
organize resources effectively, and to apply sound judgment
to difficult issues.
- 68 -
Some of these desirable qualities were described well in a
recent publication:
"Ideally, an administrator should be an individual
with proper training, experience, and temperament
to work with and through people. He must under-
stand problems of precedent, organization, personnel
administration, and decision making and be able to
function with such judicial evaluation that his
judgment will be equitable and acceptable, even
though the results are in disagreement with the
desires of many pressure groups. In addition, the
administrator must be able to appreciate the finite
quality of money and the selection of activation
priorities within dollar limits in terms of poten-
tial results. He must balance long-range planning
with decisive implementation of programs to meet
immediate needs. The success of any operational
program depends upon such energetic implementation.
It is SO easy to delay until there are more facts,
more committee meetings, 23 and more planning and
philosophizing.
Boards and Commissions
There are a great many boards, commissions, councils, and
committees related to the State's health programs. The Task
Force found it impossible, within the time available for the
study, to review the activities of each of these bodies. It
was the Task Force's conclusion that, once the Department of
Health is activated, there should be a comprehensive review
of all the advisory bodies related to health programs. Most
of them are undoubtedly serving a useful purpose, but it is
possible that there are some for which the need no long exists
or whose functions could be consolidated with other boards and
commissions.
- 69 -
The Task Force confined its attention to those statutory
boards and commissions with broad general powers, objectives,
and concerns. This revolved primarily around the State Board
of Public Health, the Health Review and Program Council, and
the Health Planning Council.
The State Board of Public Health is unique among the health-
related boards and commissions in that it has quasi-judicial
powers. It is a regulatory body in the health field, with
power to formulate policies affecting health; adopt, promul-
gate, and repeal rules and regulations consistent with law
for the protection of health; issue licenses and permits;
conduct hearings; and subpoena witnesses and documents.
The present Administration has been attempting to reduce the
number of boards and commissions in State Government and to
make those that continue in existence advisory rather than
administrative. In keeping with this general approach, the
Task Force recommends that the Director of the new Depart-
ment of Health assume from the State Board of Public Health
its regulation and licensing responsibilities. The Director,
in carrying out these responsibilities, would follow the pro-
visions of the Administrative Procedures Act.
The Health Review and Program Council is in the Department of
Health Care Services. The Council's statutory responsibili-
ties are to plan for the development of a comprehensive pro-
gram of medical care for all medically indigent persons by 1977;
- 70 -
to promote the most efficient use of available health faci-
lities; to compare the medical care given under Medi-Cal
with accepted standards of care; and to review the need for
systematic grading of health insurance prepayment plans.
It appeared to the Task Force that there were some major
areas of overlap between the responsibilities of the Health
Review and Program Council and the Health Planning Council.
The Health Planning Council was established by the Legisla-
ture in 1967. The Council has the legal responsibility to
advise the Department of Public Health in the conduct of its
comprehensive health planning activities and in the setting
of priorities. It also makes recommendations to the Director
of Public Health on the expenditure of planning money and
health grant funds. The Office of Comprehensive Health Plan-
ning in the Department of Public Health provides the neces-
sary staff work for the Council. The Task Force endorses the
concept of comprehensive health planning and feels that this
function will be an extremely important part of the total re-
sponsibility of a Department of Health.
During the first two years of its existence, the Health Plan-
ning Council has concentrated on organizing State and regional
planning services and on reviewing applications for health
grant funds. The Task Force believes that, in the future,
comprehensive health planning should devote increased atten-
tion to the health care delivery system. It should assist in
the formulation of public policy on health, clarify the roles
- 71 -
of government and the private sector in meeting health needs,
explore a whole range of social problems with health implica-
tions, direct attention to basic health issues, and provide
leadership in formulating proposals for legislation.
The Task Force recommends that the State Board of Public
Health, the Health Review and Program Council, and the Health
Planning Council be replaced by a new Advisory Health Council.
The Advisory Health Council would assume the existing powers
and duties of these bodies, with the exception of the State
Board of Public Health's authority to hold hearings on, adopt,
or hear appeals on regulations regarding public health and to
issue licenses and permits. This authority with respect to
regulations and licenses would be assigned to the Director of
Health. In addition, the Advisory Health Council would be
authorized to advise and make recommendations to the Director
on any matter within the purview of the Department.
The membership of the Advisory Health Council, with regard to
number of members, their qualifications, and appointments,
would be similar to that of the existing Health Planning
Council. However, the total membership would be reduced from
21 to 19 as a result of abolishing the positions of Director
of Mental Hygiene and Director of Public Health, both of whom
are members of the present Council. It is recommended that
the members appointed by the Governor be selected, to the ex-
tent practical, from existing members of the three boards being
abolished.
- 72 -
At some future time it may be desirable to expand the member-
ship of the Council, convert it to a part-time, paid body, or
make other basic changes in it. However, the Task Force con-
cluded that such decisions should be deferred until the pro-
posed Council has functioned for a time.
The Advisory Health Council will play a key role in assisting
the Department of Health to develop basic health goals, for-
mulate plans and policies to accomplish these goals, and es-
tablish program priorities. It will provide a forum at which
all groups with an interest in health will have an opportunity
to make their views known and to influence policy decisions.
The Task Force expects the Advisory Health Council, serving in
an advisory capacity to the Director of Health, to have a major
impact on health plans, policies, and programs for the State of
California. It will play an important part in giving meaning
to the term "comprehensive health planning", which Congress,
in enacting Public Law 89-749, defined as "
a process that
will enable rational decision making about the use of private
and public resources to meet health needs. Its concern encom-
passes physical, mental, and environmental health; the facili-
ties, service and manpower required to meet all health needs;
and the development and coordination of public, voluntary and
private resources to meet these needs."
Some Comments on the Recommended Organization
A chart showing the recommended organization appears on page 73.
It offers a concept of how a Department of Health might be
PROPOSED DEPARTMENT OF HEALTH
COMPREHENSIVE HEALTH PLANNING
HEALTH FACILITIES
HEALTH MANPOWER
Advisory
Health
Licensing
Planning
Planning
Project Plan Review - Construction
Council
Boards
Education and Training
Funding
Licensing
Licensing and Certification
Advisory
ENVIRONMENTAL HEALTH
PERSONAL HEALTH
Boards
Environmental Epidemiology
Prevention
Surveillance
Local Delivery Program and Plan
Consumer Protection from Toxic
Review
Materials
Purchased Medical Services
Solid Waste Management
Direct Community Services
Radiological Health
73 I
Occupational Health
Food and Drug
DIRECTOR
COMPTROLLER
Vector Control
Sanitary Engineering
Accounting
Business Services
Audits
Intermed. Operations
Budgets
Patients Accounts
STAFF SERVICES
Guardianship
Federal Grants
Planning and Evaluation
Health Information
HOSPITALS
Data Processing
Personnel and Training
Legal Services
Research
LABORATORY SERVICES
PROGRAM MANAGEMENT
Alcoholism
Drug Abuse and Addiction
Mental Retardation
- 74 -
organized. Several features of the organization merit special
comment.
The organization provides for three levels of planning. The
first level is comprehensive health planning which is con-
cerned with the entire field of health. It is long-range plan-
ning that includes identifying broad health needs, examining
the effectiveness of existing health services, and developing
plans and proposals for the optimum utilization of both public
and private health resources.
The second level is internal departmentwide planning. This
will be carried out by the Staff Services function, which will
be responsible for coordinating the planning and evaluation of
all the Department's programs. Being relatively detached from
line operations, the Staff Services function will be in a posi-
tion to assist the Director in raising basic program issues,
identifying the need for new programs and challenging some of
the existing ones, and recommending changes, as needed, in the
Department's allocation of its resources.
The third level of planning is the operational planning con-
cerned with specific line programs of the Department. It is an
essential part of the management job in each of the major func-
tional areas. Thus, the total planning effort proceeds from
broad comprehensive health planning concerned with both public
and private resources and services, to the more specific plan-
ning of departmental programs, to the detailed operational