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Dr. DONOHUE. That is right.
Mr. JARMAN. Mr. Rogers?

Mr. ROGERS. Thank you, Mr. Chairman. I have been impressed by the testimony here. What is the cost of this facility!

Dr. DONOHUE. Of the actual facility? When we get it all constructed it is going to cost approximately $900,000 as our estimates are now.

Mr. ROGERS. And what would be the Federal contribution?
Dr. DONOHUE. The Federal contribution in that is $531,000.

Dr. GLASS. The figure on Federal proportion in Oklahoma is 59 percent.

Mr. ROGERS. All one figure?
Dr. GLASS. Yes.

Mr. ROGERS. In establishing the facility, are you, in effect, raiding any other facility!

Dr. DONOHUE. We are taking some out of the mental hospital moving over there but we can afford to do this because we are going to be handling that portion of their patients.

Mr. Rogers. So that you don't feel that it is a case of pulling people out of another facility where they would leave a vacancy that they have to fill? They don't have to replace those personnel ?

Dr. DONOHUE. We wouldn't dare do that because I happen to have them both under my control and if I did that, I would be in trouble on the other side.

I am watching that closely but we are getting them from the outside, Mr. Chairman, and Mr. Rogers.

I think this is going to be a lot easier to staff than the State hospitals. People like to work there and these are going to be “in the community."

Mr. ROGERS. This is what I wondered about, some of these programs, for instance, some of the veterans hospitals. I think their pay scale may not match some of the suggested pay scales in this program and this may vary from State to State. I wonder what the impact will be, for instance, on the veterans hospital with their psychiatric program.

Dr. DONOHUE. I pay more than they do and I can't raid them right now because they have a lot of hidden benefits that we don't have in the state services. They have retirement programs and things so that you have to add this altogether.

Then, Mr. Rogers, I think there is another thing. This psychiatrist and other personnel who like to work in Federal and State, they pretty well stay in their own categories.

In the State service we move around much more than they do in the Federal.

Mr. ROGERS. Are your services paid for?

Dr. Donohue. If we can collect. I think this is a wonderful thing. We have never in the State of Oklahoma ever forced anybody. If they could under the law, I have to collect it and this would be the same here.

Mr. ROGERS. Let me ask you this question, and I may want to branch out to others, too. As to the theory, of course, of separating even here the Institute of Mental Health into a separate bureau and now talking

about building mental health facilities separate and apart from regular hospital overall care, is this a good trend over the long run, or don't you think eventually we are going to have to put all of the physical as well as mental care in the overall approach?

Dr. Glass. What do you mean by long run? Do you mean a time frame of 1980 or something like this?

We do know that the facilities for the physical care are now located and pretty well set. We do know that a number of these general hospitals will elaborate community mental health centers as part of their activities and this is indeed going on now, as you know.

However, the problem is mental health can't wait for this. We need to get centers in now. It may well be that in time they may locate, but I want to point out that you don't have to have them actually together.

You can have an umbrella of services in the same area and all you need to do is have a free passage of patients. The word here is continuity of care, just as we have in the center. You don't have to have all phases of the center under one roof.

You can have the outpatient clinic in one place and the inpatient five miles away, so that we are not concerned with putting them altogether now.

Mr. ROGERS. What I want to know is this: From what I have observed, there seems to be a tendency to make a direct separation of the treatment of mental problems from physical problems.

I just wonder if some efforts should be given to tie the two together, but I would think that some of the physical patients have mental problems along with their physical difficulties because of the physical problem they have.

This doesn't seem to be the approach there and I was wondering if our philosophy is right here. Perhaps this program in itself is throwing us away from bringing comprehensive health care to the community.

Dr. WINSTON. May I comment?
Mr. ROGERS. Yes.

Dr. WINSTON. Of the three approved in Tennessee, two are in connection with general hospitals.

Mr. ROGERS. Do you think this probably is the approach that we should take, to require this program to be put in with general hospitals ?

Dr. WINSTON. Of course, some general hospitals do not have the space and cannot expand.

Mr. ROGERS. You are going to build a mental health center. If you are building for them is it advisable to build them with the general hospitals or isn't it?

Dr. WINSTON. It is not inadvisable. I think it is optional.
Mr. Rogers. Which is more advisable from your experience!

Dr. WINSTON. Again, I don't have any experience because we haven't had any of these built yet. I think there would be testimony to both sides. "I think keeping it in the medical stream is healthy, but in other ways it is crippling, too.

Mr. ROGERS. You said your staffing needs for a population of 75,000 has shown that you don't have to follow the old pattern that we had previously.

Has this been expanded? Is this being brought to the attention of people in this field ?

Dr. WINSTON. This is the case.

Mr. ROGERS. Has your experience been brought to the attention of people?

Dr. WINSTON. Well, it was in Reader's Digest, I don't know if you call that necessarily brought to the attention of everyone. What I say by traditional patterning is that we don't have this in most state hospitals because we don't have the staffs available and it wasn't out of choice that we had the patterning.

It was out of the necessity. When we opened the new hospital, I had only one other psychiatrist that I could employ, but this did not keep us from getting the patients out through the selection of tranquilizers, et cetera, and the aids who had the feel for people.

Mr. ROGERS. I am talking about the psychiatric society, the mental health association.

Dr. WINSTON. Yes, sir. This is not the unique experience by any means.

Dr. Glass. Mr. Rogers, there is no traditional pattern. Everyone is experimenting and moving with various kinds of mental health workers, social workers, using their scarce psychiatrists much more in a supervisory relationship than in a one-to-one relationship.

When you say, “Is there a trend in this direction", that is the trend entirely in the direction.

Mr. ROGERS. The reason I asked the question is when the testimony was presented to us when we passed the bill, it was that they envisioned a center of 8 psychiatrists, or it was 10, for 100,000 population.

Now, Dr. Winston tells me it was 75,000 and he treats the population in the area with two. This is quite a change from basic thinking even just a few years ago.

Dr. Glass. I don't think it was thinking. I think these were guesstimates.

Mr. ROGERS. I would think guesstimates are based on what they felt was necessary. I hope they wouldn't tell us they need 10 psychiatrists for every mental health center and it is going to cost a tremendous sums of money to provide the staffing down to 35 unless it was needed.

I heard of these new ideas coming up but I don't know that they are being actually acted upon by people here in trying to encourage a new approach or think it is easier to say, “I get more money if I say I need 10, although that may not be what I need."

Dr. DONOHUE. We went over this with the National Institute of Mental Health and discussed it at length. The American Psychiatric Association is extremely interested in this and we have the Journal on Hospitals and Community Psychiatry which produces articles constantly on this as do the programs of the American Psychiatric Association but also the people in the National Institute of Mental Health whom I have dealt with. We have worked to come up with new answers and one thing would be what is your caseload, where are you, where are you located.

For instance, this will affect your staffing patterns, too, whether you have a lot of poverty and a low educational area, distances into your hospital, the type of structures you have, how many psycholo

gists, social workers, and others you have to throw into the fray, but I don't know that there is any real set standard.

At least the National Institute of Mental Health didn't present me with one. They wanted me to prove that I could treat the number of patients that I estimated with what I was asking for the money for.

Mr. ROGERS I presume there would be a minimum?

Dr. DONOHUE. Yes, sir, I think there would be a minimum but I would think this would vary with your proposed caseload and the type of things you could handle.

We are going to take all comers in Oklahoma so that it is going to be different than if you didn't take alcoholics or psychotics or this or that.

We are going to use our hospitals and the National Institute of Mental Health has encouraged that we use our hospitals and as back up services so that these centers don't get filled up.

We are 12 to 16 days on our inpatient stay. If we would extend that and keep the patients there longer, we will fill these up like they have done in other countries so that we wouldn't be able to operate.

It is according to what your back up is going to be; are you going to use full-time psychiatrists and psychologists or have part-time coming in?

There are many factors that will affect your staffing pattern.

Mr. ROGERS. I was thinking of the minimum required and presented to us in the testimony on this whole subject. The figures given which I won't go into on page 101 of our hearings were 10 psychiatrists for a population of 100,000, 8 psychologists, 8 social workers, 19 nurses and so forth.

Dr. DONOHUE. They didn't stick me with that minimum anyway. because I couldn't have found that many and I don't think I needed that many now.

Mr. ROGERS. But this is the point I wanted to develop, that unless we do go into a new approach rather than a set minimum

Dr. DONOHUE. Mr. Rogers, the National Institute of Mental Health in my dealing with the people and I have seen a lot of them because they have been real interested and we were one of the first off the ground, have been very considerate in going over in detail what we are going to be and have never held me to anything.

I think they have made me prove that I was going to realistically handle these things. I think they are doing a good job.

Mr. Rogers. What amount of money do you think we should authorize to be appropriated for the continuation of this program?

Dr. DoxOHUE. I am not at that level of operation any more but we will have to accelerate it. I know you are going to have to accelerate it because you are going to keep adding to it.

All us guys in business are already in business and then you are going to have to accelerate these new ones coming in.

Dr. Glass. It is the considered opinion of the National Association involved in this and which has most knowledge about the plans that there needs to be an increase because more centers are coming aboard and we would support the statements that are made that it may well be doubled as to the present 1968 amount of money.

Mr. ROGERS. Should the Hill-Burton law require a psychiatric unit in every hospital?

Dr. Glass. I think that one of the problems of Hill-Burton is this: For example, let's say there is a 25-bed hospital in a certain area that needs one. If you require them to have a psychiatric unit they may not be able to operate it so you are already requiring something that is functionless to them.

So one would hate to have this legislation restrictive on particularly small hospitals.

Mr. Rogers. It might not in a 25-bed hospital.
Dr. Glass. You would have to have a larger hospital.
Dr. WINSTON. I think this new program does away with this.
Mr. ROGERS. To have psychiatric from the hospital?

Dr. WINSTON. From 1963 on. The community mental health center does away with this need for a new Hill-Burton facility, let's say, is my feeling

Dr. Glass. The hospital by merging in a number of the services of the community can become the inpatient facility but these negotiations should be left to the community to do. There may be several hospitals that would want to do it, one a Catholic and one a community hospital and so forth, so that I don't believe that we should take every hospital and say, "You must do thus and so."

I think we wouldn't be wise if one hospital wants to specialize in a lot of surgery and someone else does something else. I think it would be unwise to insist that they build a certain number of beds and work to operate a certain number of beds,

Mr. Rogers. You don't think the problem is such that general hospitals of a reasonable size should have psychiatric beds or treatment?

Dr. Glass. I think they should be encouraged to and a lot are doing it spontaneously.

NÎr. Rogers. Why should it not be required ?

Dr. Glass. When you require something you have to lay a yardstick against circumstances which we absolutely don't know. There may be three hospitals in an area. One of them has a good psychiatric service which all the psychiatrists logically use. That doesn't mean the one a block away should have the same thing.

Mr. ROGERS. Suppose there is no hospital that has the good psychiatric department.

Dr. Glass. Then we will have to plan which areas.

Mr. Rogers. Is this duplicating our program to say we have to build community health centers when it can be incorporated in the hospitals which are going to be built and must be built?

Dr. Glass. There are hospitals which are going to be renovated. There are a number of areas. For example, you are talking about inpatient services but to our minds the inpatient service is the smallest element.

Mr. Rogers. I will agree. This may be so but I am saying should that be incorporated. It may not be the largest. It may not need but 25 beds. I don't know.

Dr. Glass. True, but it may not be the appropriate place to have it.

Mr. ROGERS. Should we just completely disregard the mental health problem in building community hospitals?

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