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runs the risk now of simply setting up another bureaucratic structure which does not link effectively to the local government base.

I think that beyond that, there are a number of things that have to be done that probably are not necessarily legislative issues but are management issues and development issues.


Mr. HARRIS. Might I ask you, if you would, to explain the relationship between the community mental health centers and the community hospitals in Erie County? What is that relationship?

Dr. REYNOLDS. We have only one program that would be considered a community mental health center under the Federal model. The programs that have been developed there in the past 8 years were developed at variance with the community mental health center models for a number of years.

The models simply do not fit the needs of a community as we currently see those needs. We are organized with 1.1 million people into six areas. We refer to them as management territories.

They are approximately involving 200,000 people. Each of these areas have a mental health corporation which are all the community people, organized and incorporated for the purpose of providing, coordinating, planning the mental health services for their specific area or district.

The representation on the board reflects the composition of the community at large. Each corporation has a contract with our office which is a central management group. We do not run any district services from the local government base.

Everything is contracted to local community boards. So in the case of Erie County, each of the six areas has a mental health services corporation. These corporations are backed up by some centralized services in the areas of forensic, psychiatry, mental health, children, each of these having separate corporate bodies, transitional services for individuals coming out of our institutions, a centralized crisis service, all of this is tied together with a council of executives.

This is the executives of cach of the major clusters for the service dimensions of the system which provide the major decisions with regard to policy over the entire system.

I have the material that lays out the system in more detail. Mr. Harris. Actually, as you explained it, it seems to me that the corporation principle that is in this legislation is very consistent with the type of arrangement that seems to have been successful.

Dr. REYNOLDS. Except that it is not linked into the grassroots, the core of the community to the extent that these programs are. We have hosnitals that are not part of the corporate structure. For example, we have State hospitals. The ties are through formal shared agreements with community groups and not for through a corporate structure for the hospital itself. But I believe this is a unique situation to the extent that you do not have an umbrella State agenry here and the hospital would tend to drift without such a structure on top of it.

Mr. Harris. The District of Columbia presently has four community mental health centers for a population of 750,000 people. Do you think this is enough? Do you feel like there needs to be more!

Dr. REYNOLDS. I have no idea ; the testimony before the committee does not provide the kind of detail that would be necessary to give some sense of what the extent of those programs is.

A community mental health center could be anything from a small operation to 200,000 people. Obviously with a population between 750,000 and 800,000, four would be sufficient from a planning base.

But the question is the extent to which those programs were developed and the effectiveness with which they are operated.

Mr. Harris. Thank you very much. Congressman Mann?
Mr. Mann. No questions, Mr. Chairman. Thank you very much.
Mr. HARRIS. Ms. Martin?


Ms. MARTIN. We may have some questions in writing for you. Is it your testimony that the District Government should have a separate department of mental health?

Dr. REYNOLDS. I did not include remarks to that point in my comments. I believe that local governments should have a separately defined mental health authority. I would think that the District of Columbia should have such a separately defined mental health authority if there is going to be any equitable competition for the small resource pool that is available.

There is a major effort across the country to develop human service programs the effectiveness of which have been mostly shown to occur at the operational level. At the administrative level from State down to local government there have been serious problems in trying to combine mental health, health and related services under human services.

Mr. HARRIs. Thank you again. The committee is very much indebted to you for your testimony. Our next witness is Mrs. Polly Shackleton, the chairperson of the Committee on Human Resources and Aging, the District of Columbia Council.



Mrs. SHACKLETON. Thank you.

Mr. Harris. Mrs. Shackleton, it is a pleasure and an honor to welcome you to the committee. Knowing as we do your tremendous contribution you have made to the community and the excellence of your service as a public official, we are pleased to have your testimony.

You may proceed.

Mrs. SHACKLETON. Thank you very much, Mr. Harris. I appreciate those kind words. I am accompanied by Mrs. Lee Partridge, the staff director of the Council's Committee on Human Resources and Aging.

Mr. Chairman, members of the committee, I appreciate your inviting me to testify this morning on the draft bill to establish an independent Federal corporation to operate St. Elizabeths Hospital. The Council's Committee on Human Resources and Aging, which I chair, has general oversight responsibility for the city's mental health programs, and I am therefore concerned about the impact any changes in the organization of St. Elizabeths Hospital may have on mental health services in this city.

DRAFT LEGISLATION I believe this draft bill is a major improvement over the several previous bills that would merely have transferred the hospital from the Federal to the District Government. This bill creates a corporation with a five-member board of directors.

Three members of the board are to be selected by the Secretary of Health, Education, and Welfare, and two members by the Mayor of the District of Columbia with the advice and consent of the District of Columbia City Council. Such a board preserves the Federal involvement in the hospital, but admits much more local voice in the hospital's operation.

When I testified before this committee in May 1975 on this same issue, I mentioned that the Rome committee report recommended an independent mental health authority be established and that this authority operate St. Elizabeths Hospital and all other public mental health services and facilities in the District.

St. Elizabeths is not merely the equivalent of a State mental hospital for the District. It has always had a broader mandate, and I believe the corporate approach this bill contemplates, with the FederalDistrict mix, is therefore a more appropriate organizational structure.


The transfer of the responsibility for operating St. Elizabeths to the new corporation will free the hospital from the many layers of bureaucratic supervision it now endures.

I checked recently on the organizational structure under which St. Elizabeths now works. I learned that St. Elizabeths is a part of the National Institute for Mental Health, which in turn is part of the Alcohol, Drug Abuse and Mental Health Administration, which is under the Public Health Service, which is part of the Department of Health, Education, and Welfare.

Thus, approval of any action St. Elizabeths superintendent wishes to take could require concurrence from the Director of NIMH, Administrator of ADAMHA, Director of the Public Health Service, Secretary of HEW, and finally the President of the United States. No acute care hospital should be forced to operate under such a cumbersome system.

The hospital's present status as part of HEW also, I am sure, has contributed to its funding and staff shortage problems over the past decade. When our committee studied the problems of District of Columbia General Hospital, we learned that District of Columbia General's staff had often requested funds that were cut out of the budget as it worked its way through the executive branch.

Budget protocol then precluded the District of Columbia General administration from making their true needs known to the Council

, the Congress and the community.

I am certain a similar situation has prevailed for St. Elizabeths, especially with regard to their capital budget. The result for both hospitals has finally been lack of accreditation by the Joint Commission on the Accreditation of Hospitals. A quality hospital requires sound financial support, and the best way to secure that, is a wellinformed governing board free to argue for the funds to meet the hospital's needs.

- prop LEGISLATIVE RECOMMENDATIONS Two sections of this draft bill do, I think, require some further study. Section 5 of the bill requires the Board to develop, within 2 years of the enactment of this bill, a comprehensive plan for the operation of the hospital. Section 5(b) requires the National Capital 5. Ha Planning Commission to transmit, within 1 year of the enactment of this bill, a comprehensive land-use plan for St. Elizabeths property which takes into account the needs of St. Elizabeths Hospital for such land area for its operation and any forsecable expansion or for other programs related to mental health research or treatment.

I don't think the National Capital Planning Commission can proper erly plan for the use of the site until the Board has determined the Ves hospital's future needs, and I don't think the Commission should usurp the Board's planning functions. Therefore, I would suggest that section 5(b) be amended to require the NCPC plan to be filed within 1 year of the Board's filing of its comprehensive plan.

Section 9 of the bill covers the funding for the hospital. I have two problems with this section as it presently stands. Subsection (b) is, of course, only a sense of the Congress statement and does not actually require that the District of Columbia Government make consta tributions to St. Elizabeths in addition to payment for patient care. Nevertheless, I do not believe it is appropriate for the District to have to pay for more than the care of patients who are a public responsibility. I would urge this section to be dropped.

Section 9(a) will set the appropriations for the hospital for the next 3 fiscal years. As now written, the section provides no incentive to the corporation to maximize its revenue collections from sources other than the government.

Public hospitals are traditionally weak in this area. They receive government appropriations for their entire budget and are disinclined to worry about collecting from those who have insurance or income sufficient to pay for their care.

Generally, such revenues collected become part of the general corernment income, and do not return to the hospitals. Thus, there is no incentive for collecting on the part of the hospital, and no readily visible measure of the hospital's efforts to capture such funds.

As I stated in my testimony over a year ago, before transfer of the hospital is effected, its budget must be at a level sufficient to insure good care for all inpatients and meet the deficiencies in the physical facility cited by the joint commission.

The corporation board, however, should be expected to maximize collections from those with the ability to pay.

I suspect there are, for example, persons at St. Elizabeths who were committed by the courts many years ago and their families are still contributing to their care at the same rate set by that old court order. Those situations should, at a minimum, be examined to decide whether the corporation should seek authority for higher payments.

If the corporation is required to make these efforts, they will need staff with experience in financial management, and that should be taken into account in determining the level of these appropriations.

Mr. Chairman, I appreciate your courtesy in seeking our views on this proposed bill. This draft represents a conscientious attempt by your staff to meet many of the objections to and problems raised by earlier transfer legislation,

I hope you will call upon us at the Council if there are ways we can be helpful to you as you continue your work on this very important legislation.

Mr. HARRIS. Thank you very much, Mrs. Shackleton. As an old local government man, I was interested in your comments that by the time the Council sees the budget, the executive branch has sanitized it to the extent that you don't know what the original requests were and can't properly evaluate how badly the funding has been cut or how poorly the needs have been met. Is that a fair summary of what you said ? Mrs. SHACKLETON. I would say that it is, Mr. Harris. Mr. Harris. My experience with local government is that this type of department with its clients and constituency have always been able to make its needs known to me. They always actually knew-I always knew how badly the county executive had worked them over.

Somehow, those that were particularly interested in their program also knew it. Doesn't it work that way in the District of Columbia ?

Mrs. SHACKLETON. It does and it doesn't. There are various restrictions placed on the personnel of the departments who are really not supposed to deal directly with Council members.

As a matter of fact, systems have been set up whereby if our committee wants information from the Department of Human Resources, for instance, we are supposed to put in writing a request which then goes through the city administrator who then sends it to Mr. Yeldell who then sends it to whoever is supposed to respond and then it comes back through the same route.

Mr. HARRIS. You don't really put up with that, do you? That breaches all kinds of constitutional rights.

Mrs. SHACKLETON. We obviously have people come to us. Certainly in some of these mental health situations, there are community groups which are fighting the battles and do come to us. But it is a problem. They are very secretive about these things.

Mr. HARRIS. I felt in my experience that I had detected some of that. I don't think that is good for government. The Council is composed of people with a gamut of interests representing the needs of the community.

I really think the Council needs to be able to go to department heads or division heads or what-have-you and get them to tell what they actually think. I don't think that destroys effective administration at all.

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