Revised ceiling, program 8000

Program 8200

Program 8400 Program 8500

Total full-time equivalent...............

Maximum limitations for special and training programs (included in program 8400 total shown above):

Admiral BOONE. In that connection, I found the other day that another committee seemed to have difficulty in realizing that you cannot operate a hospital with just physicians, dentists, nurses, and dietitians. You must have a balanced staff, including the cooks, the bakers and the candlestick makers; the people who heat the plant and run the plant-to buy the food and pay the bills.

I would like very much, if you would permit Mr. Baker, who is the assistant to Mr. Moore, the budget officer of the Veterans' Administration, to explain the reference made by Mr. McNamara yesterday concerning our request for $16 million and, later $23 million.

Mr. BAKER. Madam Chairman and gentlemen, at the time we asked the Bureau of the Budget to approve the apportionment of the appropriation, granted by Congress, on a deficiency basis, indicating the need for $16,700,000 additional before the end of the year, we were covering the most essential requirements that we could foresee at that time in relation to staffing new hospitals which would come in during the year and requiring activation and staffs. However, subsequently upon a review of the entire situation, it became apparent in order to properly operate the existing hospitals, that we would also have to increase the funds over those that were then available in order to avoid to the fullest extent possible, any reduction in force and that was why we increased the estimate from $16.7 million to $23 million, which was, as has been stated, disallowed at that time by the President.

I would be glad to answer any further questions, if you have any. Admiral BOONE. Toward the end of the meeting yesterday, Madam Chairman, I think you had withdrawn to go to the floor, other com

mittee members raised questions about Philadelphia, the veterans' population load and the hospitalization requirements.

I answered their questions, I hope, to their satisfaction, but I would like to extend my remarks on the subject, because there has been a great deal of discussion about Philadelphia and the matter of the veterans there.

Originally, the Veterans' Administration planned a thousand-bed hospital at Philadelphia but when the President ordered the 16,000bed cutback, I understand from my predecessor that he had just a few hours within which to make an election as to which hospitals could be eliminated and which could be reduced in size. He very kindly came to give me Christmas greetings before Christmas and he said he made a cut in Philadelphia and changed it from 1,000 to 500 beds. It is our feeling that under the present situation VA facilities will not be adequate for that great metropolitan area. However, General Gray has testified before a subcommittee of the Appropriations Committee concerning this subject, and his comments appear in the hearings of that committee.

If I may, Madam Chairman and gentlemen, I would like to ask Dr. Tompkins, who is head of our neuropsychiatric staff, and one of the most informed men in the United States on the subject, to give a very brief presentation on our situation, both as to that problem and as it relates to patients.

I know Mr. Gentry is very much interested in that subject because the other day at a hearing before a State delegation they did not seem to be able to accept the fact that we are short in neuropsychiatric staffs in this country, and mental illnesses constitute a big load and the curve is going up very fast.

With your permission, I would like for Dr. Tompkins to make his presentation.

The CHAIRMAN. We would be very glad to hear Dr. Tompkins.

STATEMENT OF DR. HARVEY TOMPKINS

Dr. TOMPKINS. Madam Chairman and members of the committee, I do not think I should belabor the point that we have difficulties in treating psychiatric illnesses in our local communities, or States or through federally sponsored programs including the Veterans' Administration.

I think this was very well brought out by a report from the Council of State governments, which was issued a couple of years ago, in which they indicated the shortage of beds and the shortage of personnel throughout the country.

I am reminded of their comment in regard to the fact that they were 300,000 beds short for current needs. It was an excellent report, and as many of you know, the governors have asked for a survey of the training and research facilities that are available in the country at the present time with the hope of developing some proceedures to combat this dearth of personnel and facilities for the psychiatric patient and particularly the psychotic patient.

With your permission, I would like to shorten my statement by staying particularly on the subject of the psychotic, which is our most pressing problem in the Veterans' Administration, as well, as I indicated, in the country as a whole.

Most of our psychiatric hospitals now carry, perhaps, a 96-percent load, almost all of them psychotic patients.

In the 35 phychiatric hospitals we have at the present time, there are about 42,000 beds for psychotic patients. We have in the neighborhood of 1,900 not available primarily because of personnel shortages. As you may know, we also have psychiatric and neurological services in our general hospitals. We have approximately, at the present time, 2,000 unoccupied P. and N. beds in these hospitals because of staff shortages.

Now, it is known, because of the scarcity of mental health personnel, that we cannot expect to recruit all the people we need. However, it is true that at present there are mental health personnel available whom we could recruit, but cannot because of lack of funds.

I have been asked recently by individuals outside the Veterans' Administration with varied interests in our program as to whether we are deteriorating. What they were asking me was whether there are any horrible examples of areas of deterioration. I could not give them, in all honesty, any examples as yet. As to what the future will bring, it will depend upon our recruitment of personnel.

Right now in our existing NP hospitals we need 1,600 more people. I do not mean 1,600 psychiatrists or social workers, I mean all the people that go to make up a trained team for the psychiatric, and particularly the psychotic patient, if we are going to continue the level of care which we are trying to maintain at the present time.

Mr. AYRES. Is that for those cases which are determined to be service-connected?

Dr. TOMPKINS. No, sir; service-connected and nonservice-connected; those patients that are in our hospitals at the present time.

Until recently, we were admitting approximately 1 service-connected to 1 nonservice-connected. However, as time goes on, we are increasingly limiting our nonservice-connected patients as far as admissions are concerned. Now it is rare that a nonservice-connected patient is admitted to our psychiatric hospitals, unless he is a dire emergency, and the communities just cannot take care of the situation. The CHAIRMAN. Practically all of your Korean patients are serviceconnected, is that not true?

Dr. TOMPKINS. Yes, that would be at this particular time. The CHAIRMAN. And you have an ever-increasing load there? Dr. TOMPKINS. That is right. And, of course, Madam Chairman, our service-connected load is increasing because of laws that have been passed recently by Congress, and I understand there is another bill which would increase presumption for service connection to 3 years following service and which would, of course, increase our serviceconnected load.

The admiral spoke of our steadily rising waiting list. That list is a nonservice-connected waiting list-that is the individuals on that list have not been adjudicated as service-connected.

Now, you heard yesterday that there were in all categories 21,000, plus-I do not know the exact figure on our waiting list. Of that 21,000 plus, 13,500 are psychiatric and neurological or neuropsychiatric and of that 13,500, 10,000 are psychotics. Now, that doesn't mean that 10,000 psychotic veterans are roaming the streets. We have reason to believe that about 8,500 are now in hospitals which are not. sustained by the Veterans' Administration.

We have calculated with approximately 20 million veterans now living, that for the next 20 years a conservative estimate would indicate that we would have about 23,000 new physchotics per year.

I do not mean they would be service-connected; I mean veterans who are psychotic. If we stopped now with our veteran load—I am not considering the additional veterans that will be added year by year— we are tremendously short.

Mr. AYRES. Do you have any figures to show the percentage of psycho cases in comparison to those that are veterans and those who have never served?

Dr. TOMPKINS. No, sir, except

Mr. AYRES (interposing). On a nonservice-connected basis. What I am trying to get at is, Do we have any justification to say that even though at the present time the case is not service-connected, that the percentage of those who have served is inclined to be higher than those who have not?

Dr. TOMPKINS. Do you mean in the civilian population?

Mr. AYRES. Yes.

Dr TOMPKINS. No. My calculation of 23,000 was predicated on the civilian incidence in the particular age groups that we have in our veteran population. Does that answer your question?

When I said 23,000 in a 20-million veteran population, I could just as well have said 23,000 in a nonveteran population in the same age groups.

Mr. SECREST. You make no distinction?

Dr. TOMPKINS. I did not make any statistical distinction. I am speaking of the incidence after the veteran comes back into the community.

Mr. AYRES. The testimony yesterday was that you had 7,500 doctors you had trained to care for the psycho cases, is that right?

Dr. TOMPKINS. There are 7,500 individuals in the United States that are practicing psychiatry, of whom 4,500 are certified as specialists.

Mr. AYRES. And you have 676 that are assigned to VA hospitals? Dr. TOMPKINS. That is true if we consider all physicians in all specialties assigned to psychiatric hospitals.

I would like to make this statement that the number of physicians who are practicing psychiatry in the Veterans' Administration amounts at the present time to about 754 full-time men. This includes both hospitals and clinics.

Mr. AYRES. Now, in order to pick up this 13,000 additional cases that you could possibly have, how many trained men in the same category that you have just listed would you need?

Dr. TOMPKINS. We would need double that amount.

Mr. AYRES. In other words, you would need about just double what you have at the present time?

Dr. TOMPKINS. Yes, sir. This is predicated not only on the fact that that number of cases will require additional psychiatrists, but also the fact that we do not have enough psychiatrists at the present time for our present load.

Mr. AYRES. What is being done to increase that number? Is that not the crux of your problem? That you do not have the trained personnel to care for those cases?

Dr. TOMPKINS. That is right, and we are doing something about it. We are and the whole country is doing something about it. The Congress has done something about it in the enactment of the National Mental Health Act, and the States are going to do something more about it as soon as they get this report on research and education, from the Council of State Governments. We in the Veterans' Administration are definitely doing something about it. We do have a training program for all mental health personnel and particularly our psychiatrists, and at the present time we are training about 20 percent of the psychiatrists that are being graduated each year throughout the country. Previously, it was a little larger, but because of certain upheavals, particularly from the standpoint of funds, candidates are veering away from our residency programs.

We are developing other approaches to the problem of training psychiatrists. We have recently developed what is called the career training program, somewhat similar to the armed services career training programs: A physician needing to be trained in psychiatry is given a staff position, and then given 3 years of formal training plus 2 years of experience, which are the required years to train psychiatrists.

Those 3 years of training will be in our regular residency training hospitals and the 2 years of experience in so-called isolated VA hospitals where we are in dire need of psychiatrists.

This is another way of approaching that problem of increasing the number of psychiatrists through training and thereby increasing the number graduating throughout the country. That is our contribution. However, at the present time the budget officers tell me that this program is being limited because of fund shortages.

The CHAIRMAN. Doctor, will you explain for the record the difference between the psychotic and the neuropsychiatric cases? I think we would like to have it go into the record.

Dr. TOMPKINS. Neuropsychiatric, the word was coined I believe in the First World War, indicates a combination of neurology and psychiatry. This name is pretty well being dropped at the present time. They are two distinct specialties although they do have common interests. When you say "neuropsychiatry," you mean "psychiatry" and "neurology," and the psychiatric case is grossly separated into the psychotic and the psychoneurotic and the character disorders. That is a rough breakdown. Neurology refers to conditions such as multiple sclerosis, infantile paralysis, or sciatica.

The CHAIRMAN. The psychotics are the very bad cases?
Dr. TOMPKINS. Those are the worse.

The CHAIRMAN. That is what I wanted to bring out particularly. Dr. TOMPKINS. Those are the ones that particularly need hospitalization. Unfortunately, the ordinary community will let a chronic disease of some other category, say, a chronic hypertensive or chronic arthritic stay at home or roam the streets without particular attention being paid to them, but when an active psychotic is on the street, of course, he needs some detention, whether it is in jail or in the hospital-it should be in the hospital. Because of this 300,000 bed shortage that the States are laboring under at the present time, in most communities even if the case has not been adjudicated as service-connected, the community does look to the Veterans' Administration for hospitalization.