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in the county seat of Trenton. They have no physicians at this time. They have been going to the hospitals and the medical centers attempting to attract interns or medical residents to the community.

Now, if that community as a community owned about 15,000 square feet of floor space, divided into offices, for nurses and for the doctor, and for the necessary diagnostic equipment, X-ray, laboratory, and examination tables, that community could go to a hospital where an interne is completing his work or is a resident and say, "If you will come down here and live with us, we will be glad to have you, and we have got a building; we have got all the necessary equipment, including X-ray and diagnostic laboratory equipment, and you can start to work next month."

That would be a godsend to that type of community that is now without hospital facilities.

Now, we are county conscious in the South, as Senator Hill knows. Senator PURTELL. Your record shows that. The way you have gathered your money shows that.

Dr. FERRELL. That Jones County, while it is small and is sparsely settled, has limited resources and, yet, it is proud and it doesn't want to subordinate itself with its medical facilities to some other neighboring county hospital that is more fortunate and that would tend to dominate it.

Senator PURTELL. Doctor, what I was getting at was not so much the availability of the money. Assuming, now, we are talking of need, because I am trying to picture this as it relates to all of our 48 States or those States which would need this type of treatment or this type of center, if you wish to call it that, and assuming, now, the money is supplied and we are not going to quibble as to from what source it comes of course, there are limitations in the bill as to where it is going to come from, but if the money is available-what sort of a physical layout do you think it should be, where it isn't a hospital, and, as you mentioned, will not become part of the hospital?

Dr. FERRELL. We are making a study now of what doctors who have built their own diagnostic clinics have. We are getting their floor plans.

A few communities have built these centers. We are getting those floor plans.

By studying them and conducting further studies we hope to be able to help the Federal agency here in the development of plans as to what should be included in a diagnostic and treatment clinic.

Just at the present time I think 1,500 to 2,000 square feet of floor space, properly divided, would make a very good center, and it will cost about $30,000 equipped.

Senator PURTELL. Of course, if this bill were passed, you know the funds would be available to the States for the States to make the surveys to determine the need for this type of center.

Dr. FERRELL. Yes.

Senator PURTELL. And you feel there is a need for that survey?
Dr. FERRELL, Absolutely.

Senator PURTELL. Thank you very much, Doctor.

Unless Senator Hill has further questions

Senator HILL. Doctor, just one other question: As I said, your State and my State have pretty much the same problem. We have these rural areas and, as you say, some of them might not be able to raise

the funds, and then some of them might not be able to maintain a hospital; and, of course, you and I don't want a hospital. We don't want white elephants, do we?

We don't want that kind of hospital, do we?

I have been very much impressed by what you said about these diag nostic centers. But, on the other hand, I suppose you and I would have to recognize that conditions in other States might be different. Is that right?

Dr. FERRELL. Absolutely.

Senator HILL. And whereas some States might have the need for the diagnostic centers there might be other States that, say, had a much more compelling or crying need for, say, beds for mental cases; is that right?

Dr. FERRELL. There is no doubt about it.

Senator HILL. Thank you, Doctor.

Senator PURTELL. Doctor, you have helped us a great deal, and I thank you for coming here.

I might say the entire statement which you have submitted, as well as the exhibits attached thereto, will be made a part of the record. Dr. FERRELL. Thank you.

(The statement submitted by Dr. Ferrell, together with the exhibits attached thereto, is as follows:)

TESTIMONY OF JOHN A. FERRELL, M. D., EXECUTIVE SECRETARY, THE NORTH CAROLINA
MEDICAL CARE COMMISSION

Mr. Charman and gentlemen, your invitation to me to appear before your committee is sincerely appreciated. In North Carolina, we have had 7 years of experience in hospital construction under the Hill-Burton Act. I am pleased to file for the record a summary of the accomplishments as Exhibit A. Exhibit A will show that of 78 hospital projects sponsored by the Medical Care Commission, 44 are new hospitals and 34 are additions to existing hospitals.

Exhibit B lists 46 hospital projects that were completed prior to December 31, 1952, and were in successful operation throughout the year 1953. The bed occupancy of half of these facilities averaged as high or higher than the national average, and half averaged slightly below the national average. One-third of the hospitals were new and located in rural areas without previous hospital experience.

Exhibit C is a map of North Carolina which shows by counties the location of 158 construction projects in 83 of the 100 counties of the State:

Local general hospital projects..

State-owned hospital projects.
Nurses' homes (residences) -
Health centers~-~-

72

8

34

44

In North Carolina, about $73 million has been spent or encumbered for 169 construction projects. There have been completed or contracted for 5,274 new beds for patients and 1.939 new beds for nurses. Some hospital facilities are available in each of 85 counties representing 95 percent of the State's 4 million population. However, because of a lack of funds, only from 50 to 60 percent of the statewide need for beds in the local general hospital field has been met. The need for mental and tuberculosis beds has been substantially met mainly with State funds.

The need of hospital beds for the chronically ill has not been met. Facilities of this type have been eligible for Federal and State aid, but there have not been sponsors, or applicants, for such aid.

The present Federal Hospital Act (Hill-Burton) has operated efficiently and it has been sufficiently flexible to meet the varying needs of the States. It should be continued without change and any expansion of facilities or new facilities for providing additional medical care should follow closely the Hill-Burton pattern.

PENDING S. 2758 (H. R. 7841 AND H. R. 8149)

With reference to the pending S. 2758 (H. R. 7341 and H. R. 8149), I can report that in North Carolina we are interested in all of the proposals, and particularly

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in the $2 million appropriation for survey and planning. An intensive study of the existing facilities and those needed for each of the proposed four categories of facilities included in the proposed act will require considerable study.

The formulation of new programs will require time: (1) Time will be needed for surveys. (2) Time will be needed for formulating programs and construction standards. (3) Sponsors must be found who will be able and willing to finance the construction, equipping, staffing, and the operation of the proposed facilities. Chronic diseases hospitals have been eligible for aid for 7 years in North Carolina, but sponsors have not been found. This may be due largely to the fact that the indigent rate among the chronically ill will be high, and funds with which to pay hospitals for their care is not available or in sight. Public funds toward the cost of operating chronic diseases hospitals will be necessary.

Nursing and convalescent homes have been opened in numbers in recent years in North Carolina. No provision for licensing them has been authorized. The medical care commission submitted a bill to the 1953 legislature requesting licensing authority for them. The measure was defeated. Most of the nursing homes, it is believed, are housed in buildings formerly used as residences. They usually are owned and operated by nurses for profit. Few, if any, are publicly owned and few, if any, are nonprofit. It is reported that many of the homes constitute fire hazards for the patients. Information is not available as to the quality of medical and nursing service that is furnished in the homes. Moreover, the extent is not known to which the chronically ill are cared for in the nursing homes. Only experience will reveal the extent to which the local government or nonprofit associations will sponsor, construct, and operate nursing homes in North Carolina.

Diagnostic and treatment facilities for ambulatory patients represents a real need in many isolated rural communities in North Carolina. A few communities have financed such facilities. Moreover, many physicians own and operate such facilities, particularly in the more densely populated areas. A number of publicly owned clinics might be operated as outposts of hospitals. The same can be said of nonprofit hosiptals. However, there are many areas needing diagnostic and treatment clinics where they will not become parts of hospitals. For example, there are seven counties served exclusively by privately owned or proprietary hospitals. Again, there are a few (10 or 12) small communities having populations ranging from 6,000 to 10,000 that cannot separately support hospitals, and yet clinic affiliations with hospitals in neighboring counties may not be feasible. The nonprofit community clinics will facilitate the location of physicians in rural areas where there are none at present.

Rehabilitation facilities are, of course, needed, but existing facilities and needs would have to be studied.

While this survey and planning regarding the four categories of facilities is carried out, funds should not be reduced for meeting the need of additional local general hospitals and health centers.

EXHIBIT A

HOSPITAL CONSTRUCTION IN NORTH CAROLINA UNDER THE HILL-BURTON PROGRAM FROM JULY 1, 1947, TO JUNE 30, 1954

The commission began surveys July 1, 1945, to ascertain the need of medical and hospital facilities in North Carolina. However, funds for hospital construction and most other activities, from State and Federal Governments, did not become available until July 1, 1947. The commission's overall activities for the succeeding 7 years to June 30, 1954, have involved the encumbrance of more than $75 million. The commission's expenditures for the administration of this program has averaged less than 1 percent of the encumbered funds.

The commission, since July 1, 1947, has sponsored 169 construction projects; of which 78 were local general hospitals-44 new hospitals and 34 additions to existing hospitals; 36 nurses' residences to serve hospitals; and 47 health centers to provide quarters for the activities of county health departments. The 78 hospitals will serve local or county communities and they will provide 4,647 new patient beds. The 36 nurses' residences will provide 1,939 new beds for nurses. Eight of the 169 projects are State-owned hospital facilities. They have provided 627 new beds for patients. In all, 5,274 new patient beds have been provided or contracted for.

The legislatures of 1949 and 1951 appropriated the funds necessary to cover the cost of State-owned hospital construction, including the 400-bed teaching hospital on the university campus. The appropriations were made directly to

the State agencies involved. However, the commission in 1951 supplied $500,000 toward the cost of the 100-bed tuberculosis hospital at the university. Other new buildings composing the university's medical center were financed with State funds. The center includes the medical school, the school of dentistry, the school of pharmacy, the school of nursing, school of public health, the phychiatric hospital wing of 75 beds, and the 100-bed tuberculosis hospital mentioned above. Other State-owned and State-financed hospitals have provided facilities for the care of mental, tubercular, crippled, spastic, and other patients.

The commission's construction program during 7 years to June 30, 1954, has required the encumbrance of $73,967,291, of which $15,040,950.18 was supplied by the State; $26,850,273.66 by the United States Government; and $32,076,067.16 by the local authorities. The construction and equipment of hospital and healthcenter projects has, of course, been the commission's major activity.

Of the 44 new local general hospital projects aided by the commission. 28 have 50 beds or more. These 28 hospitals have 1 or more rooms equipped for the isolation of patients having infectious diseases, and of these, 18 have been further designed to permit the temporary care of psychiatric patients. Several of the 34 additions to existing hospitals already had rooms in which to care temporarily for psychiatric patients. Such facilities are needed because where not available it has often been necessary to confine mental patients in jails pending the completion of arrangements for their admission to State hospitals. Fifteen counties still have no hospital facilities. The majority of them, how ever, are small and thinly populated and the total population of the 15 counties is less than 5 percent of the State's population. The people of these counties need hospital facilities, but most of them could not finance the operating cost of hospitals. In some cases, they might obtain hospital services by uniting with neighboring counties.

Several large and populous counties still have inadequate hospital facilities. Only a part of the need for beds has been met. The existing facilities in a few communities are obsolete and should be replaced. Moreover, in a few counties the hospitals are privately owned and they are not eligible for commission aid toward replacement or additions.

The towns of Washington, Wilson, Raleigh, Elizabeth City. Wilmington, as examples, have old facilities, some of which should be enlarged, modernized, or replaced. Several old hospitals barely meet the sanitary requirements of the State health department, or provide the degree of protection against fire required by the building code of the State insurance department. No new beds have been provided in Wake County. No new or enlarged facilities have been provided for Negro patients in Mecklenburg County. Several of the local hospital projects the commission has aided are inadequate to meet the need for patient beds. A shortage of funds usually accounted for the projects that were too small to meet the need. Some of these hospitals have raised additional funds and have applied to the commission for aid for additional construction.

There are in the State a large number of small but densely populated communities that are unable independently to support hospitals, yet they are in need of medical services and clinic facilities. Some hospital authorities advocate the operation of such clinics as outposts or branches of established, well staffed and equipped hospitals. The commission, at the beginning of its construction program, made the county the hospital area throughout the State. The new hospitals have been located usually at the county seat or at the principal trading center. The construction of auxiliary clinics for outpatient clinics has not been included as a part of the commission's construction program.

The United States Hill-Burton program includes aid toward the construction and equipment of chronic diseases hospitals. The plans contemplate up to 2 patient beds per 1,000 population for chronic diseases. This would mean for North Carolina a large number of new chronic diseases hospitals having in excess of 8,000 beds. No valid applications for commission aid toward financing and building such projects have been received. At present, some chronic diseases patients are cared for in local general hospitals designed to care for acute sickness and, of course, the cost is high. Some of the patients having chronic diseases may be cared for in convalescent homes. As these homes are not licensed or supervised in North Carolina, no reliable information is available as to the extent or quality of services they are rendering.

In review, it may be said that, although gratifying progress has been made in North Carolina in meeting the need for hospital facilities, a large part of the need has not been met. Accordingly, there will continue for many years a large need for more and better hospital facilities.

[graphic]

EXHIBIT B

1953 bed occupancy of 46 local general hospitals approved for 58 projects that were completed in North Carolina under the Hill-Burton program
up to Dec. 31, 1952

Alamance.
Alexander.

Alleghany.

Avery.
Ashe.
Beaufort.
Bertie..
Bladen.

Burke.
Cabarrus.

Caldwell.

Chatham.
Chowan.
Cleveland.

Do.
Durham.
Franklin.

Gaston.
Granville.
Guilford.

Do.
Hertford

Troy
Burgaw
Roxboro

Greenville.
Rockingham.
Reidsville.

Salisbury

See footnotes at end of table, p. 132.

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