SIXTH ANNUAL Report oF THE COMMISSION IN LUNAcy. 7 State Maintenance of the Insane. for support of the insane. In 1873 a legislative committee recommended direct supervision independent of local boards, and in the course of its discussion particularly condemned the management of the Hudson River State Hospital by showing that while the buildings were erected on a scale of unequalled cost, the results attained were not commensurate with this lavish outlay. In 1875 the Comptroller recommended that expenditures be put under direct central control. In 1882 a Senate committee recommended the creation of a State commission for the purpose of not only promoting the welfare of the insane, but also of closely looking after the expenditures for their subsistence and for the maintenance of the hospitals. In 1883 a legislative committee recommended central supervision and the immediate assumption by the State of full charge over all moneys received or required and expended for maintenance of the dependent insane. However, the fact should not be ignored that during all this time and for some years later, no definite scheme of defraying the cost of maintenance of the insane out of the proceeds of State taxation was seriously advanced or considered; that cost continued to be, as from the first it had been, provided for by receipts from counties for support of public patients, by the revenue from private patients, by annual appropriations direct from the State Treasury for maintenance, by income from incidental sources, and by small payments from the State Treasury for the support of a few insane Indians. Hence, when the policy of the State should finally become fixed in respect to paying the whole cost of maintenance of all its dependent insane out of its own. revenues, it was evident to even a casual observer that the need of some central control would be imperative. In reviewing the work of the past year the most prominent feature will be seen to have been the change in the relations of the several institutions, their managers and officers, to the commission, effected by chapter 214, Laws of 1893, commonly known as the estimate law, whereby a tax of one-third of a mill for support of the insane was levied on every dollar of valuation of taxable property in the State, and it was provided that no part of the proceeds thereof nor of the moneys received by the hospitals from other sources should be expended for maintenance of State Maintenance of the Insane. the inmates of State hospitals, except upon monthly itemized estimates in advance, to be revised and approved by the commission and then submitted to the Comptroller. That change took effect at the beginning of the fiscal year 1893-4, coincidently with the change in the method of paying for the cost of maintenance; and, inasmuch as it involved the giving up of established methods on the part of the hospitals - each having its own peculiar methods it was inevitable that more or less friction between the local boards and superintendents and the commission should arise. The local control over expenditures, so long held, was not let go without resistance; a struggle lasting for several months was made to prove that the commission used its function of supervision arbitrarily, unfairly and unwisely, and charging it with pursuing a policy of cheeseparing economy and practically pauperizing the hospitals, if not rendering the new system worthless for any real advantage. Efforts were made to work upon the Legislature of 1894, to induce it to materially modify and reduce the powers of the commission, and bills to that end were introduced one going the length of proposing to abolish the commission and transfer its powers and duties to a committee of the State Board of Charities. Another bill proposed a per capita allowance of funds to the hospitals to be expended as the local authorities might see fit. Consideration of the subject by the committees of both Houses served to expose the demerits of these propositions so thoroughly that neither bill reached the stage of a committee report, the one proposing the per capita plan being withdrawn by its introducer, who was also a member of a local board, on the ground that it was impracticable. In fact, the Legislature of that year found so much reason for satisfaction with the work of the commission that, instead of diminishing its powers, it materially enlarged them and widened the scope of its jurisdiction by enacting (chapter 358, Laws of 1894) that all plans and specifications for new buildings, improvements, etc., at the State hospitals should be approved by the commission, and that all moneys to be expended under special appropriations should be subject in their disbursement to the estimate plan, the same as are expenditures on account of maintenance. State Maintenance of the Insane. From the first the commission felt confident that, however severely assailed at the outset the estimate system might be, and whatever errors in the inception of organizing and administering an entirely new system it might itself fall into, the eventual success of the new method was certain, because it was seen to be in large measure self-operative. In the very nature of the case the enforcement of such safeguards as this system places around the expenditure of public money tends to insure against improvidence, waste and extravagance; it promotes economy, care and frugality; it applies the principles and governing ideas of business enterprises to the disbursement of large sums of the State's money, and it thereby secures to the State the best results from that disbursement. As a consequence, in actual operation during the first year, while the hospitals estimated for an aggregate sum of $1,932,999.26, and the commission allowed them $1,808,421.88, they expended only $1,627,766. Waiving any other comment on this showing, it may be said to demonstrate two things: 1. The commission was not niggardly in its dealings with the hospitals, but treated them with ample liberality. 2. The estimate system is in fact self-sustaining and selfenforcing, since under it the hospitals could not, or at least did not, expend the amount allowed them on revised estimates, to no less a total than $180,655.88. To illustrate more explicitly the nature and extent of the savings effected in the first year of the estimate system, it may be nted that, whereas, during the previous fiscal year, 1892-3, the daily average number of patients supported was 7,863, and the total cost of maintenance, as shown by the hospital treasurers' reports, was $1,699,371.89, during the fiscal year 1893-4, while the daily average number of patients was 8,806, the total cost, as shown by the treasurers' reports, was $1,627,766. To this direct saving should be added the cost of transportation of the insane, which the new system puts wholly upon the State, requiring that trained attendants be sent on notice to bring certified insane from their homes to the hospita's. Previously this cost, which for the fiscal year 1892-3 amounted to about $25,000, both State and county, was an independent charge, and did not appear in State Maintenance of the Insane. the hospital expenditures. It follows that the total saving effected by the estimate system in its first year equalled, or somewhat exceeded, $300,000. To state it in another way, the per capita cost of maintenance for the fiscal year 1892-3, exclusive of all account of surplus funds, was $216.12; in 1893-4 the per capita cost fell to $184 84; a reduction of $31.28. Multiplying this last sum by the daily average number of patients makes the difference $275,453.68, exclusive of the item of $25,000 expended by the State for transportation of patients from their homes to the hospitals. So far as concerns the large surpluses accumulated at some of the hospitals previous to the beginning of the estimate system and which were expended by them for betterments of various kinds, just before the Estimate Law became operative, they may be eliminated from this calculation altogether since they have nothing to do with it, and, indeed, most or all of the moneys was either paid out or covered by contracts made prior to September 30, 1893. It is worthy of special note that, while this large reduction in cost was brought about, the standard of supplies allowed to the hospitals, whether as regards quantity or quality, has been fully maintained. In fact, as compared with the previous year, there was a distinct improvement in both these respects, as well as in variety. Among the established results of the estimate system were these: The purchase of adulterated articles of food was prohibited; a higher average standard of substantially all staple articles of consumption was maintained; beef was bought in the carcass; the use of a more uniform and, in some cases, a better grade of flour was insisted on; butter, sugar, coffee, tea, etc., of a superior quality were purchased, articles of clothing, bedding, tableware, etc., were bought in quantities at lower rates but of generally better grades; a carefully prepared schedule of food supplies with a per capita ration allowance of each article based on physiological principles (see chapter 3, p. 14), served to guide in passing upon estimates for food supplies, and so far as practicable, a uniformity in grade was required in order to secure equal benefits to all. It will hardly be contended by any one, whatever his anticipation may have been, that in realization the standard care for the inmates of State hospitals has suffered in any State Maintenance of the Insane. essential particular; on the contrary, it is in evidence from the superintendents themselves that the year's experience showed a decided improvement in this respect. One of the chief benefits made attainable under the present system results from the impossibility that under, it money allowed for a particular purpose can be diverted to another. Under the former method, when no legal restrictions had been explicitly attached to the expenditure of moneys for hospitals, it was of frequent occurrence that expenditures were made for furniture, repairs, etc., at the expense of the food supply, nursing, etc., and vice versa, the chief care apparently being to keep expenditures within the limits of the aggregate sum available, in order that as rarely or to as little extent as possible no deficiency in the maintenance account should occur. Yet, despite this obvious care to prevent such deficiencies, the records of several of the hospitals show that yearly appropriations on that account were asked for and obtained. In carrying out the estimate law the commission, so far as practicable, has sought to secure concurrent or joint action of the several hospitals in the purchase of staple articles — a suggestion with which the hospital authorities generally have promptly and cheerfully complied; and it is gratifying to state that, so far as this course has been followed, the results have been very satisfactory. The commission believes that this plan of uniting in purchases could be extended to the great advantage of all the institutions as well as of the State, and it would be well if the Legislature were to direct that, so far as may be feasible, in the discretion of the commission, the hospitals should unite in purchasing all staple articles upon competitive proposals, the contracts to be awarded to the lowest responsible bidders. In this way, it is convinced, a large saving would be effected and at the same time the general character of supplies would be kept at a uniform standard of excellence for each hospital. From the foregoing it will be apparent that the transition from the former mixed system with its haphazard methods to the new and now substantially perfected system of State care and State maintenance for all of the State's dependent insane, was not accomplished by a single stroke, nor without more or less opposition on the part of those who by time-honored custom and |