One of George Gintoli's first directives as South Carolina's mental health director was for his top staff to read "Who Moved My Cheese? An Amazing Way To Deal With Change in Your Work and in Your Life."

But at a budget hearing Tuesday with Gov. Mark Sanford ,it was clear Gintoli's department has not changed quite as much as mental health advocates want or the governor demands.

Sanford brought up consolidating agencies, selling land and ending duplication of services.

Advocates brought up a crisis of mental patients clogging emergency rooms and money wasted on bureaucratic turf battles.

"At the same time we're reducing staff, we're serving about 10,000 more people than we did in the last decade," said Gintoli, who took the top mental health job in January 2001.

About half of the Mental Health Department's $345 million budget comes from the state.

Like other state agency heads who say they are trying to do more with less, Gintoli said his department is straining to serve the state's mentally ill residents through 17 community mental health centers and a variety of other programs.

"Unfortunately, we are not serving all the people who need help," Gintoli said during the 90-minute hearing in the Wade Hampton Building on the State House grounds.

Gintoli has said budget cuts - more than $40 million and about 800 jobs lost since 2001 -led to long waiting times for mentally ill jail inmates who should have been in state mental facilities. Under circuit court orders, the waiting list was whittled down to just a few, Gintoli said last week.

But mental health advocates say the problem of mental patients being held in emergency rooms is getting worse.

After listening to Gintoli speak for an hour about community-based care, school-based care, mental health courts and "assertive community treatment," the director of one advocacy group agreed all those issues are important.

But "the problem is the emergency rooms," said Bonnie Pate, director of S.C. SHARE. "That's where the crisis is."

Anne Battin, who heads Palmetto Behavioral Health System in Charleston, said one Department of Mental Health plan to free up 30 extra beds for psychiatric emergencies falls far short of what is needed. "It's picking fleas off the elephant's leg," she said.

On July 7, a statewide survey of hospitals found 91 mental patients were being held in emergency rooms because no beds were available in state facilities. Hospitals contend they aren't equipped to handle psychiatric cases - and patients wait longer for emergency care as examining rooms fill with psychotic or self-destructive patients who need constant supervision.

Fourteen such patients were being held Tuesday at Palmetto Health Richland and Palmetto Health Baptist, for example.

"One thing they have in common is they all meet the criteria for (psychiatric) commitment," said Greg Gattman, vice president for behavioral health services at Palmetto Health. "They are a danger to themselves or others."

At Palmetto Health Richland, one security worker spends his entire shift escorting mental patients to bathrooms and showers, said Judy C. Smith, Palmetto Health spokeswoman.

At least 70 percent of those patients are not eligible for Medicaid or any other type of health insurance, Gattman said.

Gintoli said one solution might be for the state to set up a health crisis line similar to a 911 number. People experiencing a health emergency could call and be directed to the right agency, he said.

"What happens is that they end up going to the emergency room, which might not be the best place."

Sanford and his chief of staff, Fred Carter, questioned Gintoli about possible cost-cutting measures.

Suggestions included:

?_Selling parcels of land. The Mental Health Department is trying, Gintoli said.

?_Privatizing more services. That generally is a cost-effective effort, he said.

?_Unloading operations such as the sexual predators unit, an option also suggested by Gintoli.

Carter said there's "a pretty compelling case" for making the Department of Mental Health a cabinet agency.

Gintoli said he was proud of collaborative projects with other agencies such as DAODAS, the Department of Alcohol and Other Drug Abuse Services. But Sanford and Carter questioned whether that agency's functions could be more economically folded into the Mental Health Department.

"Do we really need DAODAS?" Carter asked. "Does DAODAS need to exist?"

State Sen. John Courson, R-Richland, said consolidating the functions of the substance-abuse agency is the type of streamlining measure he's been advocating since Gov. Carroll Campbell's administration.

The current budget crisis "may be the catalyst we need to finish the restructuring effort that began under Gov. Campbell," Courson said.

Reach Lamb at (803) 771-8454 or llamb@thestate.com.