their psychiatrists easy to talk to, many were not satisfied with explanations about their condition, and most thought that they had not been given enough information about their treatment. Patients complained that they had not had enough time alone with their psychiatrist. Surely all these are arguments in support of a psychiatrist being a personal physician able to have a therapeutic relationship with an appropriate and not excessive number of patients. This can be achieved only with an increased number of consultants. Since writing to the BMJ Ms Hepplewhite has stated that she approves of psychiatric services in Italy and that the number of trained psychiatrists per head of population in Italy is considerably above that in the United Kingdom (paper presented at annual meeting of Royal College of Psychiatrists, Brighton, 1991). It is a pity that she does not work with the professional bodies in trying to obtain more resources for mental health to improve facilities in all areas, including social services provision, consultant psychiatric staffing, community psychiatric nursing, and other communitv and hospital developments. A C P SIMS
P'residenit, Royal Collcge of Psychiatrists, l.otndon SWIX SPG I Hcpplewhite R. Better mental hcalth scrvices. BAIJ 1991;302: 1533. (22 Jtine.) 2 Sims ACP. liven better services: a psychiatric perspectivc. BMJ 1991;302:1061-3. 4 AMay.} 3 MIND. Peopl/ first. Ltondon: MNIIND, 1990.
Licensing laws and drinking SIR,-There is a temptation, when a survey does not say what was hoped and expected, simply to dismiss its findings. Sadly, this is the line adopted in the news report of Drinking in England and Wales in the Late 1980s.' This survey shows that the changes to pub opening times made in the Licensing Act of 1988 have not had any great effect on average consumption levels. Baroness Hooper, a junior minister at the Department of Health, was quick to lend her justification to the Home Office's changes, expressing her delight that the changes had not led to increased drinking. Baroness Hooper went on to mention the government's targets for alcohol consumption as set in the green paper lThe Health of the Nation. This document proposes a reduction in the numbers of people drinking more than the sensible levels to fewer than one in six men and one in 18 women. The government has drawn up its own criteria for tackling alcohol abuse. How have the changes to licensing laws advanced the achievement of these aims? The answer, it seems, is scarcely at all. Drinking in England and Wales in the Late 1980s shows that the number of people drinking over sensible levels-21 units a week for men and 14 units for women-fell slightly, from 24% to 22% of men and from 9% to 7% of women. The numbers drinking above safe levels -50 units for men and 35 units for women -remained constant. The truth of the matter slowly begins to emerge from the figures. The changes in the licensing laws have not altered most people's drinking at allthey are neither popular nor well used. But go to your local pub on a weekday afternoon and there you will see the people who are "benefiting" from the Home Office's changes: the heavy drinkers. Average consumption among heavy drinkers has increased from 56 8 to 58-9 units per week for men and from 37 0 to 37 4 units for women. When the survey looked at who visited pubs during the new opening hours the pattern was repeated. Eight per cent of all men had visited a pub on a weekday afternoon in the week before the survey; 32% of heavy drinking men had; and 36% of all men had been in a pub at 11 pm in the week
472
before the survey; a massive 88% of heavy drinking men had. The B_J7's report of Drinking in England and Wales in the Late 1980s chose to focus on the inadequacies of the survey because of the realisation that the problem of alcohol misuse is simply too vast to be hidden behind bland headline figuresand so it is. But what the survey does show is that, while most people are ignoring the new permitted hours, heavier drinkers have taken the changes on board and are drinking to their heart's content. MARK BENNETT
ties need further to develop outreach services to caravan sites through health visitors.' GENE FEDER
1T1ERESA VACLAVIK Academic D)epartment of (icneral Practice anid Primarv Care, Mledical College of St Bartholomncw's aind Lonidoni I iohpaals, London EC IM 6B(Q MacAulev D, Anderson U. Uptake ol cervical smcar te:trin among travellers. BIMJ 1991;303:191. 2(0 Jul\.) 2 [)urward L, ed. 7raveller mothers and bablies: zt-ho cares for their health? London: Maternit\ Allianice, 1990. 3 Fcder G. Iraveller gypsies and primary care. R Coll lien Pract
1989;39:425-9.
Alcohol Colccrni,
London WC I X 8QF 1 Smith R. Licensing laws andi drinkinig. BUidjZ 1991:303:206.
(27 JIul-.)
MRCGP: examining the exam SIR,-Mr Miles Irving reports that the English
Uptake of cervical smear testing among travellers SIR,-Drs Domhnall MacAuley and Ursula Anderson discuss problems of cervical smear testing among travellers and of assessing uptake in this mobile community. In a study of health care of travellers in Hackney, east London, we included assessment of cervical smear state in 61 consecutive traveller women presenting to two general practices between August 1989 and December 1990 and compared uptake with prospective matched controls for age registered in the same practices (table). We considered women eligible for a smear if they had had sexual intercourse. The relatively high proportion of
Proportionz of eligible zwomen who had never had a smear test Group Travellers (n=61) Controls (n=65)
FRCS examination has been under expert educational scrutiny over the past two years.' This enthusiasm for professional advice is welcome news. Coupled with the surgeons' commitment to glasnost ("no part of our examination, or the statistical information concerning it, is regarded as confidential"') it will doubtless move to overcome the difficultv which many inquirers have experienced in obtaining technical information from royal colleges about their examinations (I have some gems of letters on file from those who bother to reply, collected ovcr the vears). Indeed, manv colleges are still quite unable to provide very basic statistical information about their examinations.' Draft minimum injorimnation set which candidates couild expect to receive about a medical exatnitation Content:
lorimat:
Metean age
No (%) never had smear
29 30
22 (36) 9 (14)
Length: Alarking:
D)cscription oltypcs of tcst tisc; examiiples ot qUCStion)s Awhere possible,
past papcrs:) Iime for each cotnponent, taLmIber oi questiotns in each written paper Scoring system for AMCQs (incln(ding scotring for itcns receiving incorrcct
rcsponsce Statemcint aboiti qualities rewarded ill
Difference=22% (950% confidenee initcrval 8% to 37%); x-8-4, df= 1, p=0-0038.
women who had never had a smear (36% v 14% of controls) is disappointing. Of the 22 traveller women who had never had a smear, nine were receiving antenatal care at the time their smear state was recorded. This failure to take a smear in pregnant traveller patients may be due to late booking and reluctance to have a smear while pregnant. Eviction from caravan sites of mothers with newborn babies2 before a postnatal check results in another missed opportunity for a cervical smear test, as well as depriving the mother of postnatal care and the baby of early health care. This data is based on a sample of traveller women in contact with primary care services and may not be representative of all traveller women in Hackney, whose cervical smear testing rate is probably lower. As a follow up to the cervical smear survey, 22 traveller women were interviewed on caravan sites and in the practices about their views of health and health care. Sixteen answered questions about cervical smear testing. Only six of them were aware that the smear test was used to prevent carcinoma of the cervix or had any connection whatever with cancer; 12 said that they would be more likely to have a smear if it was performed by a woman doctor or nurse. Four said they would be more likely to have one if the facility was available on their caravan site, but most of the women were. strongly opposed to this. Appropriate health education about smears for traveller women and offering opportunistic smears-particularly by women doctors and nurses-may increase uptake. Beyond these measures, if women who do not have contact with primary care are to be reached then health authori-
Aimils, objectives. specilicationi of scopC ocontent
othcr papcrs, LISCe of arkitig schedulcs
proviidc example)
For visa voice, c iical exatintatioins, (0S(CEs objective strtctured clittical
examinations); descriptioli of' examination prioccss, its fticus atid marking system
Quality conitrol: Dual markitig; training and monitoring of examitters Manipulatioi: Ainv statistical stattdardisatioii or weightitig of compoitciits, how these are combined, how boirdcrlitie candidatcs are revicwcd Pass or f'ail:
Appeals: Outcomes:
Rcqulirmeniits foi)r example, pass or mititmunit scorc in each papcr, pass ill summated overall rnark) Mechanism for appcals Pass rate oxverall and for indigenous first timc takers; reliability of each examination component for exatrtpic, coceficieltt itI
So can educational researchers and prospectivle candidates expect to see a full report on the Royal College of Surgeons' fellowship examination similar to that from the Royal College of General Practitioners describing the nature and findings of the educational scrutiny and detailing developments?4 Would the Royal College of Surgeons (and other colleges) agree to provide a set of minimum information on their examination (see figure for suggestion)? And will we shortly be reading a paper in the BMJ7 called "FRCS: examining the exam"? RICIHARt) WAKEFORD Cambridge CB] 2IE\W I Irving Al. MRCGP': cxanainitig the cxam. 13317 1991;303:363. (ItO Agttgst.: 2 Broiwsc NL. Examliting exatiners. Lancet 1990;335:73(0. 3 Wakefotrd R. Romyal cillege cxaminatiotis. Lanicet 1991;337:73Y. 4 Lockie C, ed. ExarninaiiOn for nite"bership of/the Rotal CoiiIc,c iof Genera! 1'ractitioners (MARCGP.) London: Royal Citlcgec tif Geticral Practitioners, 19911. ;Occasional papcr Nit 46.
BMJ VOLUME 303
24 AUGUST 1991
P'residenit, Royal Collcge of Psychiatrists, l.otndon SWIX SPG I Hcpplewhite R. Better mental hcalth scrvices. BAIJ 1991;302: 1533. (22 Jtine.) 2 Sims ACP. liven better services: a psychiatric perspectivc. BMJ 1991;302:1061-3. 4 AMay.} 3 MIND. Peopl/ first. Ltondon: MNIIND, 1990.
Licensing laws and drinking SIR,-There is a temptation, when a survey does not say what was hoped and expected, simply to dismiss its findings. Sadly, this is the line adopted in the news report of Drinking in England and Wales in the Late 1980s.' This survey shows that the changes to pub opening times made in the Licensing Act of 1988 have not had any great effect on average consumption levels. Baroness Hooper, a junior minister at the Department of Health, was quick to lend her justification to the Home Office's changes, expressing her delight that the changes had not led to increased drinking. Baroness Hooper went on to mention the government's targets for alcohol consumption as set in the green paper lThe Health of the Nation. This document proposes a reduction in the numbers of people drinking more than the sensible levels to fewer than one in six men and one in 18 women. The government has drawn up its own criteria for tackling alcohol abuse. How have the changes to licensing laws advanced the achievement of these aims? The answer, it seems, is scarcely at all. Drinking in England and Wales in the Late 1980s shows that the number of people drinking over sensible levels-21 units a week for men and 14 units for women-fell slightly, from 24% to 22% of men and from 9% to 7% of women. The numbers drinking above safe levels -50 units for men and 35 units for women -remained constant. The truth of the matter slowly begins to emerge from the figures. The changes in the licensing laws have not altered most people's drinking at allthey are neither popular nor well used. But go to your local pub on a weekday afternoon and there you will see the people who are "benefiting" from the Home Office's changes: the heavy drinkers. Average consumption among heavy drinkers has increased from 56 8 to 58-9 units per week for men and from 37 0 to 37 4 units for women. When the survey looked at who visited pubs during the new opening hours the pattern was repeated. Eight per cent of all men had visited a pub on a weekday afternoon in the week before the survey; 32% of heavy drinking men had; and 36% of all men had been in a pub at 11 pm in the week
472
before the survey; a massive 88% of heavy drinking men had. The B_J7's report of Drinking in England and Wales in the Late 1980s chose to focus on the inadequacies of the survey because of the realisation that the problem of alcohol misuse is simply too vast to be hidden behind bland headline figuresand so it is. But what the survey does show is that, while most people are ignoring the new permitted hours, heavier drinkers have taken the changes on board and are drinking to their heart's content. MARK BENNETT
ties need further to develop outreach services to caravan sites through health visitors.' GENE FEDER
1T1ERESA VACLAVIK Academic D)epartment of (icneral Practice anid Primarv Care, Mledical College of St Bartholomncw's aind Lonidoni I iohpaals, London EC IM 6B(Q MacAulev D, Anderson U. Uptake ol cervical smcar te:trin among travellers. BIMJ 1991;303:191. 2(0 Jul\.) 2 [)urward L, ed. 7raveller mothers and bablies: zt-ho cares for their health? London: Maternit\ Allianice, 1990. 3 Fcder G. Iraveller gypsies and primary care. R Coll lien Pract
1989;39:425-9.
Alcohol Colccrni,
London WC I X 8QF 1 Smith R. Licensing laws andi drinkinig. BUidjZ 1991:303:206.
(27 JIul-.)
MRCGP: examining the exam SIR,-Mr Miles Irving reports that the English
Uptake of cervical smear testing among travellers SIR,-Drs Domhnall MacAuley and Ursula Anderson discuss problems of cervical smear testing among travellers and of assessing uptake in this mobile community. In a study of health care of travellers in Hackney, east London, we included assessment of cervical smear state in 61 consecutive traveller women presenting to two general practices between August 1989 and December 1990 and compared uptake with prospective matched controls for age registered in the same practices (table). We considered women eligible for a smear if they had had sexual intercourse. The relatively high proportion of
Proportionz of eligible zwomen who had never had a smear test Group Travellers (n=61) Controls (n=65)
FRCS examination has been under expert educational scrutiny over the past two years.' This enthusiasm for professional advice is welcome news. Coupled with the surgeons' commitment to glasnost ("no part of our examination, or the statistical information concerning it, is regarded as confidential"') it will doubtless move to overcome the difficultv which many inquirers have experienced in obtaining technical information from royal colleges about their examinations (I have some gems of letters on file from those who bother to reply, collected ovcr the vears). Indeed, manv colleges are still quite unable to provide very basic statistical information about their examinations.' Draft minimum injorimnation set which candidates couild expect to receive about a medical exatnitation Content:
lorimat:
Metean age
No (%) never had smear
29 30
22 (36) 9 (14)
Length: Alarking:
D)cscription oltypcs of tcst tisc; examiiples ot qUCStion)s Awhere possible,
past papcrs:) Iime for each cotnponent, taLmIber oi questiotns in each written paper Scoring system for AMCQs (incln(ding scotring for itcns receiving incorrcct
rcsponsce Statemcint aboiti qualities rewarded ill
Difference=22% (950% confidenee initcrval 8% to 37%); x-8-4, df= 1, p=0-0038.
women who had never had a smear (36% v 14% of controls) is disappointing. Of the 22 traveller women who had never had a smear, nine were receiving antenatal care at the time their smear state was recorded. This failure to take a smear in pregnant traveller patients may be due to late booking and reluctance to have a smear while pregnant. Eviction from caravan sites of mothers with newborn babies2 before a postnatal check results in another missed opportunity for a cervical smear test, as well as depriving the mother of postnatal care and the baby of early health care. This data is based on a sample of traveller women in contact with primary care services and may not be representative of all traveller women in Hackney, whose cervical smear testing rate is probably lower. As a follow up to the cervical smear survey, 22 traveller women were interviewed on caravan sites and in the practices about their views of health and health care. Sixteen answered questions about cervical smear testing. Only six of them were aware that the smear test was used to prevent carcinoma of the cervix or had any connection whatever with cancer; 12 said that they would be more likely to have a smear if it was performed by a woman doctor or nurse. Four said they would be more likely to have one if the facility was available on their caravan site, but most of the women were. strongly opposed to this. Appropriate health education about smears for traveller women and offering opportunistic smears-particularly by women doctors and nurses-may increase uptake. Beyond these measures, if women who do not have contact with primary care are to be reached then health authori-
Aimils, objectives. specilicationi of scopC ocontent
othcr papcrs, LISCe of arkitig schedulcs
proviidc example)
For visa voice, c iical exatintatioins, (0S(CEs objective strtctured clittical
examinations); descriptioli of' examination prioccss, its fticus atid marking system
Quality conitrol: Dual markitig; training and monitoring of examitters Manipulatioi: Ainv statistical stattdardisatioii or weightitig of compoitciits, how these are combined, how boirdcrlitie candidatcs are revicwcd Pass or f'ail:
Appeals: Outcomes:
Rcqulirmeniits foi)r example, pass or mititmunit scorc in each papcr, pass ill summated overall rnark) Mechanism for appcals Pass rate oxverall and for indigenous first timc takers; reliability of each examination component for exatrtpic, coceficieltt itI
So can educational researchers and prospectivle candidates expect to see a full report on the Royal College of Surgeons' fellowship examination similar to that from the Royal College of General Practitioners describing the nature and findings of the educational scrutiny and detailing developments?4 Would the Royal College of Surgeons (and other colleges) agree to provide a set of minimum information on their examination (see figure for suggestion)? And will we shortly be reading a paper in the BMJ7 called "FRCS: examining the exam"? RICIHARt) WAKEFORD Cambridge CB] 2IE\W I Irving Al. MRCGP': cxanainitig the cxam. 13317 1991;303:363. (ItO Agttgst.: 2 Broiwsc NL. Examliting exatiners. Lancet 1990;335:73(0. 3 Wakefotrd R. Romyal cillege cxaminatiotis. Lanicet 1991;337:73Y. 4 Lockie C, ed. ExarninaiiOn for nite"bership of/the Rotal CoiiIc,c iof Genera! 1'ractitioners (MARCGP.) London: Royal Citlcgec tif Geticral Practitioners, 19911. ;Occasional papcr Nit 46.
BMJ VOLUME 303
24 AUGUST 1991
