them, as I expected would be the case when I referred them. Were these referrals inappropriate, or is it only general practitioners who can see patients without diseases? T R G HOWARD
Corfe Mullen, Wrimborne, Dorset BH2 1 3RJ 1 Ntunez DA. Genieral practitioner outpatient referrals. BMJ
1991;302:1468. (15 Jttne.)
General practitioners' attendance at case conferences SIR,-In his leading article Dr Andrew Harris' seems to have ignored a vital factor in general practitioners' attendance at case conferences-that is, the motivation of the local social workers in making it convenient for general practitioners to attend. I have been a principal in two (adjoining) boroughs. In the first, after the local social worker found out that I was not only willing but able to attend case conferences she would telephone me well in advance and would even reschedule a case conference to suit me. In contrast, the borough in which I am working now typically posted a letter (dated two weeks earlier) to my practice on a Friday, which arrived on the Monday morning, inviting us to a case conference on the Tuesday morning at 10 am. I do a clinic on Tuesday mornings yet the person arranging the case conference had not bothered to find out if it would be
standardised survey method. Although much of the detail of the manual relates specifically to users of maternity services, most of the basic stages and procedures described would apply to any survey of consumer satisfaction, and more generally. For example, planning a survey (including estimating the resources required), sample design, and computer editing and analysis are considered in detail. Where the need for local surveys on other topics is widespread investigators and others requiring the information will often find it useful to discuss their intentions, through an appropriate central body, with survey specialists as advisers. An example of a recent initiative of this sort was the workshop on health lifestyle surveys held jointly by the Health Education Authority and Department of Health and Social Security in 1989.5 In some cases the best next step may be for local bodies to group together through a national organisation to commission a survey manual on the subject.
provide a psychodynamic interpretation of their behaviour rather than to identify and treat any psychiatric disorder they might have. Nevertheless, the problems posed by those disorders still require management, so it is perhaps unsurprising that social services staff would attempt to (as they claimed) "treat" these youngsters, and get it horribly wrong. Certainly, one child who had suffered pindown, and whom I saw subsequently, had a mild frontal lobe syndrome. In moving to hospitals we need to ensure that those who refer patients to us do not become more suspicious of us than they already are. Fourthly, liaison with social services departments takes considerable time, which since April this year means money. With money following the patient, will general practitioners want to pay for us talking to social services staff? If they don't, will hard pressed local authorities be able to afford enough of our services at an economic rate?
MARGARET R BONE Social Survey D)ivision, Office of lPopulation Censuses and Surveys, London WC2B 6J1'
North Staffordshire Hospital Centre, Stoke on Trent Sr4 7QB
I Harris A. General practitioners and child protection case con-
ferences. BM. 1991;302:1354. (8 June.)
Surveys of patient satisfaction SIR,-As is obvious from Dr Ray Fitzpatrick's excellent, concise accounts of the value and conduct of surveys of patient satisfaction,' 2 even small surveys require considerable resources and skill if the results are to provide sound information. Such resources may not often be available to health professionals at local level. The scarcity of the necessary professional support to conduct local surveys of consumer satisfaction is not unique to people working in the health service. For this reason the social survey division of the Office of Population Censuses and Surveys is sometimes asked by government departments and public bodies to provide a manual of how a particular survey should be conducted. The most recent example is Women's Experience of Maternity Services-a Survey Manual.' A companion pamphlet illustrates the uses of the manual.4 The manual and pamphlet are intended primarily for district health authorities wishing to measure patients' views of local services. The manual is more than a detailed exposition of the principles outlined by Dr Fitzpatrick; it is a practical guide to designing and implementing local projects and contains, for example, model questionnaires as well as guidance on sample designs, methodology, and analysis. It is based on test surveys conducted by the social survey division for the purpose and draws on the division's experience over 50 years of a wide range of surveys for public sector bodies. The stated purposes of the manual are: to improve the quality of local surveys; to reduce the resources and skill needed locally to carry out surveys; and to enable more comparison of (maternity) services in different districts by using a
60
RAI7 1991;302:1359-60.
(8 June.) general considerations. BMJ7 1991;302:887-9. (13 April.) 2 Fitzpatrick R. Surveys of patient satisfaction. II. Designing a questionnaire and conducting a survey. BMJ 1991;302: 1129-32. (11 May.) 3 Mason V. Wown's experience of maternity care-a survey manual. London: HMSO, 1989. 4 Garcia J. (Getting consumers' views of maternttv care. London: Department of Health, 1989. 5 Health Education Authority. Health and lifestyle surzveys-toscards a common approach. London: HEA, 1990.
JONATHAN S CHARLTON North Harrow, Middlesex HA2 6HL
1 Dillner L. Pinning down the problem.
1 Fitzpatrick R. Surveys of patient satisfaction. I. Important
convemnent. Elmcroft Surgery,
D M FOREMAN
Departmenit of Psvchiatrv, University of Keele,
Liaison between child psychiatrists and social services staff SIR,-The recent publicity about "pindown," an attempt by staff to modify the behaviour of some children in children's homes in Staffordshire, has concentrated primarily on social services,' but it raises several issues important in child psychiatry. Firstly, are child psychiatric services in a position to detect such abuses, particularly if they may have psychiatric sequelae? As the Levy report of the inquiry into pindown shows, the vast majority of the children concerned did not come to the attention of the local psychiatric services. One child did, however, come to my attention before the problem was exposed, and, though I protested to the workers concerned (and was told that the child had recovered), I did not think to ask whether this was routine practice. It now seems that such an inquiry is indicated whenever poor practice is encountered in a referring agency. Secondly, how should child psychiatrists relate to social services staff? In Staffordshire it proved impossible to establish meaningful working relationships between consultant child psychiatrists and senior social services managers outside specific issues such as child protection. Clearly, good working relationships with social workers, or even having social workers attached to child psychiatry departments (both of which obtained in north Staffordshire), are not sufficient in themselves, and good routine contact at senior levels should be given high priority by both health authorities and social services departments. Thirdly, is the current move towards preferring hospital settings for child psychiatry necessarily in the best interest of our patients? Keeping away from social services is likely to result in a increase in suspicion of child psychiatry rather than the reverse. In north Staffordshire there is considerable concern about "psychiatric labelling" in social services, and most of my patients sent from the social services department were referred for me to
Part time training in obstetrics and gynaecology SIR,-I agree with many of the points raised by Miss Luisa Diliner in her article on the future development of maternity services.' We certainly do need changes in policy, based on the results of research, to give the consumer greater choice while using medical and midwifery skills most effectively. As a female registrar struggling to follow a career in obstetrics and gynaecology and at the same time maintain a family life with a small child, however, I find little in the way of encouragement. Consumer groups may want more women obstetricians, but the powers that be seem to have little commitment to flexible training schemes that might allow such women to make it to the top. Citing my own position as an example, I am geographically confined to Wales, where the Welsh Office has so limited the budget for part time training that only one person can begin the scheme this year. The outlook for my being able to train part time in this onerous specialty is therefore bleak, and the skills I have acquired look set to be lost. Having worked for 10 years since qualifying and having gained the MRCOG, I think that I have something to offer the consumer of any new maternity service. Evidently the government is prepared to overlook this resource. ALISON FIANDER
Llandaff, South Glamorgan CF5 2EQ I Dillner L. Maternity services: the shape of things to come. BM7 1991;302:1198-200. (18 May.)
Present day anatomy SIR,-Dr Bruce Charlton's gloomy assessment of anatomy as the ultimate horror of the modern biomedical sciences' does not hold true in my experience. I entered the discipline 11 years ago as a science rather than a medical graduate, and I cannot agree with the suggestion that anatomy is in decline either in its scientific research or in its teaching. Certainly, one has only to attend the annual winter meeting of the Anatomical Society to observe how much elegant, well executed research is presented by undergraduate and graduate students and anatomists in general. Applications of current molecular techniques such as in situ hybridisation, immunolabelling, and
BMJ VOLUME 303
6 JULY 1991
Corfe Mullen, Wrimborne, Dorset BH2 1 3RJ 1 Ntunez DA. Genieral practitioner outpatient referrals. BMJ
1991;302:1468. (15 Jttne.)
General practitioners' attendance at case conferences SIR,-In his leading article Dr Andrew Harris' seems to have ignored a vital factor in general practitioners' attendance at case conferences-that is, the motivation of the local social workers in making it convenient for general practitioners to attend. I have been a principal in two (adjoining) boroughs. In the first, after the local social worker found out that I was not only willing but able to attend case conferences she would telephone me well in advance and would even reschedule a case conference to suit me. In contrast, the borough in which I am working now typically posted a letter (dated two weeks earlier) to my practice on a Friday, which arrived on the Monday morning, inviting us to a case conference on the Tuesday morning at 10 am. I do a clinic on Tuesday mornings yet the person arranging the case conference had not bothered to find out if it would be
standardised survey method. Although much of the detail of the manual relates specifically to users of maternity services, most of the basic stages and procedures described would apply to any survey of consumer satisfaction, and more generally. For example, planning a survey (including estimating the resources required), sample design, and computer editing and analysis are considered in detail. Where the need for local surveys on other topics is widespread investigators and others requiring the information will often find it useful to discuss their intentions, through an appropriate central body, with survey specialists as advisers. An example of a recent initiative of this sort was the workshop on health lifestyle surveys held jointly by the Health Education Authority and Department of Health and Social Security in 1989.5 In some cases the best next step may be for local bodies to group together through a national organisation to commission a survey manual on the subject.
provide a psychodynamic interpretation of their behaviour rather than to identify and treat any psychiatric disorder they might have. Nevertheless, the problems posed by those disorders still require management, so it is perhaps unsurprising that social services staff would attempt to (as they claimed) "treat" these youngsters, and get it horribly wrong. Certainly, one child who had suffered pindown, and whom I saw subsequently, had a mild frontal lobe syndrome. In moving to hospitals we need to ensure that those who refer patients to us do not become more suspicious of us than they already are. Fourthly, liaison with social services departments takes considerable time, which since April this year means money. With money following the patient, will general practitioners want to pay for us talking to social services staff? If they don't, will hard pressed local authorities be able to afford enough of our services at an economic rate?
MARGARET R BONE Social Survey D)ivision, Office of lPopulation Censuses and Surveys, London WC2B 6J1'
North Staffordshire Hospital Centre, Stoke on Trent Sr4 7QB
I Harris A. General practitioners and child protection case con-
ferences. BM. 1991;302:1354. (8 June.)
Surveys of patient satisfaction SIR,-As is obvious from Dr Ray Fitzpatrick's excellent, concise accounts of the value and conduct of surveys of patient satisfaction,' 2 even small surveys require considerable resources and skill if the results are to provide sound information. Such resources may not often be available to health professionals at local level. The scarcity of the necessary professional support to conduct local surveys of consumer satisfaction is not unique to people working in the health service. For this reason the social survey division of the Office of Population Censuses and Surveys is sometimes asked by government departments and public bodies to provide a manual of how a particular survey should be conducted. The most recent example is Women's Experience of Maternity Services-a Survey Manual.' A companion pamphlet illustrates the uses of the manual.4 The manual and pamphlet are intended primarily for district health authorities wishing to measure patients' views of local services. The manual is more than a detailed exposition of the principles outlined by Dr Fitzpatrick; it is a practical guide to designing and implementing local projects and contains, for example, model questionnaires as well as guidance on sample designs, methodology, and analysis. It is based on test surveys conducted by the social survey division for the purpose and draws on the division's experience over 50 years of a wide range of surveys for public sector bodies. The stated purposes of the manual are: to improve the quality of local surveys; to reduce the resources and skill needed locally to carry out surveys; and to enable more comparison of (maternity) services in different districts by using a
60
RAI7 1991;302:1359-60.
(8 June.) general considerations. BMJ7 1991;302:887-9. (13 April.) 2 Fitzpatrick R. Surveys of patient satisfaction. II. Designing a questionnaire and conducting a survey. BMJ 1991;302: 1129-32. (11 May.) 3 Mason V. Wown's experience of maternity care-a survey manual. London: HMSO, 1989. 4 Garcia J. (Getting consumers' views of maternttv care. London: Department of Health, 1989. 5 Health Education Authority. Health and lifestyle surzveys-toscards a common approach. London: HEA, 1990.
JONATHAN S CHARLTON North Harrow, Middlesex HA2 6HL
1 Dillner L. Pinning down the problem.
1 Fitzpatrick R. Surveys of patient satisfaction. I. Important
convemnent. Elmcroft Surgery,
D M FOREMAN
Departmenit of Psvchiatrv, University of Keele,
Liaison between child psychiatrists and social services staff SIR,-The recent publicity about "pindown," an attempt by staff to modify the behaviour of some children in children's homes in Staffordshire, has concentrated primarily on social services,' but it raises several issues important in child psychiatry. Firstly, are child psychiatric services in a position to detect such abuses, particularly if they may have psychiatric sequelae? As the Levy report of the inquiry into pindown shows, the vast majority of the children concerned did not come to the attention of the local psychiatric services. One child did, however, come to my attention before the problem was exposed, and, though I protested to the workers concerned (and was told that the child had recovered), I did not think to ask whether this was routine practice. It now seems that such an inquiry is indicated whenever poor practice is encountered in a referring agency. Secondly, how should child psychiatrists relate to social services staff? In Staffordshire it proved impossible to establish meaningful working relationships between consultant child psychiatrists and senior social services managers outside specific issues such as child protection. Clearly, good working relationships with social workers, or even having social workers attached to child psychiatry departments (both of which obtained in north Staffordshire), are not sufficient in themselves, and good routine contact at senior levels should be given high priority by both health authorities and social services departments. Thirdly, is the current move towards preferring hospital settings for child psychiatry necessarily in the best interest of our patients? Keeping away from social services is likely to result in a increase in suspicion of child psychiatry rather than the reverse. In north Staffordshire there is considerable concern about "psychiatric labelling" in social services, and most of my patients sent from the social services department were referred for me to
Part time training in obstetrics and gynaecology SIR,-I agree with many of the points raised by Miss Luisa Diliner in her article on the future development of maternity services.' We certainly do need changes in policy, based on the results of research, to give the consumer greater choice while using medical and midwifery skills most effectively. As a female registrar struggling to follow a career in obstetrics and gynaecology and at the same time maintain a family life with a small child, however, I find little in the way of encouragement. Consumer groups may want more women obstetricians, but the powers that be seem to have little commitment to flexible training schemes that might allow such women to make it to the top. Citing my own position as an example, I am geographically confined to Wales, where the Welsh Office has so limited the budget for part time training that only one person can begin the scheme this year. The outlook for my being able to train part time in this onerous specialty is therefore bleak, and the skills I have acquired look set to be lost. Having worked for 10 years since qualifying and having gained the MRCOG, I think that I have something to offer the consumer of any new maternity service. Evidently the government is prepared to overlook this resource. ALISON FIANDER
Llandaff, South Glamorgan CF5 2EQ I Dillner L. Maternity services: the shape of things to come. BM7 1991;302:1198-200. (18 May.)
Present day anatomy SIR,-Dr Bruce Charlton's gloomy assessment of anatomy as the ultimate horror of the modern biomedical sciences' does not hold true in my experience. I entered the discipline 11 years ago as a science rather than a medical graduate, and I cannot agree with the suggestion that anatomy is in decline either in its scientific research or in its teaching. Certainly, one has only to attend the annual winter meeting of the Anatomical Society to observe how much elegant, well executed research is presented by undergraduate and graduate students and anatomists in general. Applications of current molecular techniques such as in situ hybridisation, immunolabelling, and
BMJ VOLUME 303
6 JULY 1991
