Quality indicatorsfrom general practice No of comments
perhaps time for the BMJ to be more positive about some of the opportunities that the changes present to improve the quality of care. I F GREATOREX
Most frequent comments on two highest rated departments: Short waiting time for patients Helpful/efficient/appropriate service Good communication Good consultant access to general practitioners Most frequent comments on two lowest rated
30 27 24 12
departments: Long waiting time for patients Poor communication/liaison with general practitioners Inappropriate service Poor emergency service
1 Paton CR. Changes to the NHS. BMJ 191;302:1024-5. (27 April.)
50 28 5 6
service improvement differ both from those of the local NHS trust, which places an emphasis on technical innovation, and from the local purchasing health authority. An important and continuing part of the study has been discussion of the findings with both providers and purchasers. This shows that surveys such as these are valuable for their ability to initiate change. Developing a corporate view of service provision has enabled general practitioners to discuss changes with individual departments and to identify priorities for the quality specifications in contracts. S A HULL Steel's Lane Health Centre, London El 0I.R NANCY DENNIS LISA LOUGHLIN
College of Health, London E8 I Hicks NR, Baker IA. General practitioners' opinions of health services available to their patients. BMJ 1991;302:991-3.
(27 April.) 2 Maxwell RJ. Quality assessment in health. BMJ 1984;288: 1470-3.
Changes to the NHS SIR,-Although Dr Calum R Paton's analysis of the changes to the NHS may be received sympathetically by some medical colleagues, to me it seems naive and somewhat muddled.' The introduction of service agreements or contracts between purchasers and providers will undoubtedly make the existing rationing of health care more explicit and might well lead to increased expenditure on health care, which we should all welcome. The NHS has, however, tried strategic planning in the past in an attempt to obtain agreement about service development among doctors, managers, and others, and, judging by the perennial financing problems, it could be argued that this strategic planning has failed. In addition to making rationing more explicit the changes in the NHS will make the issue of choosing between competing priorities more explicit and will exacerbate any political tensions in the allocation of health care resources. I believe that there is a deliberate intention behind the reforms to include alternative assessments of health need to those made by the medical profession. These assessments might include those of other agencies, such as social services, and those of people living in local communities. I do not believe that the contracts are governed purely by the need for economy, and those of us who are working, as doctors, for district health authorities as purchasers are striving hard to use the new arrangements to improve the quality of care. It cannot be argued that the service hitherto has ensured equality of access, relevance to social need, social acceptability, and cost effectiveness. I can understand scepticism about yet another reorganisation, but we should acknowledge that something had to be done and perhaps it is too soon to predict the outcome of the current changes. It is
1406
Department of Public Health Medicine, Salford Health Authority, Eccles, Manchester M30 ONJ
What's in a name? SIR,-Minerva's belief that doctors who marry should adopt different names for their professional (Dr A) and home (Mrs B) personas has flaws. ' It is complicated to have two names. Many areas, such as finance, span the division between home and work. A doctor may travel abroad for both professional and social reasons-which name should she use for her passport? Major complications can ensue if this name doesn't tally with that on travel and other documents connected with the conference or the family holiday. When I married I decided not to change my name as I preferred to retain my identity rather than becoming-as I saw it-a nominal adjunct of my husband. Most of our friends, however, assumed that I had changed my name, and I found this quite disconcerting. This was resolved by discussion, and the only people who now call me "Mrs" are telephone salesmen who thus (usefully) betray their presence. A new problem arose during pregnancy, when discussions about names concerned surnames rather than first names. It seemed unfair for our daughter to be named after one parent alone, and she eventually ended up with two surnames, hyphenated. Others have given each child one surname, alternating maternal and paternal names. Are there better solutions? JAN WELCH
Department of Genitourinary Medicine, St Giles Hospital, London SE5 7RN 1 Minerva. Views. BMJ7 1991;302:1162. (11 May.)
Charging for responding to a postal questionnaire survey SIR, -Postal questionnaire surveys are often used to elicit information from general practitioners on various topics ranging from experience in general practice to caring for patients in the community after their discharge from hospital. A casual glance at this year's BMJs elicited 11 studies using this method. Dr Nicholas R Hicks and Dr Ian A Baker recommend it as a "practical and acceptable" means of obtaining information from general practitioners. ' As part of my attachment to the regional neurosurgical unit I conducted a survey on head injuries in the elderly. One of the general practitioners declined to give the information and returned the questionnaire with this note: "Thank you for the above. We are a business now; current costs for filling in such forms is £8.50. Could you confirm this is the fee that you will happily pay. God Bless the Government!" The current trend for audit would be severely hampered if this became a widespread attitude; I hope that it is an isolated incident. NIRU BURCHETT
Accident and Emergency Department, Norfolk and Norwich Hospital, Norwich NRI 3SR 1 Hicks NR, Baker A. General practitioners' opinions of health services available to their patients. BMJ 1991;302:991-3. (27 April.)
Women in medicine SIR,-We were interested in the letter by Ms Ursula Ackermann-Liebrich and colleagues on the survival of female doctors in Switzerland.' The careers of women in medicine have recently received considerable attention.2` Women are still underrepresented on consultant posts, even when only newly appointed consultants are considered6; the main discouragement for women embarking on a career in hospital medicine must be the difficulties in combining this with bringing up a family. We recently surveyed female consultant staff at the Royal Free Hospital in London to ascertain how they have combined professional and family lives. The 25 women form a quarter of our consultant staff. Most of these women are employed in "undersubscribed" specialties-general medicine (seven); anaesthesia (four); psychiatry (four); paediatrics (two); pathology (two); radiology (two); and epidemiology, accident and emergency, occupational health, geriatrics, obstetrics and gynaecology, ophthalmology, and genetics (one each). Replies to our questionnaire were received from 22 women. Their median age is 42, and they were appointed to a consultant post a median of 13 years after qualifying. Most (73%) are married, generally to other doctors, and have children (68%; mean number of children 2-3). Most commonly, the first child was born when the women were registrars, but the women started their families at all stages of their career, from senior house officer to consultant. One third of the mothers had participated in part time training schemes. This underlines the importance of these schemes in enabling women to complete their training, although many junior doctors seem ignorant of their existence. One third of the women stated that their choice of career had been influenced by their intentions to have children, and one third of the mothers thought that having children had not slowed their careers. All respondents now work full time, although several have preschool age children. Problems that were commonly highlighted included heavy administrative duties, lack of secretarial help, long and inflexible hours, research demands, entitlement to maternity leave, and the provision of reliable child care. To reverse the underrepresentation of women in senior hospital posts problems encountered by women consultants should be carefully addressed. We hope that by providing accurate information and timely advice we will enable junior doctors to make informed decisions about career plans and so achieve their potential in hospital medicine. We hope that this will be mirrored in a more flexible approach by our employers, particularly with regard to part time training and job sharing. ALISON WEBSTER
Department of Virology, CHRISTINE A LEE Department of Haematology, DORA BLACK
Department of Child Psychiatry, Royal Free Hospital, London NW3 2QG I Ackermann-Liebrich U, Wick SM, Spuhler T. Survival of female doctors in Switzerland. BMJ 1991;302:959. (20 April.) 2 Levinson W, [role SW, Lewis C. Women in academic medicine. N Engl Med 1989;321:1511-7. 3 McKeigue PM, Richards JDM, Richards P. Effects of discrimination by sex and race on the early careers of British medical graduates during 1981-7. BMJ 1990;301:961-4. 4 Rhodes P. Medical women in the middle: family or career? Periods not working and part-time work amongst women doctors who qualified in 1974 and 1977. Health Trends 1990;22:33-6. 5 Allen I. Doctors and their careers. Any room at the top? London: Policy Studies Institute, 1988. (Policy Studies Institute report 675.) 6 Department of Health and Social Security Medical Manpower and Education Division. Medical and dental staffing prospects in the NHS in England and Wales in 1987. Health 7rends 1988;20: 101-9.
BMJ
VOLUME 302
8 JUNE 1991
perhaps time for the BMJ to be more positive about some of the opportunities that the changes present to improve the quality of care. I F GREATOREX
Most frequent comments on two highest rated departments: Short waiting time for patients Helpful/efficient/appropriate service Good communication Good consultant access to general practitioners Most frequent comments on two lowest rated
30 27 24 12
departments: Long waiting time for patients Poor communication/liaison with general practitioners Inappropriate service Poor emergency service
1 Paton CR. Changes to the NHS. BMJ 191;302:1024-5. (27 April.)
50 28 5 6
service improvement differ both from those of the local NHS trust, which places an emphasis on technical innovation, and from the local purchasing health authority. An important and continuing part of the study has been discussion of the findings with both providers and purchasers. This shows that surveys such as these are valuable for their ability to initiate change. Developing a corporate view of service provision has enabled general practitioners to discuss changes with individual departments and to identify priorities for the quality specifications in contracts. S A HULL Steel's Lane Health Centre, London El 0I.R NANCY DENNIS LISA LOUGHLIN
College of Health, London E8 I Hicks NR, Baker IA. General practitioners' opinions of health services available to their patients. BMJ 1991;302:991-3.
(27 April.) 2 Maxwell RJ. Quality assessment in health. BMJ 1984;288: 1470-3.
Changes to the NHS SIR,-Although Dr Calum R Paton's analysis of the changes to the NHS may be received sympathetically by some medical colleagues, to me it seems naive and somewhat muddled.' The introduction of service agreements or contracts between purchasers and providers will undoubtedly make the existing rationing of health care more explicit and might well lead to increased expenditure on health care, which we should all welcome. The NHS has, however, tried strategic planning in the past in an attempt to obtain agreement about service development among doctors, managers, and others, and, judging by the perennial financing problems, it could be argued that this strategic planning has failed. In addition to making rationing more explicit the changes in the NHS will make the issue of choosing between competing priorities more explicit and will exacerbate any political tensions in the allocation of health care resources. I believe that there is a deliberate intention behind the reforms to include alternative assessments of health need to those made by the medical profession. These assessments might include those of other agencies, such as social services, and those of people living in local communities. I do not believe that the contracts are governed purely by the need for economy, and those of us who are working, as doctors, for district health authorities as purchasers are striving hard to use the new arrangements to improve the quality of care. It cannot be argued that the service hitherto has ensured equality of access, relevance to social need, social acceptability, and cost effectiveness. I can understand scepticism about yet another reorganisation, but we should acknowledge that something had to be done and perhaps it is too soon to predict the outcome of the current changes. It is
1406
Department of Public Health Medicine, Salford Health Authority, Eccles, Manchester M30 ONJ
What's in a name? SIR,-Minerva's belief that doctors who marry should adopt different names for their professional (Dr A) and home (Mrs B) personas has flaws. ' It is complicated to have two names. Many areas, such as finance, span the division between home and work. A doctor may travel abroad for both professional and social reasons-which name should she use for her passport? Major complications can ensue if this name doesn't tally with that on travel and other documents connected with the conference or the family holiday. When I married I decided not to change my name as I preferred to retain my identity rather than becoming-as I saw it-a nominal adjunct of my husband. Most of our friends, however, assumed that I had changed my name, and I found this quite disconcerting. This was resolved by discussion, and the only people who now call me "Mrs" are telephone salesmen who thus (usefully) betray their presence. A new problem arose during pregnancy, when discussions about names concerned surnames rather than first names. It seemed unfair for our daughter to be named after one parent alone, and she eventually ended up with two surnames, hyphenated. Others have given each child one surname, alternating maternal and paternal names. Are there better solutions? JAN WELCH
Department of Genitourinary Medicine, St Giles Hospital, London SE5 7RN 1 Minerva. Views. BMJ7 1991;302:1162. (11 May.)
Charging for responding to a postal questionnaire survey SIR, -Postal questionnaire surveys are often used to elicit information from general practitioners on various topics ranging from experience in general practice to caring for patients in the community after their discharge from hospital. A casual glance at this year's BMJs elicited 11 studies using this method. Dr Nicholas R Hicks and Dr Ian A Baker recommend it as a "practical and acceptable" means of obtaining information from general practitioners. ' As part of my attachment to the regional neurosurgical unit I conducted a survey on head injuries in the elderly. One of the general practitioners declined to give the information and returned the questionnaire with this note: "Thank you for the above. We are a business now; current costs for filling in such forms is £8.50. Could you confirm this is the fee that you will happily pay. God Bless the Government!" The current trend for audit would be severely hampered if this became a widespread attitude; I hope that it is an isolated incident. NIRU BURCHETT
Accident and Emergency Department, Norfolk and Norwich Hospital, Norwich NRI 3SR 1 Hicks NR, Baker A. General practitioners' opinions of health services available to their patients. BMJ 1991;302:991-3. (27 April.)
Women in medicine SIR,-We were interested in the letter by Ms Ursula Ackermann-Liebrich and colleagues on the survival of female doctors in Switzerland.' The careers of women in medicine have recently received considerable attention.2` Women are still underrepresented on consultant posts, even when only newly appointed consultants are considered6; the main discouragement for women embarking on a career in hospital medicine must be the difficulties in combining this with bringing up a family. We recently surveyed female consultant staff at the Royal Free Hospital in London to ascertain how they have combined professional and family lives. The 25 women form a quarter of our consultant staff. Most of these women are employed in "undersubscribed" specialties-general medicine (seven); anaesthesia (four); psychiatry (four); paediatrics (two); pathology (two); radiology (two); and epidemiology, accident and emergency, occupational health, geriatrics, obstetrics and gynaecology, ophthalmology, and genetics (one each). Replies to our questionnaire were received from 22 women. Their median age is 42, and they were appointed to a consultant post a median of 13 years after qualifying. Most (73%) are married, generally to other doctors, and have children (68%; mean number of children 2-3). Most commonly, the first child was born when the women were registrars, but the women started their families at all stages of their career, from senior house officer to consultant. One third of the mothers had participated in part time training schemes. This underlines the importance of these schemes in enabling women to complete their training, although many junior doctors seem ignorant of their existence. One third of the women stated that their choice of career had been influenced by their intentions to have children, and one third of the mothers thought that having children had not slowed their careers. All respondents now work full time, although several have preschool age children. Problems that were commonly highlighted included heavy administrative duties, lack of secretarial help, long and inflexible hours, research demands, entitlement to maternity leave, and the provision of reliable child care. To reverse the underrepresentation of women in senior hospital posts problems encountered by women consultants should be carefully addressed. We hope that by providing accurate information and timely advice we will enable junior doctors to make informed decisions about career plans and so achieve their potential in hospital medicine. We hope that this will be mirrored in a more flexible approach by our employers, particularly with regard to part time training and job sharing. ALISON WEBSTER
Department of Virology, CHRISTINE A LEE Department of Haematology, DORA BLACK
Department of Child Psychiatry, Royal Free Hospital, London NW3 2QG I Ackermann-Liebrich U, Wick SM, Spuhler T. Survival of female doctors in Switzerland. BMJ 1991;302:959. (20 April.) 2 Levinson W, [role SW, Lewis C. Women in academic medicine. N Engl Med 1989;321:1511-7. 3 McKeigue PM, Richards JDM, Richards P. Effects of discrimination by sex and race on the early careers of British medical graduates during 1981-7. BMJ 1990;301:961-4. 4 Rhodes P. Medical women in the middle: family or career? Periods not working and part-time work amongst women doctors who qualified in 1974 and 1977. Health Trends 1990;22:33-6. 5 Allen I. Doctors and their careers. Any room at the top? London: Policy Studies Institute, 1988. (Policy Studies Institute report 675.) 6 Department of Health and Social Security Medical Manpower and Education Division. Medical and dental staffing prospects in the NHS in England and Wales in 1987. Health 7rends 1988;20: 101-9.
BMJ
VOLUME 302
8 JUNE 1991
