despite a second reminder letter being sent. Our practice is centred on several large council estates, though appreciable numbers of patients live in relatively more affluent areas towards the periphery. The mammography caravan was sited 2-5 km from the heart of the practice area with reasonably direct public transport. One hundred and fifteen of the non-attenders live in the council estates, indicating that this screening programme is having its least impact on the poorer women in our practice. Also of great concern, however, is that overall attendance rates are well below the 70% expected and the hoped for 25% reduction in mortality from breast cancer is thus unlikely to be achieved. The screening programme has been organised at district level, and we have gained the impression that for many women it is seen as separate and distant from other forms ofprevention offered by general practice and primary care. If the government wishes to see more equitable screening coverage increased resources may need to be given to promoting the campaign at a more local level using existing networks of health education and health promotion in general practice. TONY DOWELL MARGARET GOSLING

Meanwood Health Centre, Leeds LS6 4JN I Wald N, Frost C, Cuckle H. Breast canicer screening: the ctirrent position. BMJ 1991;302:845-6. (6 April.) 2 Muir Gray JA, X'esses MP, Patrick J. Breast cancer screening: the cturrent position. B.VjJ 1991;302:1084. (4 May.) 3 Skrabanek P, MlcCorrnick J. Breast cancer screening: the current position. BMJ 1991;302:1401. (8 June.)

Nightmare of extracontractual referral SIR,-The following is an example of the new levels of efficiency being achieved in the postreformed NHS. A child resident in my district was referred to me by his general practitioner for help with enuresis. It is an unusual case with an underlying psychological element. The boy subsequently moved 8 km with his parents to an ad joining district. He continued to attend the same school and had the same general practitioner. He had increasing behaviour problems and was seen by the educational psychologist in the district in which I work. The phsychologist and I agreed that psychiatric help was necessary. I met the boy and his parents to explain this, and they agreed to see the child psychiatrist based in the hospital in which I work. So far, so good. But then the bureaucratic nightmare began. The child psychiatrist was informed by the contracts manager of the mental health unit that the adjoining district did not have a contract with the unit and suggested that the referral should be returned to me, which he did. I discussed this with the director of public health in my district, who contacted the director of public health in the adjoining district. The director of public health in the adjoining district replied to the director of public health in my district, saying that the paediatrician needed to discuss the referral with the patient's general practitioner and that in his view referral to his district's child psychiatry services would be better. The director of public health in my district forwarded the letter to me. Naturally, I blew a fuse. I replied to the director of public health in the adjoining district to explain the nature of the teamwork involved with such a patient and the need to be prompt and cohesive in dealing with the sort of problem presented. Fortunately, throughout all this the child psychiatrist decided on the clinical need, saw the patient, and prepared to face the music, thinking this preferable to allowing the bureaucracy to harm the boy through further

delay.

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At this stage it is still not clear whether the referral will be paid for. The costs are considerable in terms of delay for the patient correspondence, telephone calls, time wasted, and blown fuses. P M JONES

General Hospital, Bishop Auckland, County Durham DL14 6AD

Doctors and the European Community SIR,-Two recent articles on doctors and the European Community have prompted me to write.' 2 I am convinced that the free movement of professionals in the European Community is an advantage for the cultural, scientific, and socioeconomic progress of a united Europe. Socioeconomic progress cannot take place if cultural exchanges are not encouraged and increased. Doctors from the European Community are entitled to full registration with the General Medical Council. Messrs Stephen Brearley and Douglas Gentleman report that 1000 practitioners from the European Community have registered with the General Medical Council,2 but it would be interesting to know how many British doctors have registered elsewhere in Europe. How many of these actually find a position in the guest country? The linguistic difficulties and the different educational systems in the various countries make it difficult to find posts as visiting registrars and opportunities for specialist training, which are necessary for financial reasons. This is the main reason why most doctors, being unable to subsidise themselves for more than one year, return to their country of origin. It is as difficult to obtain a grant from one's own government as it is from the European Community, and these are often reserved for new graduates. I hope that soon the European Commission will come up with a system to standardise educational training in Europe, although this would benefit only future generations. Middle aged doctors at the apex of their career, eager to learn new technologies so necessary to the progress of medicine and scientific research, are seriously penalised by the lack of specific laws encouraging them to go to other countries. Married doctors encounter even more difficulties. As long as these problems are not solved, working in the European Community will remain elitist. A solution may be to allow free exchange of medical staff from European universities or hospitals by keeping a certain number of places open for specialist training for doctors from member states. Has the European Commission contemplated this? MARIA ROSARIA CARDILLO London W14 I DF 1 Richards T. Edging into Europe. BAI, 1991;302:1173. (18 Mav.) 2 Brearlev S, Gentleman 1). Doctors and the European Cotnmunity.

BMIJ 1991;302:1221-2. (25 May.)

SIR,-In her report on Euromigration Dr Tessa Richards has reported the xenophobic fears that lie behind a veil of concern.' The European Community's mutual recognition acts of 1975 have never prompted a cross-Channel passage of multilingual, multicoloured "hordes of doctors"2 and never will. Indeed, there has been a moderate inflow of junior doctors into the United Kingdom from other countries in the European Community-predominantly as registrars or senior house officers. This should be welcomed by both patients and employees of the NHS. These doctors have come to fill needs. Firstly, they wish to continue studies. The oversaturation of doctors in countries such as Germany and Spain

has meant that talented doctors are unemployed. Dr Richards also ignores the economic incentives for junior doctors from the European Community to come to the United Kingdom. Stated simply, a junior doctor earns 300% more here than in an equivalent position in Germany. Many work here -to the good fortune of the NHS-until they can return to their country with firm offers of employment and respectable pay. Secondly, these doctors are filling the needs of the NHS and its patients. They have not wormed their way into this country by bribes or by influence. They have been actively recruited by British agencies, which are paid a considerable sum by British health authorities for each doctor they place. These doctors are not taking the place of British doctors; British doctors do not fill these

positions. Furthermore, it is unlikely that any appreciable number of doctors from the European Community will continue into consultant positions in Britain. Though a fifth have stated that this is what they plan to do, the plans of life often go awry. Doctors from the European Community hold 6% of all senior house officer posts yet only 1% of all senior registrar positions. Finally, the question remains of whether these doctors are qualified to practise in Britain. Shouldn't we trust the ability of British agencies to hire qualified staff and the judiciousness of British consultants and registrars to weed out those who are in over their heads? For every example of other countries' leniency in terms of time spent in training there is another that reflects the converse. For example, doctors have to spend 18 months in the preregistration grade in Germany compared with 12 months in Britain, and the duration of medical education in Germany is one year longer than that in Britain (six and five years respectively). We would be interested to hear of a British doctor who is unemployed directly as a result of the employment of a peer from the European Community, or of one doctor from the European Community who has continued for more than a week in the NHS after it has been determined, albeit belatedly, that he or she is underqualified for the post. Yes, training and qualifications should be standardised within the European Communityfor the safety of all the countries, not just the United Kingdom. JOHANNA SCHWARZENBERGER CHRISTOPHER TYRONE

Medway Hospital, Gillingham, Kent ME7 5NY 1 Richards T. Euromigration. BMJ 1991;302:12%-7. (1 June.)

General practitioner outpatient referrals SIR,-If Mr Desmond A Nunez means what he says-and I sincerely hope that he does not-he demonstrates well the gulf in perceived roles that lies between primary and secondary care. ' Mr Nunez describes a study in which inappropriate referrals were classified as those in whom no otolaryngeal disease was identified. In other words, if the patient does not have a defined illness he or she should not see an ear, nose, and throat surgeon. Whatever happened to the generally accepted medical tasks of excluding important disease and of reassuring and educating patients? During the past year I have referred a clergyman with hoarseness of three months' duration, a woman with episodes of disabling dizziness, and a young woman with globus hystericus-all to ear, nose, and throat outpatient clinics. All were distressed by their symptoms: no disease was found in any of

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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

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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

General practitioner outpatient referrals.

despite a second reminder letter being sent. Our practice is centred on several large council estates, though appreciable numbers of patients live in...
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