854

COSTING CAN BE FUN

SIR,-I sympathise with chemical pathologists three-quarters ofwhose budgets are consumed by the assays for "urea and electro-lytes, please" (Sept 10, p 609). So often the results will be normal.Renal medicine necessitates frequent requests for plasma and serumelectrolytes. The only plasma electrolyte concentration I regularlyrequire is potassium. Plasma sodium is almost always normal andthe urea is often irrelevant. A creatinine assay should be substitutedfor that of urea. Serum creatinine is a good index of renal functionand, unlike urea, the concentration varies little with diet, sepsis, guthaemorrhage, or corticosteroid therapy. However, the system-atleast in this hospital-is such that to obtain the concentrations ofpotassium and creatinine two request forms have to be filled in andtwo frequently unnecessary variables (sodium and urea) are alsoassayed. Can one anticipate requests for "creatinine and potassium,please" which avoid unnecessary measurements of sodium and ureaand thus save money?Department of Renal Medicine,St Mary’s Hospital,London W2 1NY ROGER GABRIEL

DENTAL X-RAYS

SIR,-I must take issue with your offensively titled editorialDental X-rays, for Caries or Cash? (Sept 10, p 609). The five-foldincrease in the number of dental X-rays referred to is a testimony tothe increased diligence of the younger dentists who have entered theprofession during the past twenty years. You may take comfort foryour anxiety by the knowledge that dentistry is already the mostclosely monitored profession (by the fully computerised DentalEstimates Board) and by the fact that pantomograph films areaccepted only if at least 18 months has elapsed since the previousone.

Hillingdon Area Family Practitioner Committee,Fourth Floor, 1 Olympic Way,Wembley, Middlesex HA9 0LF

W. F. HOLLIS,Chairman

SIR,-My confidence in The Lancet as a responsible journal wasundermined by your editorial on dental X-rays. The first paragraphsuggests that dental disease has fallen by about 50% in the past tenyears. This is a misquote of the findings of Dr R. J. Anderson, whostated that in some areas caries reduction was as high as 50%, and hehighlighted Birmingham, where they have had water fluoridationfor about 16 years-but he went on to say that this reduction indecay was not so obvious in some other parts. In the West ofScotland the decrease is more like 15-20%.Where did Wall and Kendall get their figures for the massive

increase in X-rays? I checked with the Dental Estimates Boardfigures and in 1971 there were 3528 750 and in 1981 the overallfigures were 6230 080, the latter including 727 790 pantomographX-rays. In 1975 the pantomograph figures were 45 720. Thesefigures are very different from the ones cited by Wall and Kendall inthe article on which your editorial draws.Discussion should take into account the fact that the number of

dentists has increased by over 5000 in this period, the great benefitsof using orthopantomography (with its exceptionally low radiationdose) and the fact that as more people retain their natural teeth somore X-rays will be needed. Furthermore, early diagnosis of dentaldisease is always of benefit to the patient.Lanarkshire Health Board,14 Beckford Street,Hamilton ML30TA CHARLES F. A. DOWNIE

INTEGRATION OF GERIATRIC WITH GENERALMEDICAL SERVICES

SiR,-Professor Grimley Evans (June 25, p 1430) describes howgeneral physicians with special responsibility for the elderlyprovide a geriatric service integrated with other general medical

services in Newcastle upon Tyne. Although an integrated modelmay be a practical alternative to more traditional "separatist"geriatric services in an appropriate setting, there may be limits to itswider application.In west Newcastle, three such physicians (backed up by generous

provision of junior medical staff) serve a population of 27 800people aged 65 and over. The elderly population of England andWales will remain at about 8 million for some years (though with adramatic increase in the oldest and most frail).1 There are at presentsome 430 consultants in geriatric medicine in England and Wales:we will need double this number of general physicians with specialresponsibility if we extrapolate from the Newcastle staffing levels.Ifwe had to find over 400 additional physicians with an interest in

the elderly, and if such a solution were politically and financiallyacceptable, how would they be recruited? Evans argues that theintegrated approach is more attractive as a career. His view is

supported by new graduates (July 23, p 221) and by applicants forsenior registrar and consultant posts.2 However, I am not certainthat geriatric medicine should seek to emulate other medicalspecialties in which the excess of trained applicants for scarceconsultant posts is an embarrassment. Still less would I be happy ifthe future pattern of British geriatric medicine were determined bythe desire of doctors for self-fulfilment rather than by the needs ofthe elderly themselves.

It is most helpful to those of us planning the future of our servicesthat Evans has published details of the Newcastle system. I hopethat both "integrationists" and "separatists" such as Dr O’Brienand colleagues (Aug 6, p 339) will continue to provide figures whichenable us to plan on the basis of performance rather than

philosophy.Geriatric Medicine,Faculty of Medicine,University of Southampton,Southampton General Hospital,Southampton SO94XY R. S. J. BRIGGS

IMMUNOLOGY AND THE CLINICIAN

SIR,-In his paper on the development of services in immunologyand allergy in the UK, Dr Reeves (Sept 24, p 721) paid particularattention to the laboratory aspects. The training of physicians in themanagement of common allergies is even more deficient-whichmay partly explain why so many patients have sought help wherethey could find it and have turned to unorthodox procedures ofdoubtful value.The recognition given to allergy and clinical immunology on the

Continent of Europe and in the United States is in striking contrastto the attitude in the UK, where the developments of the past 25years are only now being acknowledged. The Specialist AdvisoryCommittee for Thoracic Medicine has taken the lead by requiringthat training programmes for chest physicians should includeexperience in allergy and immunology, and my Society has putforward the proposal that a similar training should be given topaediatricians, dermatologists, and ear, nose, and throat specialists.Like Reeves, we believe that the discipline of immunology, which atfirst placed its main emphasis upon basic scientific knowledge, hasnow reached the point where it has many practical applications.Recognition of this fact is long overdue.

Department of Medicine,Guy’s Hospital Medical School,London SE1 9RT

M. H. LESSOF,President, British Society forAllergy and Clinical Immunology

ALCOHOL AND GOVERNMENT POLICY

SIR,-Your Westminster correspondent (Aug 13, p 409) suggeststhat the Government is sponsoring alcoholism by neglecting it. The

1. Acheson ED. The impending crisis of old age: a challenge to ingenuity. Lancet 1982, ii

592-94.2. Graham JM, Playfair HR. General medicine with special responsibility for care of the

elderly. Health Trends 1983; 15: 66.