Letter: Glucose is dextrose is glucose.

SIR,-Your leading article (12 June, p 1425) reads as an attempted defence of a poor, persecuted minority-the consultants in acute general hospitals. We all live in difficult times. No doubt they will have the sympathy of those wealthier than themselves with more resources at their disposal. What worries me is what you say in their defence and what you don't say. For instance, you were challenged (24 April, p 1013) to justify a figure quoted ("every drop of even 01-( . . .") in a previous leading article (3 April, p 787). Usually such challenges are answered by a reference, an explanation, or an apology. Your technique is a vague quote, from a source not entirely free from bias. In addition you argue about "absolute standards" in medicine. "If a . new drug or procedure has been proved to make a substantial difference to mortality or morbidity then the doctors working in the specialty will not be content until they use the new treatment on their patients. " For the world as a whole the statement is clearly untrue, but even in Britain I have some doubts-although much depends on how you define "proof" and "substantial," and the choice of referee, when there is conflict between specialties. Even so I would argue that there are other factors involved, such as the degree of effectiveness, the cost, the age and general health of the patient, and his or her wishes. You also mention diagnostic aids. For many years it has been known that if, before giving barbiturate anaesthetics, patients were tested the reduction in specific mortality for porphyria might be substantial. My family would profit from such a routine but I have always understood that it was not done because it was not cost-effective-and I rather agree. Your other point concerns "workhouses. " I agree that they are depressing places to work in, and to die in, but do new buildings really affect morbidity, mortality, or morale ? I observe in Cardiff and remain sceptical. The omissions in your defence are even odder. You seem curiously unaware of the rising tide of criticism of these consultants over the past 10 years. It is based in general on their inability to justify the vast increase in their resources by evidence of a comparable increase in "output. " In greater detail one could cite the lack of reaction on behalf of these consultants to a considerable mass of observational and experimental evidence about the effectiveness of some treatments, place of treatment, and length of stay in hospital. Possibly the most striking example is the conspiracy of silence with which the cardiologists have welcomed Gordon Mather's comparison of case fatality in coronary care units and at home.1 I know from my travels that it is much more discussed abroad than here, where it represents our one big chance to save both lives and money at the same time. It is evidence of this nature without adequate reply which has convinced so many people, medical and lay, that the acute sector could well survive a cut in resources without detriment to outcome. I would in conclusion like to stress areas of agreement. I would agree that there are possibly too many administrators. It is unfortunately at present impossible to measure their ineffectiveness. Similarly, I am suspicious of the rapid growth of the social services without proper evaluation. Finally, I can't agree more about over-prescribing, but what has the BMA done to control it ? A L COCHRANE