Urban slums and primary health care.

provide substantial benefits for the dental health of six million people, many of them living in the west midlands and the north east ofEngland.4 The arguments for extending fluoridation are not as overwhelming as they were in 1956. The prevalence of dental caries has fallen in both fluoridated and non-fluoridated districts,5 and the costs of fluoridation plant designed to meet modem operating standards are considerable.6 It is sensible therefore that the health departments should give priority for new schemes to areas such as the north west of England7 and the west of Scotland where the prevalence of dental caries remains high and where large water treatment works allow for economies of scale. The Water (Fluoridation) Act 1985 placed the responsibility for decisions on water fluoridation with district health authorities, who are required to consult locally before making a formal request to the water undertaker. It was assumed, incorrectly as we now know, that water undertakers would concern themselves mainly with the technical feasibility of the proposal.8 Experience in the North Western Region, where 18 district health authorities completed consultation in 1988, and more recently in Strathclyde, Yorkshire, Wessex, and Northern Ireland, clearly shows that health authorities can obtain substantial public and professional support for fluoridation, even though opinion among local authorities remains divided. It is also clear that the cooperation of the water companies cannot be assumed. For example, the chairman of Welsh Water stated recently that, in spite of assurances from the Drinking Water Inspectorate concerning the safety of fluoridation plant designed according to the Department of Environment's code of practice,6 his company would not continue fluoridation on Anglesey or extend fluoridation into the rest of Wales unless required to do so by the secretary of state. While ministers quite correctly point out that the act requires local consultation, it was surely not the intention of parliament that water undertakers should have such an absolute veto. The recent fundamental review of dental remuneration by Sir Kenneth Bloomfield called for "a more robust approach" to fluoridation "which would not allow for indefinite procrastination in adopting measures judged by the competent health authorities to be both beneficial and cost effective."9 The secretary of state should now require water undertakers to implement fluoridation schemes when they are requested to do so by health authorities, subject to assurances that the proposed schemes are technically feasible and economically sensible.