§ Mr. David Lock (Wyre Forest)I am extremely grateful for the opportunity that this debate provides to speak about the important subject of fluoridation in water.
None of us likes going to the dentist. The shrill whining of the dentist's drill causes most of us to feel our shoulder blades coming together as we are reduced to a state of quivering submissiveness. Despite many strides that have been made in recent years, a visit to the dentist is even more frightening for children than for adults.
However unpleasant a visit to the dentist may be, I hope that everyone accepts that dentists should be a vital part of our national health service. Living with poor dental health for years is infinitely worse than the pain of a visit to the dentist. Years of unnecessary toothache, having tooth after tooth removed and replaced by dentures at an early age, is a reality for far too many people in Britain today. However, in many parts of the country there are no NHS dentists. The systematic removal of dentistry from the NHS may not have been the previous Government's intention, but their policies had that effect. Despite being warned about those effects, they took no steps to promote NHS dentistry. Poor dental health for our children is the result.
Poor dental health is also the result of poor diet and poor oral hygiene and is symptomatic of poor education. We have known for many years that illnesses disproportionately affect our poorest citizens. That was conclusively shown by the Black report that was published—or, rather, not published— as long ago as 1979. Heart disease, cancer and mental health all strike hardest on our most vulnerable citizens. It should therefore be no surprise to find that tooth decay is no exception.
This is an appropriate time to raise such issues because in February the Government published the highly acclaimed Green Paper "Our Healthier Nation", which rightly raises the issues of health inequality, including those of dental health. The Green Paper recognises that the single most effective step that can be taken to improve the dental health of our poorest citizens is to fluoridate water to an optimum level of one part per million.
Fluoridation is strongly approved by the British Dental Association, which is to be commended for promoting better public health above the financial interests of its members. Fluoridation means fewer fillings, fewer extractions and thus fewer painful visits to the dentist. It also means a cut in the money that the NHS spends on dentists. I wryly reflect that the public health arguments for fluoridation must be compelling for the BDA— and others— to press for a measure that is so much against its members' financial interest.
The arguments for water fluoridation are strong. I shall illustrate that by using my constituency as an example. Kidderminster does not have— and has never had— the benefit of fluoridated water. The adjacent Worcestershire towns of Bromsgrove and Redditch were part of the old Birmingham system and are fluoridated. Differences in dental health between the two areas are startling. There is about 2.5 times as much tooth decay in children in Kidderminster as in Bromsgrove and Redditch, despite the fact that Kidderminster has a better Jarman score— the 694 accepted indicator of social deprivation— of minus 16.8, in comparison with minus 21.6 for Bromsgrove and Redditch. The effects of greater social deprivation have, in dental health, been more than outweighed by the simple expedient of putting minute traces of fluoride in drinking water.
The effects are not confined to children. Adults' teeth are worse in Kidderminster than in the neighbouring towns, with a 37 per cent. higher rate of dental extractions compared with fluoridated areas. Those figures have been validated by a comprehensive study in Anglesey, which confirmed the long-lasting benefits of fluoride for children and adults. It is also clear from academic work that such benefits accrue most to those in the worst economic circumstances. Proper levels of fluoride in drinking water are a simple and effective way of achieving equity in dental health across Britain.
§ Mr. John Butterfill (Bournemouth, West)There may be other medical conditions that could be improved by the adding of medicine to the water supply. Does the hon. Gentleman support those as well?
§ Mr. LockThe hon. Gentleman's point is— I am afraid— confused because it assumes for the purpose of the argument that fluoride is not a natural constituent in many areas of Britain. In fact, fluoride is naturally present in many areas, and adding it would merely bring some areas up to the natural state of others.
Adding fluoride to water will save the NHS and our country many millions of pounds. Every tooth that is unnecessarily filled or extracted is an unnecessary expense. Every day off work due to avoidable toothache is a day lost to British industry. Surely there are better uses for scarce NHS resources than paying dentists for work that could be avoided.
What are the arguments against fluoride? As I see it, there are essentially three: first, medical objections, secondly, civil liberties objections, and thirdly, indemnity problems. The anti-fluoridation lobby sees adding minute traces of fluoride to water as a threat to health. The health issues are now as clear as the drinking water itself. I do not have time in this short debate to recite the history of every health scare that has been based on half-baked research over the years. Skeletal fluorosis, cancer, hip fractures and many other conditions have been laid at the door of fluoride in drinking water, but the core of problems for those promoting such theories is that there are large areas of Britain, such as Hartlepool, for example, where fluoride at the optimum level is naturally present. Also, in countries such as the United States of America, very large areas— about half the country— are fluoridated. There is no chemical difference between added and natural fluoride.
The absence of diseases and complained of conditions in such areas compared with areas where there is no fluoride should be more than sufficient proof to satisfy the experts that the hypothesis of a link is unfounded, however the claims have been subject to extensive scientific analysis and found wanting. For example, the cancer scare was examined comprehensively by a Department of Health working party under Professor George Knox in 1984, and just as comprehensively dismissed. There are, of course, those who refuse to be convinced. However, given the tangible and demonstrable benefits of fluoridation, opposing it on scientific grounds against the views of scientists is unreasonable.
695 I turn to the civil liberties argument, for which I have more respect. At its base, it is an argument for individualism and against democratic bodies working for the public good. There are many occasions when we, as a society, take decisions that impact on the freedom of an individual to carry on life as he or she desires, justifying the decisions on the basis of greater public good. Speed limits on our roads, gun control law, prohibited drugs and restrictions on certain foodstuffs that have public health concerns all come into that category. In such cases, the individual's freedom is curtailed to a limited extent for the greater public good.
The supposed right to drink water free of minute traces of fluoride does not of course exist in many parts of the country, where natural levels of fluoride are present. Therefore, it is not a right in any sensible meaning of the word. Adding fluoride to water in other places thus only takes its constituency up to the natural level elsewhere. When properly examined, this is not a natural rights argument at all.
Fluoridation is no different in principle from any other action that the Government take on behalf of the majority which is, in some instances, against the wishes of the minority. [Interruption.] If the hon. Member for Bournemouth, West (Mr. Butterfill) wishes to intervene, he can, but his sedentary interventions cannot be encouraged.
§ Mr. ButterfillAll sorts of substances occur naturally in water— some beneficial, some harmful. In some areas, there is a natural occurrence of lead, and there are radioactive substances in the water in Cornwall. Does the hon. Gentleman suggest that those should be added to the water as well?
§ Mr. LockThe hon. Gentleman makes my point precisely. Where there are substances in the water, we should analysis them carefully to see whether they are for the public good or the public harm. If they are for the good, they should be retained. If harmful, they should be removed.
Tangible benefits flow from fluoridation to the socially deprived, and where health authorities have consulted, upwards of four out of five people actively supported fluoridation. In those circumstances, I find it difficult to justify the right of a small number of determined, but perhaps narrow-minded, individuals who wish to oppose the benefits that the general public want.
The third problem— the one on which I seek to press my hon. Friend the Minister—is the issue of indemnities for the water companies. The existing system, under the Water (Fluoridation) Act 1985, provides for health authorities to request water companies to provide fluoridation in water where, after public consultation, the health authority decides that it is appropriate for its area. The Green Paper raised the issue of the level and the process of consultation. I can only say that the consultations in which I have been involved have been models of consultation and public debate, and have provided a real opportunity for the public to discuss both sides of the argument. These are the processes which have, after public education, produced a 79 per cent. approval rating for fluoridation.
Certain indemnities against criminal or civil liabilities can be given by the Secretary of State to the water companies to protect them against claims, good or bad, 696 arising as a result of fluoridation of the water supply. The water companies have, in effect, a discretion under existing law whether to comply with a request from the health authorities. Some companies— including Severn Trent, which serves my constituency— are seeking much wider indemnities than those provided by the current scheme.
The problem of the extent of indemnities is complex. I accept that, as indemnities can lead to exposing the public purse to the risk of extensive liabilities, the Minister must consult the Treasury before any extended liabilities can be given. Although I have some sympathy for the position of the water companies— which do not wish to expose themselves or their shareholders to unquantifiable liabilities— it must be recognised that they are monopoly suppliers which make substantial profits out of exploiting their monopoly position. In those circumstances, they are entitled to reasonable indemnities, but it cannot be right for companies to seek an indemnity from all criminal acts— even if there is fault on the part of a company or its employees.
Today, I am seeking assurances from the Minister on three grounds: first, that she will, at an early date, conduct discussions with the water companies and her Treasury colleagues to seek to agree a standard set of indemnities that can be given by public authorities where a request to fluoridate is made; secondly, that when the Green Paper is followed by a White Paper and legislation, the standard indemnities will be set out in a schedule or in secondary legislation so that everyone knows where they stand on indemnities and so that these issues are not open to further negotiation; thirdly, that when she comes to consider new legislation on fluoridation, my hon. Friend will look carefully at the discretion given to water companies by section 1(1) of the 1985 Act to comply with a request from a health authority.
If a public body such as a health authority conducts a public consultation exercise and reaches a view, in public, that fluoridation of the water supply is right as a public health measure, it should not be open to a private water company to have the discretion to block that measure. There have been no new fluoridation schemes since the discretion was given in the 1985 Act. That has resulted in the blocking of health benefits for a large number of our citizens. I ask the Minister to carefully consider whether the time has come to remove the discretion.
I close by commending the Government on raising the issue in the Green Paper. I hope that the excellent start which has been made will, in the near future, be turned into an effective scheme to give local health authorities an enforceable power to require water to be fluoridated where they consider that appropriate to local circumstances. With this power, I look forward to seeing tangible benefits for my constituents so that the rate of children's tooth decay in Kidderminster falls by two thirds, as demonstrated in neighbouring towns.
§ Mr. Butterfillrose—
§ Mr. Deputy Speaker(Sir Alan Haselhurst)Order. If the hon. Gentleman wishes to speak in an Adjournment debate— which is essentially for the hon. Member who raises the matter— he must have the permission of the hon. Member and the Minister. Without that, I am afraid that I cannot call him.
§ The Minister for Public Health(Ms Tessa Jowell)I commend my hon. Friend the Member for Wyre Forest (Mr. Lock) on securing this important debate at a time when the public consultation on the Green Paper on public health is drawing to a close. We have received more than 5,000 responses, and there has been overwhelming support for the Government's approach to improving health and tackling health inequality.
As my hon. Friend has described, tackling inequalities in oral health is an important part of the overall programme. There is very good evidence that significant inequalities remain in the oral health of the population. Even at a regional level, there are factor differences in the levels of tooth decay in children. For example, in 1995-96, five-year-olds in the west midlands had, on average, less than half the numbers of decayed, missing or filled primary teeth than those in the north-west.
As my hon. Friend mentioned, some 5 million people receive water where the fluoride content has been artificially increased to a level of one part per million. Major schemes are in operation in Birmingham and throughout the west midlands, and also in Tyneside. About 500,000 people in this country receive water which is naturally fluoridated at or about the optimum level of one part per million. A further one million people receive water which is naturally fluoridated at a lower level, but which still confers some dental benefit.
Well-documented studies have shown that fluoridation of the water supply can produce a reduction in dental decay in children of about one third or one half. Sandwell was fluoridated in 1986. Over the following 10 years, the amount of tooth decay in children had more than halved. During the same period, an area with a comparable population mix— Blackburn, in the north-west— saw little change in its children's oral health. That example has been replicated in many other places over the past 50 years.
§ Mr. ButterfillVery few people in the House would deny that there are health benefits from fluoridation. All my children have received fluoride treatment, and it is difficult to buy toothpaste without fluoride. However, does the Minister agree that there is a significant civil liberties argument, which is that people should be able to choose the medicines they receive? Once the state starts saying that it will enforce the addition of medicine to the water supply, we will be in a dangerous area. We may be open to challenge from the European Court of Human Rights.
§ Ms JowellI thank the hon. Gentleman for that intervention. We recognise that strongly held views exist on both sides of the argument. Undoubtedly, important civil liberties matters need to be considered and I hope that as I continue with my remarks he will understand that the Government's approach is intended to take proper account of those concerns.
My hon. Friend referred to the important deterioration in dental health that occurred when fluoridation was withdrawn in Anglesey. Obviously, in considering a public health measure such as fluoridation, we are concerned above all else with safety. Nothing can ever be pronounced safe in absolute terms, but no ill effects have ever been found to exist as a result of drinking fluoridated water. The view that water fluoridation is safe is that of 698 the majority of medical and scientific opinion throughout the world, based on practical experience and research over 50 years. In that time, many health problems have been alleged to be linked to fluoridation. They have been investigated and no link was found. I must make it clear to the House that the Government will proceed with an open mind, always willing to consider evidence on either side of the argument. That is a policy pursued in the interests of tackling inequality and applying what works, not in the pursuit of dogma.
§ Dr. Peter Brand (Isle of Wight)Does the Minister agree that a precedent to counter the civil liberties argument is the addition of vitamins to white flour, bread and margarine, which has been going on for many years in this country, about which no one has complained and which has certainly prevented much disease?
§ Ms JowellUndoubtedly, there are analogies, but rather than drawing on a point of principle, our concern is to examine fluoridation as a potential area of public policy that would effectively tackle inequality in the enjoyment of oral health. To do so, it is extremely important to enable proper opportunities for local representation.
To underline the safety issues, the most recent research of which we are aware in this country concerned a potential link with hip fracture, which has also proved to be unfounded. Any convincing evidence of harm to general health as a result of drinking artificially fluoridated water at one part per million has yet to emerge. Indeed, it is estimated that throughout the world 210 million people drink artificially fluoridated water.
§ Mr. Butterfillrose—
§ Ms JowellI have already given way to the hon. Gentleman and I hope that he will forgive me if I do not do so again as I wish to cover a considerable amount of information.
Legislation is the problem at the heart of the issue and the final decision on implementing fluoridation schemes rests with the water undertaker. The Water (Fluoridation) Act 1985 was consolidated in the Water Industry Act 1991. Section 87(1) of the 1991 Act states:
Where a … Health Authority have applied in writing to a water undertaker for the water supplied within an area specified in the application to be fluoridated, that undertaker may, while the application remains in force, increase the fluoride content of the water supplied by the undertaker within that area.That is the legislative framework, but it is clear that there are shortcomings in the effectiveness of the legislation— the Act has not worked.Since 1985, 55 health authorities in England— nearly half taking into account the mergers of the past 12 years— have requested water companies to introduce water fluoridation. None of those requests has been accepted. As a result, there have been no new water fluoridation agreements since 1985. The reason is simply that none of the water companies has exercised its discretion to agree to a health authority's request. Since 1985, none of the requests has been accepted and implemented for the benefit of the local populations.
The legislation is also deficient in not specifying how a health authority should test local opinion during consultation. The Act requires only that the proposal be 699 published in at least one local newspaper and for local authorities to be consulted. Health authorities need to be much more pro-active and we need a much clearer and explicit framework within which consultation is carried out.
My hon. Friend mentioned indemnities, which are clearly another stumbling block in the operation of existing legislation. Water companies are concerned about any liabilities that they may incur from fluoridation. I am aware that some water companies, including Severn Trent, have sought changes to the statutory indemnities that we are able to offer when they implement fluoridation schemes. Our public health White Paper will set out a clear policy framework for fluoridation and we will need to consider any changes to indemnities in that context— it is also in that context that I shall deal with the points about indemnities that my hon. Friend raised. However, in the meantime I would encourage the water industry to work with the health authorities, using the current indemnities available against civil liabilities.
Briefly, on alternative sources of fluoride, to which the hon. Member for Bournemouth, West (Mr. Butterfill) referred, among the other options for improving oral health is the adding of fluoride to selected foods. Both milk and salt have been tried, but their effect is not universal; nor is it as effective as fluoridating water because of personal preference and compliance. Adding 700 fluoride to school milk has been shown to have beneficial effects throughout all social classes, but the problem is essentially one of compliance and consent.
To sum up, the present situation is a mess. The public health benefits of fluoridation are clear. The overwhelming evidence is that fluoridation of water is safe and effective. Recent opinion surveys have shown that more than two thirds of the public are in support, but, as I willingly acknowledged, there are those who hold alternative views. Doing nothing is not an option. The fluoridation programme is at a complete impasse. We cannot allow decisions on the principle of introducing a fluoridation scheme to be taken by a body that is accountable to its shareholders rather than its local population. That is why our public health White Paper, when it is published in the autumn, will draw on the extensive range of views offered during extensive consultation. The White Paper will set out the Government's intended framework for a way forward on fluoridation that will be recognised as workable, fair and taking account of the wide measure of public support for that practical policy to tackle inequality in oral health.
§ It being before Two o'clock, the motion for the Adjournment of the House lapsed, without Question put.
§ Sitting suspended, pursuant to Standing Order No. 10 (Wednesday sittings), till half-past Two o'clock.