Fluoridation

HC Deb 29 January 2001 vol 362 cc146-54

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Mike Hall.]

11.23 pm

Mr. Bill Etherington (Sunderland, North)

I begin by explaining to my hon. Friend the Minister that no discourtesy was intended on my part when I failed to get in touch with her. When I arrived this afternoon, I phoned her office and got an answerphone; I left word that I would be present at 7.15 pm but got no word back. I apologise only when I do things wrong so I am not apologising, but I regret that this has happened, because it puts a person at a disadvantage, and I would not seek to do that.

Since coming to this House in 1992, it has been my opinion that the Department of Health is absolutely paranoic in its support for fluoridation of water on the basis that it goes a long way to help reduce dental caries during the formative years of a child's growth. I am pleased to say that, since my party came to power, two significant moves have alleviated that position to some extent, although there is still a long way to go.

The first big step forward was when the Government agreed that, instead of local health authorities having the power to decide whether water should be fluoridated, it would be left to local councils to consult the people living in the area and to make a recommendation to the local health authority, which the health authority would accept.

The importance of that change is that health authorities do their work as they are told to do it by the Department of Health. There is no independence, and anyone who thinks otherwise does not have much knowledge of the Government or of those whom they appoint to do a job for them. Councils are rather different. They are, to some degree, influenced by the fact they can be removed by the people in their area, if they do not provide what the people want. That change was particularly welcome to me.

When this matter was discussed at great length in my constituency four years ago, there was a phone-in to a local newspaper in which more than 2,000 people took part. More than 90 per cent. of those who responded were against the fluoridation of water supplies. I have no fears about this matter. If we can go out and campaign fairly, I have no doubt that the public will democratically decide that they do not want fluoridation.

There was a second important factor. There must have been some doubt on the matter somewhere in the Department of Health, because last year it set up a review procedure under Professor Sheldon at York university. That review would take note of whatever evidence was available on the advantages and disadvantages of the fluoridation of water, and notice would, of course, be taken of the resulting report.

When the report came out in late autumn last year, I was delighted, as someone who is opposed to fluoridation and the secretary of the all-party parliamentary group against fluoridation. Having read the report, my view was that it in no way endorsed the views that we have been given for many years about the tremendous benefits of fluoridation, about there being no danger involved and about there being no evidence that it could be harmful.

I say to the Minister with all sincerity that I am very disappointed that the Department of Health has joined forces with the British Dental Association, the British Medical Association and the British Fluoridation Society in a pre-emptive strike to try to undermine the report. I make no apology for reading out a letter that was sent to the Government on 10 September by Professor Sheldon. I shall read it word for word, although I do not like doing that; I like spontaneity rather than chuntering on. Professor Sheldon wrote: In my capacity as chair of the Advisory Group for the systematic review on the effects of water fluoridation recently conducted by the NHS Centre for Reviews and Dissemination at the University of York and as its founding director, I am concerned that the results of the review have been widely misrepresented. The review was exceptional in this field in that it was conducted by an independent group to the highest international scientific standards and a summary has been published in the British Medical Journal. It is particularly worrying then that statements which mislead the public about the review's findings have been made in press releases and briefings by the British Dental Association, the National Alliance for Equity in Dental Health and the British Fluoridation Society. I should like to correct some of these errors.

1. 1 Whilst there is evidence that water fluoridation is effective at reducing caries, the quality of the studies was generally moderate and the size of the estimated benefit, only of the order of 15 per cent., is far from 'massive'.
2. 2 The review found water fluoridation to be significantly associated with high levels of dental fluorosis which was not characterised as 'just a cosmetic issue'.
3. 3 The review did not show fluoridation to be safe. The quality of the research was too poor to establish with confidence whether or not there are potentially important adverse effects in addition to the high levels of fluorosis. The report recommended that more research was needed.
4. 4 There was little evidence to show that water fluoridation has reduced social inequalities in dental health.
5. 5 The review could come to no conclusion as to the cost-effectiveness of water fluoridation or whether there are different effects between natural or artificial fluoridation.
6. 6 Probably because of the rigour with which this review was conducted, these findings are more cautious and less conclusive than in most previous reviews.
7. 7 The review team was surprised that in spite of the large number of studies carried out over several decades there is a dearth of reliable evidence with which to inform policy. Until high quality studies are undertaken providing more definite evidence, there will continue to be legitimate scientific controversy over the likely effects and costs of water fluoridation."

I pay tribute to Lord Baldwin, who has been an inspiration to all those who are worried about water fluoridation. I shall now pick out one or two highlights from a piece by Jerome Burne in the Financial Times on 27 January. The article is headed "Fluoridation findings set teeth gnashing" and says: A systematic research review has failed to find reliable evidence that it works, but doctors and dentists are refusing to accept the fact". I do not have time to read out the whole article, but it also says: Anyone who thinks this report a ringing endorsement is either scientifically illiterate or dishonest". Those are not my words, but I certainly go along with them.

Several statements have been made since the York review. I shall call it that because everyone—not that many are here—will understand it. The BDA said: The review … confirms that water fluoridation is safe and effective. The York review said: The studies included for [effectiveness] were of moderate quality (level B [moderate risk of bias]), and limited quantity. John Hunt, chief executive of the BDA, refers to the compelling evidence provided by the review", but the review says: Any future research … [should use] … appropriate methodology to improve the quality of the existing evidence base. The BDA says: The report confirms that there is clear evidence that fluoridation reduces [decay]. The York review says: To have clear confidence in the ability to answer the question [on caries reduction], the quality of the evidence would need to be higher. The BDA says: The report confirms that fluoridation reduces dental health inequalities … [and] significantly narrows the dental health gap". The York review, in its executive summary conclusions, says: The research evidence is of insufficient quality to allow confident statements about other potential harms [than dental fluorosis] or whether there is an impact on social inequalities. The BDA says: There is no evidence that water fluoridation is linked to cancer, bone disease, or any other adverse effect. The York review says: High quality research [into adverse effects] that takes confounding factors into account is needed. The BDA says: Dental fluorosis is recognised by the York review as a cosmetic issue, not a health problem. The York review says: This is nowhere to be found in the report. The lead researcher confirms 'we … did not say it was a cosmetic issue. The BDA says: projections in the review estimate that fluoridation might … increase … dental fluorosis of 'aesthetic concern' … to around 10 per cent. The York review says: The proportion who have teeth that are affected enough to cause aesthetic concern is approximately 12.5 per cent. That is pretty good for the BDA: it was only 25 per cent. out on that issue, whereas on all the others it was nearly 100 per cent. out. I could go on indefinitely with those quotations, but I shall not.

According to a BDA parliamentary newsletter, the York review confirmed that water fluoridation is safe and effective". The York review replied: Interpreting the results of studies of other possible negative effects is very difficult because of the small numbers of studies … and poor study quality … other potential adverse effects"— other than dental fluorosis, that is may take longer to occur, or may occur largely in an adult population … High quality research is needed.

I think I have made my point in that regard, but the Department of Health, which commissioned the report, has made statements on one or two issues. It has said: This report clearly shows that fluoridating water helps to reduce tooth decay. The York review said: The studies included for effectiveness— were of moderate quality … and limited quantity … Only one study addressed the positive effect of fluoridation in the adult population. Assessment of the long-term benefits of water fluoridation is needed. According to the Department of Health, The findings show that water fluoridation improves dental health". The York review said: it is surprising to find that little high quality research has been undertaken.

Perhaps the most surprising aspect involves a statement by the British Fluoridation Society, which compared dental health in fluoridated Sandwell with that in unfluoridated Bolton. to Bolton' s disadvantage. According to the York review: Crude league tables cannot be scientific, as they do not control for other variables. Ireland for example, most heavily fluoridated in Europe, ranks below 4 unfluoridated countries for dental health in 12-year-olds.

I have quoted quite enough, and I want to give the Minister a chance to reply—after all, she has already suffered one disadvantage—but I think that the present situation is untenable. I want the Department of Health not to try to rubbish reports that it has commissioned, and to ensure that what goes out to the public uses such reports in their proper context. I consider it scandalous for a Government Department to act in such a way: I cannot put it more strongly than that.

This is nothing short of deception. It is not for me to say whether it constitutes a deliberate attempt to mislead people—I leave others to judge that—but I know that it does mislead people. Despite all its problems, most of the population have a high regard for the Department of Health; I have myself, but not on this issue. It is about time the Department took another look at the matter.

I should like to know why we are about the only European country that tolerates the poison that is put into our water—for that is what we are talking about: it is a poison, nothing else. The Government themselves have said that fluorosis is a sign of toxicity, although people are saying that it is only cosmetic.

Let me say to the Minister again, in all honesty and sincerity, that if we do not get this matter right there will be a public backlash that will make many other recent events seem fairly small. There has been a bad misjudgment for many years, and it is time that it was corrected.

11.39 pm

The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart)

I congratulate my hon. Friend the Member for Sunderland, North (Mr. Etherington) on securing this debate on the important issue of oral health. The subject provokes strong reactions, both for and against the fluoridation of water supplies. His speech showed great passion, but I accept that he has never intended any discourtesy. I am just sorry that we were not able previously to speak about the subject so that I could address the specific issues that he has raised.

I pay tribute to my hon. Friend's record on the issue. Not only has he expressed his concerns in today's Adjournment debate, but he has a long track record of tabling parliamentary questions on the issue. He also paid tribute to Lord Baldwin, who in the past few months has pursued the issue in the other place.

The United Kingdom has seen dramatic improvements in health, and that includes oral health. Last July, to build on those improvements, the Government published the NHS plan, which is the most far-reaching reform programme in the history of the national health service. Part of the plan details how we intend to redesign the NHS around patients and deliver fast and accessible care. We should remember that the fluoridation debate has arisen because we wanted to improve dental health.

In September, the dental strategy "Modernising NHS Dentistry—Implementing the NHS Plan" dealt in greater detail with oral health matters. The strategy essentially will give the next generation a healthier start with oral hygiene that will benefit them throughout their lives". The strategy also has the support of the British Dental Association's recently published five-point plan, which includes a comprehensive programme to improve oral health and reduce inequalities.

Quite apart from the fluoridation issue, which I shall address in a moment, I should like to assure my hon. Friend that the Government are determined to address oral health inequalities and to allow everyone who wants it access to NHS dentistry. At the front door to those services will be NHS Direct. When it goes live for dentistry, NHS Direct will be a convenient route for patients to access NHS dentistry whether for urgent or routine treatment. No matter where in the country one lives, one telephone call to NHS Direct or logging on to NHS Direct Online will enable one to find the nearest NHS dentist or dental access centre.

Additionally, NHS Direct will provide information on self-care and patients' rights and charges, so that patients are fully informed about dental treatment and services. Currently, two pilot projects—one in the south-west and the other in the north-east, which covers the Newcastle and north Tyneside area—are testing NHS Direct's ability to direct callers to dental treatment. NHS Direct will also provide useful information and feedback to health authorities about dental services, ensuring that access difficulties are identified and dealt with in all parts of the country, and will help to tackle inequality in dental services.

However good the access to dental treatment is, people still need help in reducing their need for restorative treatment. Oral health is central to healthy living and contributes to the well-being of us all. We know that children who start brushing their teeth in infancy are less likely to experience tooth decay than those who start brushing later. We also know that using fluoride toothpaste is an effective way of preventing decay.

We cannot, however, be complacent, and I hope that my hon. Friend accepts that the Government are not complacent on the issue. Later I shall outline in more detail what we are doing as a result of the York research. However, the fact is that more than half the country's 15-year-olds still experience decay in their permanent teeth. We also have very good evidence that significant inequalities remain throughout the population. Children from deprived communities, for example, including some black and minority ethnic communities, are less likely to visit a dentist regularly. Even at regional level, there are major differences in the levels of tooth decay in children.

In 1999, for example, five-year-olds in the west midlands had on average less than half the number of decayed, missing or filled primary teeth than those in the north-west. Moreover, 19 per cent. more five-year-olds in the west midlands had no tooth decay at all compared with their counterparts in the north-west. A similar picture emerges in relation to 12-year-olds and their permanent teeth.

The challenge for local health authorities is how to improve oral health generally and to tackle those inequalities in health status. Reducing inequalities in dental health is not easy. One option that was considered was to add fluoride to school milk. A number of health authorities—such as Knowsley, St. Helens and the Wirral, where water is not fluoridated—are currently running pilot schemes. However, although those are worthwhile initiatives, for the best benefits children need to start using fluoride before the age at which they start school. That is why successive Governments have preferred the further option of fluoridating the water supply in areas with high levels of dental decay. It is the view of dental professionals that the fluoridation of water offers the most effective means of reducing tooth decay.

As the recent review of the evidence shows, fluoridation of the water supply to the optimum level of one part in a million can significantly reduce the amount of tooth decay in children from similar backgrounds. About 500,000 people in this country receive water that is naturally fluoridated at, or about, this level. I was interested in the reports about the mottling of teeth. One of my children has mottling, simply by virtue of growing up in a part of Essex which has extremely high natural levels of fluoride.

A further 1 million people receive water which is naturally fluoridated at a lower level, but which still provides some dental benefit. These areas are generally found in a band running down the eastern side of the country, from Hartlepool in the north, down to parts of Essex. Some 5 million people receive water where the fluoride content has been artificially increased to this level. Major schemes are in operation in Birmingham and throughout the west midlands, and also in Tyneside.

Successive Governments have recognised that fluoridation is an important and effective method of protecting the population from tooth decay. In "Modernising NHS Dentistry", we quoted the example of Sandwell, which is next to my constituency. The water supply there was fluoridated in 1986. Over the following 10 years, the amount of tooth decay in children had more than halved. During the same period, Bolton—an area with a similar population mix, but without fluoridated water—saw little change in its children's oral health.

I am grateful to my hon. Friend for raising the example of Ireland and I will look at the comparison he raised. That example has been replicated in many other places over the past 50 years. Sadly, it is also true that where fluoridation schemes have been withdrawn—in Anglesey and Kilmarnock, for example—levels of tooth decay in children have risen after having fallen during the periods of fluoridation.

Nevertheless, we have a duty—as my hon. Friend forcefully reminded me—to examine carefully any claims that there are risks which may be attached to fluoridation, as well as benefits. It was for this reason that we commissioned the NHS centre for reviews and dissemination at the university of York to review the evidence on the relationship between fluoride and health. The report of the review was published last October.

The review confirmed that fluoridating water helps to reduce tooth decay and that there is no clear evidence of other adverse effects on general health associated with water fluoridation. The only problem identified was the cosmetic side effect of fluoridation—dental fluorosis. The report did, however, identify the need for more good-quality research on the effect of water fluoridation.

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(i) of which states: Where a Health Authority has 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.

Since 1985, nearly half of all health authorities in England have requested water companies to introduce water fluoridation. None of these requests has been accepted. The reason for that is, quite simply, that none of the water companies has exercised the discretion to agree to a health authority's request. The key issue here is whether the "may" should become "shall".

We have been encouraged by the readiness with which the water industry has indicated that it is prepared to look again at both the legal and practical problems around fluoridation. What the water operators want, above anything else, is clarity over the distribution of responsibilities. They have emphasised that their primary duty is to provide a sufficient and wholesome supply of water. They consider that the question of whether a water supply should also contribute to wider public health objectives should be for the health service to decide. When a fluoridation scheme is approved, the health service meets the operational costs and indemnifies the water operator against any unforeseen cost consequences. There is little that we can disagree with in that.

How, then, are we to proceed? I have seen evidence in the west midlands that fluoridation can reduce dental decay, but there is strong public opinion against it. My hon. Friend cited a radio phone-in. National opinion polls show that about 70 per cent. are in favour of fluoridation, but environmentalists have considerable concerns. The York study showed that there are some shortcomings.

Oral health measures, such as regular brushing with fluoride toothpaste, can achieve good results, but experience shows that the best reduction in dental decay, particularly among deprived communities, is achieved when the fluoride is added to the water, so we will encourage health authorities in areas of high dental decay to consider holding consultations with local people to discuss current views on fluoridation, in light of the York report's findings. No community would or should be required to fluoridate unless there is a significant majority in favour.

The York report highlighted the need for more good-quality research. We have asked the Medical Research Council to suggest where it might be possible to strengthen the evidence currently available. It is certainly not our intention to cover the same ground, but rather to give advice on how to fill in the gaps identified in the York report. We are also discussing the report with representatives of the water industry. When the discussions are complete, we will review the need for legislation.

The MRC has provisionally agreed terms of reference stating that it should Provide advice on current scientific evidence regarding the health effects of water fluoridation … Consider whether further research in this area is required to inform public health policy … Report to the MRC Physiological Medicine and Infections Board and the MRC Health Services and Public Health Research Board and Report to the Department of Health. The MRC has let us know that its working group may want to refine those terms of reference. Its first meeting will be in February.

Any proposals for change will, of course, be brought to the House and right hon. and hon. Members will have the opportunity to debate further this sensitive issue before any decisions are reached. We are clear that we need a good, solid evidence base, but we are also clear that we need the support of the public. The two elements will go forward in tandem.

I respect my hon. Friend's strong views. I hope that he is reassured by the fact that we are commissioning further research to fill in the gaps clearly identified in the York study. I thank him warmly for raising the issue tonight.

Question put and agreed to.

Adjourned accordingly at seven minutes to Twelve midnight.