HC Deb 13 March 2003 vol 401 cc520-6

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

6.4 pm

Andy Burnham (Leigh)

Many perceive water fluoridation as a political hot potato; a subject for the "too difficult" pile. I do not understand why that view has been allowed to take root. To me, the question is simple: do we want to give children in some of our most deprived communities a better quality of life through improved dental health? More to the point, is it morally right to allow children to go through the pain and discomfort of bad teeth and for some, the trauma of tooth extraction under general anaesthetic, when we know of a proven, safe public health measure that can alleviate their suffering?

The arguments against fluoridation do not stack up in the face of the overwhelming health and human benefits. I am therefore grateful for the chance to air a passionately held view. The timing of the debate is important because the House will soon have an opportunity to resolve the matter once and for all. My message is blunt: it is time to stop a vocal, letter-writing minority standing in the way of a progressive change that will benefit millions of people in Britain, especially in our most deprived communities.

Tooth decay is a class issue. The British Dental Association's excellent briefing for today's debate states: eighty per cent. of dental disease can be found in only twenty per cent. of the population. That is the poorest 20 per cent., which the chief medical officer said in his 2001 annual report had not enjoyed the general health improvements of the rest of the population in the past 20 years.

Many of the health problems in poorer communities are deep and entrenched. They will take years to erode, if that ever happens. However, dental disease is different. Fluoridation is a known device, which could narrow the health divide at a stroke. It is scandalous that we are failing to use it. In 1998, Sir Donald Acheson's report, the "Independent Inquiry into Inequalities in Health" acknowledged that although overall dental health has improved, inequalities remain wide. He recommended water fluoridation to reduce them.

I shall spend a moment illustrating the inequalities with figures from the 1999–2000 survey by the British Association for the Study of Community Dentistry. It ranks all health authorities and boards in the United Kingdom by the average number of decayed, missing or filled teeth per five-year-old. The midlands are not used to dominating league tables in this country, as any football fan will readily admit. However, they are the undisputed kings of dental health.

Solihull is top of the league with 0.58—that is an average of half a decayed, missing or filled tooth per five-year-old. It is closely followed by Dudley, with 0.59. Walsall is tenth with 0.81, and Birmingham and Coventry are joint 21st with 0.97. In other words, the clear majority of children in those areas have no tooth decay. Let us compare those places with the worst areas. Greater Glasgow is at rock bottom. Five-year-old children there have, on average, three and a half missing, filled or decayed teeth. Among the two thirds of children who have some tooth disease, the average is five decayed teeth.

In England, north-west health authorities, including Wigan and Bolton, account for seven of the bottom 10 places. I am referring to the former health authorities before they became primary care trusts. Manchester is worst, with an average of three decayed teeth per five-year-old.

Unlike league tables for other diseases, the dental health league does not follow the usual pattern of wealthy areas at the top and deprived areas at the bottom. Birmingham and Manchester, which have a similar social profile, are at opposite ends. Why? The explanation is water fluoridation. All the midlands areas that I mentioned have fluoridated water; Birmingham's supply was fluoridated in 1964.

I do not necessarily favour the imposition of blanket water fluoridation throughout the country. Perhaps it should initially be targeted where dental disease is worst and where communities want it. Only 10 per cent. of our water is fluoridated, even though most people believe that they have a fluoridated water supply. Experts predict that increasing that to 30 per cent. by fluoridating some of our main conurbations—Greater Manchester, Leeds, Bradford, Merseyside, Glasgow and inner London—would make a massive difference to combating dental disease.

Opposition to fluoridation often comes from non-urban areas or smaller towns, but no one is talking about imposing fluoridation on any area if there is no local support for it. If the issue causes controversy, it should be because of the utter scandal that we know about these problems yet the law cannot give people in the areas concerned the chance or the choice to do anything about them. There is an outcry from the opponents of fluoridation and it is growing again as we seek to address theissue in Parliament.

A variety of arguments against fluoridation are tossed about, but most revolve around two main strands: health risks and loss of civil liberties. Let us take them both head on. On the health risks, let us remember that we are talking about adding one part per million to water. Again, I quote the BDA's briefing: There is no scientific basis whatsoever to claims that fluoride in water is unsafe. All robust scientific research shows that fluoridation is still considered safe and effective. Scientific opinion in the US and Australia is identical. If the health risks were real, why are the communities of Britain that have fluoridated water—both naturally and artificially—not calling for it to be removed forthwith? In the US, simultaneously the most health-conscious and litigious country on earth,47 of the 50 biggest cities have fluoridated water, and Los Angeles is about to come on stream.

In my view, the claimed health risks are a smokescreen to hide the real objection of the opponents of fluoridation, which is the enforced medication argument. Perhaps they are right. We could say that fluoridation is enforced medication, but I would ask, "What is wrong with that?" If the price of improving children's lives is everyone taking in a negligible amount of fluoride in water when it does them no harm, most reasonable people will conclude that it is well worth doing. It is because the opponents of fluoridation know that the civil liberties argument is not strong enough to stand on its own two feet against the overpowering evidence of the health benefits that talk of spurious health risks is tossed around to muddy the waters.

The truth is that we do not need to re-run those arguments. They have already been debated in this House and Parliament has already spoken in favour of water fluoridation. In 1985, the House passed the Water (Fluoridation) Act. The only reason I am having to keep the Minister from the delights of Tottenham on a spring Thursday evening is that the House passed a flawed Act. Rightly, it determined that decisions to fluoridate should be determined by local communities. Wrongly, it said that, when presented by health authorities with a positive request to fluoridate, water companies "may" choose to do so. That word "may" is the crucial flaw that creates the legislative impasse that we have today, and which has led to Parliament's will being thwarted. It places the onus on the water companies to decide, but this is primarily a health issue. Water companies should not have an active decision and no legal liability but, because they do, about 60 requests for fluoridation, made on the back of local votes, have been turned down by water companies in the last 10 years. A judicial review upheld Northumbrian Water's decision not to fluoridate supplies despite the request of Newcastle and North Tyneside Health Authority, thereby confirming the legislation's flaws.

It is time to create a democratic framework in which communities, not water companies, take the final decision. Even if people oppose fluoridation, they cannot oppose democracy. Thankfully, we shall soon have an excellent opportunity to create such a framework. Last week, the Water Bill was introduced in another place. I believe that it is the last chance for a generation to bring about this change in the law and to see that Parliament's will is carried out. A private Member's Bill probably would not succeed, and when will we next get the chance to debate Government-inspired water legislation? Ten, 15 or 20 years hence? I am not prepared to wait that long, and I would ask how many children in Leigh would suffer unnecessarily in that time.

My specific purpose in raising this debate is to give notice to the Government that I shall seek to amend the Water Bill when it comes to this House, by changing that "may" to a "shall". Given the overwhelming health evidence, may I urge the Minister and his colleague, the Minister with responsibility for public health, to meet their ministerial colleagues from the Department for Environment, Food and Rural Affairs soon and to urge them that this sensible amendment should be debated and voted on?

I hope that the Minister will not mind if I am so presumptuous as to second-guess one of the points that he might raise in answer to this debate. I suspect that he may refer to research that the Department has commissioned on the recommendation from the Medical Research Council relating to research into the absorption of artificially added fluoride. That is important, but it is not an argument against taking this vital opportunity to get the legal framework right. It merely means that, once the research is completed, communities will have access to even better research when making their decisions.

A head of steam is now building around a successful amendment to the Water Bill, and 106 Members of all parties have signed early-day motion 247. I suspect that many more would sign if they were able to do so. It is strongly supported by the British Medical Association, the BDA and the Royal College of Nursing. Not surprisingly, it is also supported by the British Fluoridation Society. I should like to pay tribute to its chair, Professor Mike Lennon, Sheila Jones and others too numerous to mention for doggedly pursuing a cause they know to be morally right.

While neutral on the pros and cons of fluoridation, Water UK, the representative body for water companies, now supports clarification of the legal position and the transfer of the decision-making process from water companies to strategic health authorities. It has recently called for the fluoridation stalemate to be resolved.

It seems to me that everything is in place to introduce this change and let the House express its view. My plea to colleagues on both sides of the House and from all parts of the country is not to let this chance go by to improve dental health for children and adults in our deprived communities and in their constituencies. Fluoridation can bring improvements to dental health, even if it is good already. Most people will get the lifelong benefits of good teeth: the ability to eat, speak and drink without pain, discomfort or embarrassment, and savings on dentistry costs. Society will see an easing of pressure on dentistry services and savings for the NHS. At what price? There will be a small financial cost, and people will have to consume an additive too negligible for the vast majority ever to notice or even care about. I suggest that the tiny minority of the population who do care are well off enough to afford Evian.

The price of failing to act is far greater. I shall finish with an appalling statistic from the dental school at a Manchester hospital. Last year, 1,500 children mostly under 10 years of age had teeth removed under general anaesthetic. I thank my colleagues from Greater Manchester constituencies, my hon. Friend the Member for Bolton, South-East (Dr. Iddon) and the hon. Member for Cheadle (Mrs. Calton), who are present to listen to this debate. We have a duty to represent those children. Think of the cost to the NHS in our area of those avoidable procedures. Most of all, think of what those 1,500 children have had to go through at such a young age, when we know that we could have spared many of them that trauma. If the communities of Greater Manchester decide to do something about those appalling figures, no one should stand in their way.

6.17 pm
The Parliamentary Under-Secretary of State for Health (Mr. David Lammy)

I congratulate my good friend the hon. Member for Leigh (Andy Burnham) on securing a debate on such an important issue. If his football team, Everton, played with the commitment that he has shown on this issue, it might stand a chance of winning the premiership.

This subject provokes strong reactions from those who support fluoridation and those against it. People who argue about this matter would agree that tackling inequalities in oral health is an important part of the overall public health programme, and that we should take action to help to reduce the significant inequalities that remain in the oral health of the population.

This country has seen dramatic improvements in health over the past 50 years, including in oral health. The dental profession has played a key role in reducing tooth decay. The addition of fluoride to toothpaste and water has also helped significantly to improve the oral health of the nation. However, with more than half the country's 15-year-olds experiencing decay in their permanent teeth, and more than one in three five-year-olds experiencing decay in their baby teeth, there is still a lot of work to be done.

As my hon. Friend said, there are still major inequalities in oral health. Unfortunately, the worst off in society still have the poorest oral health. The Government are determined to change that, and to narrow the health gap in accordance with the recommendations of Sir Donald Acheson's report, to which my hon. Friend referred.

The challenge for local health communities is to improve oral health generally and tackle the inequalities in health status. One way of meeting that challenge is, of course, to encourage people to visit the dentist. Today we published the Health and Social Care (Community Health and Standards) Bill, which will provide a legislative framework for radical changes in the provision of dental services. In particular, it will move the focus of dental care to prevention rather than just treatment of oral disease. We hope that that will encourage more use of NHS dental services and persuade people to visit the dentist routinely, rather than just when they are in pain. We have also established the "brushing for life" campaign to promote regular brushing regimes with fluoride toothpaste, following the finding of a child dental health survey by the Department in 1993 that 5 per cent. of children brush their teeth less than once a day.

My hon. Friend has made an impassioned case for fluoridation. As he knows, York university's report "A Systematic Review of Water Fluoridation", commissioned by the NHS Centre for Reviews and Dissemination, concluded that fluoridation increased the number of children with no decayed teeth by 15 per cent.

About half a million people in this country receive water that is naturally fluoridated at about the optimum level of one part of fluoride per 1 million parts of water. A further 1 million receive water that is naturally fluoridated at a lower level, which still confers some dental benefit. The areas involved are generally found in a band running down the eastern side of the country, from Hartlepool in the north to parts of Essex. Some 5 million people receive water whose fluoride content has been artificially increased to one part per 1 million of water. Major schemes are operating in Birmingham, throughout the west midlands—as my hon. Friend said—and in Tyneside.

We are aware of the persuasive evidence that fluoridation is an important and effective method of protecting the population from tooth decay. The water supply in Sandwell, for example, was fluoridated in 1986; over the following 10 years, the amount of tooth decay in children more than halved. During the same period, Wigan and Bolton—the area that contains my hon. Friend's constituency, with a comparable population mix—saw little change in children's oral health. Sadly, it is also true that where fluoridation schemes have been withdrawn, for instance in Anglesey and Kilmarnock, levels of tooth decay in children have risen, having fallen during the periods of fluoridation.

That may not sound too disturbing when expressed as cold statistics, but the personal experience underpinning those statistics is of children and young people in pain owing to avoidable toothache, children unable to get to sleep because of the pain, children taking time off school to go to the dentist and, worst of all, children having to go to hospital and be given general anaesthetics for the extraction of decayed teeth.

Obviously, when considering a public health measure such as fluoridation, we are concerned with safety above all else. We must therefore examine carefully any claims that risks as well as benefits may be involved. The majority of medical and scientific opinion throughout the world believe that fluoridation is safe, based on practical experience and research over the past 50 years.

Nevertheless, I fully respect some people's concerns about the scientific evidence on the safety of fluoride and the difficulty of defining exactly how excessive an intake of fluoride is necessary to pose any risk to health. On the overall question of safety, it is unfortunately true that virtually all medical and public health intervention carries risks as well as benefits. On fluoridation, it is for the scientists—specialists in toxicology and dentistry—to advise on the balance of those risks, for the Government to decide what is acceptable and for local people to be consulted and empowered throughout that process.

Within that context, the evidence that I mentioned earlier is encouraging. As I said, some 6 million people receive water that either has had its level of fluoride adjusted or is naturally fluoridated to around that level. In the United States of America, some 160 million people drink optimally fluoridated water. Before and during the past half-century of fluoridation, there have been extensive studies of the health of those populations and, apart from improved oral health, the health experience of those receiving the optimal concentration of fluoride is no different from that of the population at large.

York university's systematic review of water fluoridation not only found evidence that fluoridating water helps to reduce tooth decay, but no clear evidence of adverse effects on general health, other than dental fluorosis. However, York university was critical of the quality of that evidence, which is why the Government asked the Medical Research Council to advise on any further research priorities in the light of the York review findings. The MRC reported last September and we have already acted on the most fundamental of its recommendations on research into the absorption of fluoride. We expect to have the results of that study in September.

I emphasise that no water fluoridation scheme has been introduced without local consultations, and we intend to extend the range and content of those consultations before any further requests are made for a water company to fluoridate its water supply. The new style of consultation would need to cover questions of consent and the means by which people could opt out. Information would need to be available on the cost and specifications of water filters capable of removing fluoride from drinking water.

As my hon. Friend has said, 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 which states: Where a District 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. We realise that there are problems with legislation and that water companies, fearing a backlash from opponents, do not fluoridate water following requests from strategic health authorities, but we have been encouraged by the readiness with which the water industry has indicated its willingness to look again at both the legal and practical problems of fluoridation. What the water operators want, above anything else, is clarity of accountability.

Local communities need accessible, authoritative information on the effects of fluoridation and the opportunity to discuss the issues with both proponents of fluoridation and those sceptical about its effects. To enable that to happen, the chief medical officer and chief dental officer are reviewing their guidance to support the consultation.

Water operators 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. Should a fluoridation scheme be approved, the health service should meet the operational costs and indemnify the water operator against any unforeseen cost consequences. There is little there that we would disagree with and, naturally, we will seek the water industry's views in reviewing our policies.

I realise that the need to resolve these issues is frustrating for my hon. Friend, who wishes to see improvements in the oral health of his constituents. As I said at the outset, fluoridation has always been controversial. I hear what he says and the Under-Secretary of State for Health, my hon. Friend the Member for Salford (Ms Blears)—the Minister with responsibility for public health—will continue a dialogue on this subject. Legislation is clearly an option, but we will have to show that we have made a thorough assessment of the scientific basis for fluoridation and provide a framework for informed consultations on whether it should be implemented locally.

Question put and agreed to.

Adjourned accordingly at half-past Six o'clock.