HL Deb 08 March 2005 vol 670 cc704-19

8.7 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Warner)

rose to move, That the draft regulations laid before the House on 22 February be approved [10th Report from the Joint Committee].

The noble Lord said: My Lords, I have a feeling this could rapidly empty the Chamber.

One of the Government's main priorities is to reduce inequalities in health. There is a strong correlation between dental decay and social deprivation, and yet, in deprived areas where the water is fluoridated, people have as good oral health as residents of much better-off areas of the country. However, we recognise that some people have strong views on fluoridation, and it is fundamental to our policy that a strategic health authority should only arrange for its drinking water to be fluoridated where the local population is in favour. Studies show that children in non-fluoridated areas are more than twice as likely to have had toothache during their lives as those in fluoridated areas. A study in the north-east has shown that five-year-old children were five times more likely to suffer from a dental abscess in non-fluoridated areas than in fluoridated areas.

Fluoridation does not only benefit children. In adults, studies in this country and abroad have shown that adults living in fluoridated areas keep more of their own teeth for longer and have fewer dental problems. The Water Fluoridation Consultation (England) Regulations 2005 apply to situations where SHAs propose to enter into, vary, terminate or maintain arrangements with a water undertaker to fluoridate its water. The indemnity regulations, which I will come on to, provide for indemnities to be given to water undertakers who fluoridate the water on behalf of an SHA.

Our intention with the consultation regulations is to ensure that an SHA conducts wide-ranging consultations in which the issues around the effects and safety of fluoride are fully explored, and then that the SHA assesses the outcome of the consultations in an objective and transparent manner.

I turn now to the details. During the consultation conducted by the Department of Health on these regulations, the need was stressed to ensure that the "bodies with an interest", which the SHAs would be required to consult in Regulation 3, covered all those organisations for which fluoridation might have implications. That would include not just medical and dental organisations, but, for example, food or drink companies that might need to consider whether the use of fluoridated water was compatible with their business aims and manufacturing processes. We will certainly refer to businesses in the guidance we will issue on implementation of the regulations.

Our only reason for not being more specific in the regulations is to ensure that we do not limit the scope of SHAs to involve bodies with an interest in their localities that we had not thought of in the department. SHAs must consult all local authorities whose area falls even partly within the area to be fluoridated.

Regulation 3 describes the measure an SHA must take to publicise and encourage debate on its proposals. During the consultations, it was suggested that we should insist that the SHA published its proposals in more than one newspaper. I am the last person to underestimate the power of the press, but we wish to see SHAs use the full range of modern communication techniques in conducting consultations. I am well aware that not every family has a computer, but resources like websites, helplines and focus groups are capable of reaching sections of the population who may not read the public notices in the local paper.

I am sorry if Regulation 4 looks a bit complicated. We wish to respond to representations made during the passage of the Water Bill that fluoridation schemes should not be allowed to continue indefinitely without some public reappraisal. On the other hand, water distribution systems are complex engineering schemes that periodically require variation and maintenance.

We have sought to strike a balance between allowing sufficient flexibility for relatively minor changes to be made without consultation, while ensuring that major variations or investment decisions are not taken without consultation. Where, for example, major investment was required in new plant to maintain a fluoridation scheme, there would be a need to check whether the benefits to oral health would be justified by the costs of this investment. The SHA would need to consult on cost benefits in accordance with these regulations.

Turning to Regulation 5, it will not surprise your Lordships that more comments were received on this regulation during our consultation than on any of the others. We remain of the view, though, that decisions on fluoridation should not be undertaken as a result of referendums. However well they were organised, it is unlikely that a majority of the population would vote. There is a strong correlation between tooth decay and social deprivation, and we want SHAs to take account of the views of all people across all social classes.

Let me dispel any suggestion, however, that we have diluted our commitment that fluoridation schemes would only be introduced where the local population were in favour. Regulation 5 requires SHAs to take account of the extent of support for their proposals. They must also consider the cogency of the arguments. There is a host of disinformation put around about fluoridation, which is likely to be recycled in consultations. In the past, the department has received identical standard letters, all citing an association between fluoridation and commonly-occurring illnesses or disabilities, for which there is no published research evidence. The SHA needs to scrutinise the responses received and weigh the arguments in favour of proceeding with those against.

I now turn to the indemnity regulations. We are often asked why, if the Government are so confident that there are no risks to health from fluoridation, they need to indemnify water companies against claims arising from fluoridation schemes. The answer is that the companies are commercial organisations whose core purpose is to supply water. As fluoridation is a public health measure, the strategic health authorities pay the companies the full cost of fluoridation. In accordance with good business practice, they need to be able to indemnify the water companies however remote is the possibility of any claims.

Schedule 1 to the regulations contains a model indemnity. As your Lordships would expect, the water industry would like a very wide indemnity. For public policy reasons we cannot cover criminal liability and the industry must bear the costs of any negligence. Notwithstanding that, we have gone as far as we can to meet the industry's concerns. The indemnity covers the defence costs of a water undertaker or supplier that successfully defends a prosecution for an offence which relates to the fluoridation of water. Moreover, provided there has been no fault or negligence, it covers any civil liability that arises in respect of fluoridation, even where that liability arises in circumstances which may also give rise to a criminal offence.

Hence Clause 2 of the schedule covers liabilities resulting from any criminal proceedings that might arise from fluoridation with the proviso that the proceedings have not led to a conviction. The industry accepts that we cannot indemnify water companies which have been found guilty of negligence.

Under Clause 4 the Secretary of State may assist a water company in defending a claim if he might incur liability under the indemnity. Likewise, under Clause 5, the Secretary of State may pursue claims on behalf of water companies. We envisage that if, contrary to any available evidence, a claim was made that fluoridation had adverse effects on general health, the Department of Health would take over the defence. The reason is that the claim would have implications for all the fluoridation schemes in the UK and the department would probably wish to submit evidence from its research programme on the effects of fluoridation and to call expert witnesses.

I hope my explanation of the regulations has been helpful and that noble Lords will be able to approve them. I beg to move.

Moved, That the draft regulations laid before the House on 22 February be approved [10th Report from the Joint Committee].—(Lord Warner.)

Earl Howe

My Lords, the House will be grateful to the Minister for his helpful explanation of the orders. I begin by making it clear that for my party water fluoridation is a matter of individual conscience. It is not an issue on which we wish to impose an official party position. What follows represents a personal view, although it is a view that is shared widely on the Conservative Front Bench, both here and in another place.

In 1998, during a debate in this House on water fluoridation I expressed my support for a wider rollout of fluoridation as an effective and, indeed, necessary measure for improving dental health in the general population, but especially in deprived areas. When Section 58 of the Water Act 2003 was introduced by way of an amendment in the House of Lords I voted against it. The reason for my change of mind was one thing only; and that was the York review of 2000. That review, for me, completely changed the landscape. A proposition which most had taken for granted up to that point—that water fluoridation had proven benefits for dental health—turned out to be without solid foundation. That is not to say that the review found no proven benefit from fluoride. However, contrary to expectation, it found that the quality of previous research on the issue was quite low, with a moderate to high risk of bias, and that while fluoridation does reduce the prevalence of dental caries, the extent to which it is reduced is not quantifiable.

Alongside that the review was able to arrive at definite conclusions about the prevalence of dental fluorosis at a water fluoride level of one part per million, which is the approved level for water supplies. That was estimated at 48 per cent. For fluorosis of aesthetic concern, it was predicted to be 12.5 per cent. Furthermore, the report said that, the research evidence is of insufficient quality to allow confident statements about other potential harms or whether there is an impact on social inequalities". It is significant that, so far as I am aware, no research has ever been done on continuing long-term exposure to fluoride and no randomised controlled trials have ever been done.

We all recognise that a public health measure of this kind cannot be introduced on the normal principle of individually informed patient consent. However, if individuals cannot elect whether to receive fluoridated water, then the very least we should be doing, if we are going to mass-medicate whole population groups, is to proceed only on the basis of impeccable science.

The York review shows us that the science, far from being impeccable, is of doubtful quality. In my opinion, Section 58 of the Water Act 2003 was wrong—and this order is, and will remain, wrong until such time as we can state, with much greater scientific confidence, that the benefits of fluoridation outweigh the disbenefits by a considerable margin. The convention of the House is not to vote on secondary legislation. I do not intend to instigate a breach of that convention. However, the Minister needs to answer some questions about the terms of these orders—and how he proposes to make sure that they are fairly implemented.

The consultation regulations set out the process which a strategic health authority must follow to ascertain local opinion on a proposal to fluoridate. It is far from clear, however, what is supposed to constitute a satisfactory consultation process or a satisfactory degree of canvassing of local opinion. For a start, the strategic health authority will have an agenda. It is hardly the most appropriate body to be tasked with ensuring that local consumers are given a fair and unbiased presentation of the case both for and against. Indeed, the order only requires the strategic health authority to detail the reasons it has for making the proposal—nothing more balanced than that.

The strategic health authority is required to publicise the proposal, but what more ought it to do? Surely, it should try actively to garner local opinion, rather than sit back and wait for opinions to roll in. How should it do that, when there is no mention of any such process in the order? Regulation 5 says that: A Strategic Health Authority shall not proceed with any step regarding fluoridation arrangements that falls within section 89(2) of the Act unless, having regard to the extent of support for the proposal and the cogency of the arguments advanced, the Authority are satisfied that the health arguments in favour of proceeding with the proposal outweigh all arguments against proceeding". What is this supposed to mean? Supposing that the strategic health authority receives replies from 20 per cent of the population who would be affected by a change to fluoridated water—and let us say three quarters of those replies are in favour—is that a mandate for change or not? In any event, the strategic health authority only has to have regard to the extent of support for the proposal. Principally, it has to be satisfied that the health arguments in favour of proceeding with the proposal outweigh all arguments against proceeding. Presumably, they will already be persuaded of that view; so, without a clear indication of what will constitute a meaningful degree of public support—or the lack of it—it seems that the order is deficient.

When we debated Section 58 of the 2003 Act, the Minster emphasised that: no new fluoridation scheme would go ahead without the support of the majority of the local population"— majority of the local population— determined by local consultations conducted by strategic health authorities in England and the National Assembly in Wales".— [Official Report, 9/7/03; col. 300.] I see nothing in the order which fulfils that undertaking. Nor do I see any provision allowing a local community to revisit its decision—if, for example, new scientific evidence about fluoridation were to emerge.

The Minister will be aware that there are some areas of the country where a proposal to fluoridate by one strategic health authority would present particular difficulties. One such area is London, which has five strategic health authorities, four water suppliers and one route of delivering water. If one strategic health authority secures a fluoridated water supply for its area, how will it be possible to ensure that no other areas receive such treated water if they have not elected to do so? Of course, it will be impossible. In that general context, I hope that a strategic health authority, having secured a fluoridated supply, would commit itself to a public information campaign on the inadvisability of supplementing consumption of fluoridated water with the use of fluoride toothpaste.

I have only one query on the indemnities regulations. My understanding is that existing fluoridation schemes will be brought into line with the new regulations. When that happens, the strategic health authorities will have to make new agreements with their water companies. Will the water companies be entitled to indemnification, notwithstanding the fact that they may not be indemnified at present?

I apologise to my noble friend Lord Colwyn, who has been such a consistent and principled champion of fluoridation, from his perspective as a very experienced dentist. I readily concede to him that my scepticism about fluoridation may turn out to be misplaced. I hope that it is, but I cannot yet say so; nor in conscience can I support the consultation regulations, given the terms in which they are couched.

I look forward to the Minister's reply, which may provide at least some clarification and comfort.

Baroness Barker

My Lords, I suspect that the Government Front Bench is delighted to move on to this subject towards the end of a long day's proceedings. It is a great shame that we are under the time constrictions set by the Government Chief Whip to discuss the matter.

I have a great deal of sympathy with the arguments that the noble Earl, Lord Howe, put forward, much more eloquently than I could. I did not take part in debates on the Water Bill but, as noble Lords will know, my noble friend Lord Clement-Jones supported this aspect of the Bill, because it is our party's view that decisions on public health matters such as this should be made locally.

I agree wholeheartedly with the noble Earl, Lord Howe, that the worrying aspect of the first set of regulations is the requirements on the strategic health authority. I have read the Explanatory Notes several times. They say: The requirement is that SHA must not take any such step unless, having regard to the extent of support for the proposal and the cogency of the arguments advanced, the SHA are satisfied that the health arguments in favour of proceeding outweigh all arguments against proceeding. Thus the SHA will be able to consider the cogency to be attached to any representations made and to look at the extent of support for the proposal

It seems that the extent and the cogency of the opposition are somewhat downplayed. In some ways, these regulations are extremely biased, although they do not appear so on first reading. The noble Earl, Lord Howe, is right; the extent of opposition at least must indicate the level of uncertainty in an area. A public health authority ought to take into account the simple fact that there is uncertainty in an area, whether or not it believes that the science behind it is sound.

I listened to what the noble Lord, Lord Warner, said about circular letters. I understand that quite often campaigns are vociferous but not well founded in science. But if the process that a strategic health authority must go through is to live up to the terms that the Minister indicated—it must be objective and transparent—the extent of the opposition must be taken into account. The noble Earl, Lord Howe, is right: it is unusual, and it would not be right, to pray against such regulations, but I, too, want to signal that I am deeply unhappy with their drafting.

I agree with the noble Earl that the effects of fluoridation have yet to be proven in the scientific terms that the medical world normally applies. However, in this particular circumstance it seems that there is an element of bias to be dealt with.

On the indemnity proposals, I have one question. The terms of this order are surprisingly generous, on the part of both the Department of Health and the Treasury. The explanatory notes state that Clause 2 of the indemnity, is intended to be widely drawn so that, as far as possible, water undertakers and licensed water suppliers will not suffer loss as a result of entering into an agreement to increase the fluoride content of water or to supply such water". As the noble Earl, Lord Howe, said, this will apply to claims that arise under the existing system as well. I simply ask the Minister what the Treasury estimate of the potential cost is of this quite wide ranging indemnity? With that I rest my case.

Lord Turnberg

My Lords, I had not intended to speak in this short debate, but I want to make two comments.

First, the evidence is reasonably strong that people who live in areas where the natural fluoride levels in water are as high as those proposed to be added to the water supply have healthier teeth. The evidence that healthy teeth provide healthy mouths is quite strong. It is perhaps not widely recognised that a healthy mouth is also associated with a healthier person. The influence of oral hygiene and oral health on general health is considerable.

I understand the anxiety of the noble Earl, Lord Howe, about the evidence in the York survey not being particularly strong. With respect, he may be quoting only part of the report. There is no doubt that the York report came down strongly in favour of the idea that water supplies, where possible, should be fluoridated. I am not convinced that the York report is such strong evidence against the idea that we should move along this route.

Unfortunately, I do not have the York report with me but I remember in the previous debate quoting quite extensively from it to demonstrate that fluoride was positively helpful and that the recommendations were along those lines. I am in favour of these regulations.

Lord Colwyn

My Lords, it is not my intention to prolong the debate this evening, but I have been involved with discussions in this House on fluoridation for over 35 years. I feel that I should make a brief contribution. I declare an interest as a practising dental surgeon, although of course it is not really an interest, because the fewer caries there are, the less work I have to do.

When we last discussed fluoridation in July 2003, as an amendment to the Water Bill, there were many of the usual speeches from the usual suspects. The noble Lord, Lord Warner, concluded by saying: We shall continue with our research programme … and monitor the outcome of the research conducted in other countries … We have made the regulations under which we want any new local consultations to be conducted". He went on: In a nutshell, the amendment"— that we were talking about at the time— provides for local communities, after consultation, and after an informed discussion, to take steps to give their strategic health authorities a clear message that they want their water to be fluoridated. On the evidence that I have heard today, I do not see a case for denying those communities that choice".—[Official Report, 9/7/03; col. 360.]

I made some comments in that debate on the problem of oral health inequalities. The difference in dental health of five year-olds in fluoridated and non-fluoridated areas is marked. The rate of dental decay is about three times as much in non-fluoridated areas and, of course, those children with high levels of decay are also more likely to have had treatment under general anaesthetic—always with a slight risk—and have been prescribed antibiotics.

Over the past five years, the University of York Centre for Reviews and Dissemination and the Medical Research Council have undertaken reviews on water fluoridation. The York remit was to look at the safety and effectiveness of fluoridation. It concluded that addition to water of fluid up to one part per million helps to reduce tooth decay, but left the way open for further research.

My noble friend Lord Howe referred to this and to the problems, but he did not refer to the MRC report in 2002, which had looked at the apparent health risks in more detail and concluded that fluoridation was safe and effective. Further research commissioned by the department in 2004 on bioavailability of fluoride in drinking water, or the difference in absorption of fluoride in natural and artificially fluoridated water, concluded that there was no difference.

It is essential that strategic health authorities have all the necessary information to make informed decisions. The Chief Medical and Chief Dental Officers have made this quite clear.

These regulations apply to England and I should be grateful if the Minister could clarify the situation in areas that would derive great benefit from fluoridation that cross the Wales-England border. What will be the situation in Cheshire, Liverpool and Hereford?

I also note the list of interested bodies that have been defined in Regulation 2(1). Can the Minister say why the unitary districts and metropolitan authorities have been omitted?

These regulations provide a sensible and workable framework by which strategic health authorities must consult on future fluoridation proposals and give an assurance to the public that the outcome of such public consultations will be properly judged by health authorities. They provide adequate indemnity to suppliers, covering all criminal liability or civil liability arising out of negligence.

While regretting the delay in seeing these regulations, I urge the House to pass them and to let people have a choice on whether to fluoridate.

Lord Tomlinson

My Lords, I declare an interest as the president of the British Fluoridation Society, a role which is, of course, unremunerated. I clearly welcome the two sets of regulations put before us today by my noble friend.

It is not necessary at this stage to debate the merits or otherwise of fluoridation. They were determined by the House, with overwhelming support, with the passage of the Water Act 2003. Today, we are merely giving by these regulations, once they are approved not only by this House but by the House of Commons, the authority to allow the provisions of Section 58 to be put into effect. But those provisions have been already agreed by an overwhelming decision of this House.

The consultation regulations are very straightforward and simple. They require strategic health authorities to undertake widespread public consultations on their water fluoridation proposals. They also provide for the requirements which must be satisfied before any such proposal is implemented.

Under these regulations, strategic health authorities must give notice to every local authority within the area affected and undertake a three-month period of public consultation. Everything that needs to be done is being properly done in these regulations and I congratulate my noble friend upon it.

Turning briefly to the indemnities regulations, under Section 58—the section already carried by Parliament—water suppliers may be required to fluoridate supplies when requested to do so by a strategic health authority. The indemnity regulations ensure as far as possible that water suppliers will not suffer loss as a result of acceding to a request for fluoridation. Section 58 makes it clear that they will not be required to fluoridate until an indemnity has been given by the Secretary of State. The indemnities regulations are therefore necessary before any new fluoridation proposal can be implemented under Section 58.

I first became interested in fluoridation through being a constituency representative, elected over a period of 20 years in the West Midlands—an area where water was fluoridated already by the Severn Trent Water Authority. The one thing you could not help but notice was that the normal correlation between economic deprivation and bad dental health was exactly reversed in some of the poorest parts of the West Midlands. Those areas in the lowest quartile of economic prosperity in the UK all appeared in the top quartile of dental health. Having noticed this over a period of 20 years—20 years in which I never received a single letter of complaint, either as a Member of Parliament or a Member of the European Parliament —I became convinced that the electorate in the large Severn Trent area, where they were already receiving the benefits of fluoridation, was a sample that showed complete satisfaction.

I thought we were going through a filibuster a bit earlier, to prevent these regulations being brought before the House. Eventually, however, we finished with terrorism and got on to these regulations. I congratulate my noble friend the Minister on this. He is doing something which will be widely welcomed throughout the country.

Lord Maxton

My Lords, like my noble friend, it was not my intention to speak in this debate. When I was Member of Parliament at the other end, I too campaigned to have fluoride put in the water—in Scotland, I hasten to add, and these regulations will not do that, of course. We need it, but that is a matter for the Scottish Parliament.

I do not live in an area which has fluoride in the water. I have three sons, and they all have extremely healthy teeth. Why? Because—and I give her the praise for this, not myself —their mother insisted that they cleaned their teeth with fluoride toothpaste morning and night. She gave them fluoride tablets when they were young. That has ensured that they have kept up the habit of cleaning their teeth, and they now have stronger teeth than they otherwise might have had.

That is the case with most middle-class parents. When the noble Lord, Lord Colwyn, says that it is a matter of a divide between those areas which have fluoride in the water and those that do not, he is, of course, right. It is also a class divide, however. It is a divide between middle-class parents—many of whom are actually opposed to fluoride being put in the water, but quite happy to give fluoride to their children in other ways—and those who unfortunately do not bring up their children with good oral hygiene. Therefore, I welcome this, because the beneficiaries will be those who are most deprived in our society, particularly some of the young in the most deprived areas.

Lord Stoddart of Swindon

My Lords, the noble Lord, Lord Maxton, in making the case for fluoridation also made the case against it. He made it quite clear that there is an alternative to mass fluoridation and mass medication: proper dental health being imposed by parents. Indeed, as he says, that is what happens with most middle-class parents.

The argument has changed over a long time. I have probably been around this issue even longer than the noble Lord, Lord Tomlinson. I was the chairman of the Land and Works Committee of the Thames Valley Water Board, as well as being a member of the local authority which was then responsible for public health. At that time, we were told that all children—about 15 per cent of the population—would benefit. But my local authority never took the view t hat it had to ask the water board. of which I was chairman, to fluoridate the water because it believed that there were other methods of inducing oral health. And so there are.

The noble Lord, Lord Tomlinson, said that all the arguments about fluoridation had been worked out in the Water Act 2003. I have to tell him that the issue will not go away just because Parliament passed an Act. There are a lot of people—more than the noble Lord thinks—who are still opposed to mass medication through fluoridating water. As the noble Earl pointed out, the York review criticised the quality of the research that had been carried out and had said that a minority of the population would benefit from fluoridating all water supplies.

The argument has now come down to benefiting not all children but just poor children. In that case, the problem is smaller than it used to be and should be easier to deal with by other methods such as the proper education of working-class or deprived children and inducing a better diet. Indeed, it would be far cheaper than fluoridating water to give children fluoride toothpaste and toothbrushes as well. The argument for mass medication is by no means a good one and is by no means accepted by the vast majority of the population. People like me will not be convinced that it is necessary to force 60 million people and countless million animals to ingest fluoride, flooding the environment with it, simply to benefit a small part of the population which could receive the same benefit by other means. That argument will not go away, no matter what the noble Lord, Lord Tomlinson, says.

The arrangements for consultation in the two orders are deficient. The 2003 Act and these measures affect everybody. Every individual will be forced to drink water which has fluoride—a poison—added to their water supply. Therefore, they are entitled to be consulted individually. No matter what the Minister says I repeat what I said when we discussed the Bill that became the 2003 Act—there is no real substitute for referendums. I know that he disagrees, but that is the only way in which a proper consultation can take place when you are forcing mass medication on people. Not everybody reads the newspapers. I reckon that in my area, about 20 per cent read the local newspapers, so they will not be informed of what will happen to their water supplies. The arrangements for consultation will be in the hands of a small elite clique bent on inflicting fluoride, come what may.

What is more, there is no provision for all interested organisations to be informed. The anti-fluoride organisations will not be informed as a right, and I think that they should be. Taxpayers' money is going to be used to promote fluoridation and to issue propaganda—I call it that advisedly—to promote the policy, whereas those people who are against it or have reservations have to finance their opposition from their own pockets. That does not seem to be a fair situation. These points were made in the discussions on the 2003 Water Bill.

What about the Human Rights Act 1998? Is compulsory mass-medication—that it what it is—compatible with that? The Minister is going to tell us, if he has not already done so, that the legislation and these orders will be compatible, but that is what the Government told us about the measures that we are now discussing in the Anti-terrorism, Crime and security Act 2001. That was said to be compatible with the Human Rights Act and was proved not to be. That is why we have had these days and hours of debate, trying to put that situation right. The Law Lords declared that, after all, Section 4 of that Act was not compatible with the Human Rights Act, so I am not at all sure that this measure is either. It may well be tested in the courts, and I hope that the courts will strike it down.

I understand that that is probably a minority view in the House tonight, and perhaps at other times as well. We can vote against such orders as these, but it is the practice not to do so. Like the noble Earl, Lord Howe, I will not seek to divide the House tonight.

Lord Warner

My Lords, we have had an interesting rerun in some respects of the debates on the Water Act 2003. We have a bit of time while the Prevention of Terrorism Bill is printed, but I do not want to go over all that debate again. I agree with my noble friend Lord Tomlinson that we have had this discussion, Parliament has spoken, and an Act which was certified by the responsible Minister as compatible with the Human Rights Act 1998 has passed Parliament. We are talking about the narrower set of issues in the consultation regulations and in the indemnity regulations.

However, just to clarify one or two points on research, I remind noble Lords that the University of York report concluded that water fluoridation increased the number of children without tooth decay by at least 15 per cent. It also said that currently around 6 million people receive water which either has had its level of fluoride adjusted or is naturally fluoridated to around 1 milligram per litre. No ill effects have been identified. That was in the University of York report.

It did acknowledge that there might be improvements made in the quality of research that was available. The need for more good quality research was also accepted by the Government, who are committed to a continuing programme of research which takes account of the Medical Research Council's findings about the research necessary to strengthen the evidence base. That was not saying that there was no evidence base. As I have said, the University of York report was a strong endorsement of fluoridation, as well as acknowledging that there could be a need for a continuing programme of good quality research.

The Chief Medical Officer and the Chief Dental Officer were asked to advise on the implications of the MRC report for government policy on fluoridation. Their advice and recommendations for research will inform a continuing programme. It is worth bearing in mind that the Department of Health commissioned the University of Newcastle's School of Dental Sciences to undertake a study into the bio-availability in naturally and artificially fluoridated drinking water. That study was published in July 2004 on the University of Newcastle's website. I am sure that noble Lords who have a fascination and interest in this subject will be able to read the research on that website. It concluded that there was no statistically significant difference in the absorption of fluoride between artificially and naturally fluoridated water or between soft and hard water. I do not want to go into the details, but that demonstrates the Government's continuing willingness to carry out research in this area and to make that research available in the public arena.

A number of people have expressed concerns about the consultation process. It has never been our intention that the majority of responses should be interpreted as meaning that the issue will be settled by a head count. I do not want to go over all the ground again, but for the reasons that I gave in my opening speech and in the debate on the Water Act, we do not consider that referendums are appropriate here. However, there is no question of strategic health authorities being able to proceed on the basis of representations from one group of people or another. If we want to be conspiracy theorists, I suppose the argument would be that the dental profession would try to capture the ground in this area.

The strategic health authorities have to weigh up all the arguments on all the views that are put forward and they have to take account of the cogency of the arguments. Part of that cogency argument is taking account of the research evidence, particularly where there is evidence showing that there is no association between fluoridation and a wide range of illnesses like cancer, thyroid disease or osteoporosis. People have made those claims. In the consultation process it is important that the weight of research evidence is taken into account in weighing the cogency arguments that are provided for in the regulations. We have to recognise that there will be some who are under misapprehensions about this matter.

The department will also issue guidance on the approach to consultation. I certainly accept the argument that representations opposing fluoridation on the grounds that it is a form of mass medication which breaches human rights, have some cogency, if people want to argue that. But we would expect the strategic health authorities to weigh against those arguments the opposing view that any breach is justified by the benefits of a population-based approach to reducing dental disease. That is another counter-argument and the evidence of those two arguments has to be weighed by the strategic health authority in considering whether to proceed.

I can confirm that it is our intention, when consulting on proposals to fluoridate, that the strategic health authority should publish a summary of the current research evidence with its sources and details of where additional information can be obtained. The Government have no intention of imposing fluoridation in any area. Our policy throughout has been that decisions must be taken locally, following well informed consultation on the issues involved.

The noble Earl, Lord Howe, raised issues about the strategic health authority being required to show a majority in favour. As I have tried to say, we do not consider a head count alone is the most appropriate means of reaching a decision. The noble Earl raised the question of what happens if only 20 per cent of residents respond? The strategic health authority will have to look at the issues and weigh the responses from the interested bodies to ensure that the weight of opinion is in favour. I would argue that that is a demanding requirement.

The noble Lord, Lord Colwyn, asked "What about Wales?" and raised the border issues. I understand that the Welsh Assembly will in due course be considering similar regulations for any proposals for fluoridation schemes in Wales. There may be a need for the Assembly and this Parliament to consider whether a third set of regulations is required for any schemes that cross the border between England and Wales.

I can understand that a number of Members of this House may be a little dissatisfied if I quote from a letter which I, and I suspect a number of noble Lords, received from the British Fluoridation Society. It says, We believe that the draft regulations provide a sensible and workable framework by which strategic health authorities must consult on future water fluoridation proposals". However, I think that it is worth looking at the heading of the letter, which points out very clearly that the society has a president and vice-presidents from across the political spectrum. This is not a party political issue, and these regulations command a wide spectrum of political support.

I was asked whether it is not sufficient to ensure that people clean their teeth, because there is enough fluoride in toothpaste. We have been over this ground. The big difficulty is in ensuring that families in deprived areas can buy the toothpaste and will establish regular brushing regimes.

I cannot mention too often the point that is covered in Regulation 3. This was brought out very strongly in the consultations conducted by the department on these regulations, in which we stressed continually that this regulation makes it clear that bodies with an interest have to be consulted. Under Regulation 3, strategic health authorities will have to demonstrate that they have consulted all the organisations for which fluoridation may have implications. There is therefore a clear requirement in that area.

A couple of points were raised on the subject of the indemnity regulations. The noble Earl, Lord Howe, raised the issue of existing schemes. I can inform the House that the Secretary of State will issue new indemnities, in the form of the schedule to the regulations, to those water companies with existing schemes.

The issue of the cost of indemnities was raised by the noble Baroness, Lady Barker. No association has been established between fluoridation and ill health, so no claims have been made. So far, the indemnities have been invoked in respect only of actions by opponents of fluoridation: for example, refusing to pay their water bills. This may he an interesting piece of information for the noble Baroness. Since 1997–and these are about the only data we have in this area—one payment of some £400 was made to a water company which had prosecuted a resident for non-payment. We are talking about quite small sums of money which have been paid out so far. We do not have any other information that I can put in the public arena in terms of the future costs of the indemnity regulations.

We have been over this ground many times. I believe that, with the guidance we will be providing, these consultation regulations provide a satisfactory way forward for implementing the legislation that was put in place under the Water Act 2003. I reiterate that the Government have no intention of imposing fluoridation in any area. It has been our policy throughout, and continues to be our policy, that decisions must be taken locally, following well-informed consultations on the issues involved.

On Question, Motion agreed to.

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