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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".
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."
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"
- "Report to the Department of Health."
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.
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