Water Bill [Lords]

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Mr. Osborne: The Minister explicitly says, ''if local communities want it''. What advice would she give to a strategic health authority that had decided on medical grounds that it would be good for the area if fluoride was added to water, but which, after public consultation, got an overwhelming negative response? Should it trust its medical instinct or advice, or should it listen to local opinion in that situation? It is a serious point and I think she will find that this happens in many areas.

Miss Johnson: We are not suggesting a referendum, as hon. Members know. I mentioned the consultation in my constituency. Judgments have to be made in weighing up the thousands of responses generated as a result of widespread consultation over time, as I sketched out.

Mr. Swire: Will the Minister give way?

Miss Johnson: I shall give way when I have answered the question asked by the hon. Member for Tatton.

There is a difficulty in weighing up the responses, but whatever the case, local opinion must be in favour of the proposal. It will not proceed if all the indicators are overwhelmingly against it, as the regulation to be introduced will make absolutely clear. Local opinion must support the measure overall.

3.30 pm

Mr. Osborne: Will the Minister give way?

Miss Johnson: I shall give way to the hon. Gentleman and then reply to the hon. Member for East Devon (Mr. Swire).

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Mr. Osborne: I am sure that my hon. Friend does not mind. I am reassured by what the Minister said, and by what may be in the regulations. What does she mean by local opinion? Will sheer numbers—the fact that thousands of people write in to say that they are against it—be taken into account, or will more weight be given to the opinion of local doctors and dentists than that of ordinary people, to use that awful phrase?

Miss Johnson: I hope that the hon. Gentleman is not insulting his many constituents who belong to those two admirable professions. At the end of the day, judgments will have to be made, just as they are in deciding how hospital provisions are to be redeployed in the long term.

If the hon. Gentleman is asking whether the views of certain professionals will carry more weight, as in a block vote, that should not be the case. We are talking about the opinion of the local community, which means that the views of the ordinary person on the street are taken as seriously as anyone else's.

Andy King (Rugby and Kenilworth): The discussion appears to be about how to introduce fluoridation. Can the Minister clarify what will happen when fluoridation is already in place, and evidence is produced that makes us say, ''Well this is not quite how we thought it would be.''? What mechanisms are in place to deal with such a case? Decisions cannot be once and for ever, because we live in an ever-changing world.

Miss Johnson: Obviously, we do not expect things to swing backwards and forwards on a pendulum basis. The expectation is that the decision would stand for a considerable time. The water companies would have to make a capital investment in fluoridation so it would cause difficulty if we allowed different views to prevail every couple of years.

The hon. Member for Leominster and others mentioned the cost of consultation. I do not conceal the fact that there will be such a cost, which will come out of the NHS budgets. However, given the cost of providing dental treatment on a much more significant scale to children and others with decaying teeth on the basis proposed earlier by my hon. Friend the Member for Bolton, South-East, there would probably not be a net cost—there may even be even be a saving—but that would not be the reason for doing it.

Mr. Swire: I am grateful to the Minister for giving way, and for the delay in doing so, because it has prompted another thought. Can she confirm what she has just said, that the costs of consultation will be absorbed by her Department, and not passed on to the taxpayer? Does that also apply to fluoridation? Will the water companies bear the cost, or will it be passed on to the hard-pressed taxpayer?

Miss Johnson: No, in both cases the costs will be borne through NHS funding. That is the proposal.

Mr. Swire: I will now ask my original question, if I may. Given our discussions about how the consultation would work in practice, has the Minister had a chance to consider the problem that would arise if one area was keen to have fluoridation and another area, which was under the same or a

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neighbouring health authority and shared certain pipes, was vehemently against it? How would that problem be resolved?

Miss Johnson: That situation is almost bound to crop up. I certainly foresaw that it would be an issue early on. The water distribution systems do not cover exactly the same areas. Nothing overlaps exactly in anything here. There is obviously no overlap with any other mechanism for making these decisions either. Boundaries are not coterminous. There would need to be discussion if the water company was going to cover an area wider than the strategic health authority by fluoridating its water at a single source, for example.

When I talked to someone in the water industry about this matter informally, I was told that it was possible to fluoridate at different points in the water distribution systems, depending on the company and the way that the distribution takes place. Therefore it can be done nearer or further away from the customer and with more or less fine-tuning. That obviously will not overcome all the difficulties that hon. Members have described, but it would overcome many of them.

There will be occasions when two strategic health authorities may need to have discussions with a part of a population that might be affected by a decision in a neighbouring area. There could be a marginal additional cost for example to remove that area from the water distribution system and put in the supplies nearer to the sources so ensuring that it covered a more limited area that was more naturally coterminous with the strategic health authority boundaries.

Norman Baker (Lewes): Two points flow from that. First, if we are to take local opinion seriously, decisions need to be taken—whether or not they are organised by the health authority—about local communities within the health authority area. Brighton and Hove, for example, might be in favour and the rest of east Sussex might be against. The water company should be required to respond to sophisticated public opinion, even if that is more expensive, rather than try to make the case that it is more convenient for it to put the necessary works further up the chain, which would mean that others would get fluoride whether they wanted it or not.

Secondly, I should like to make a point in response to the intervention by the hon. Member for Tatton about the tests that will be applied by the consultation process. Under clause 61, the proposed new section 89(1)(a) to the Water Industry Act 1991 states that

    ''a relevant authority shall . . . consult and ascertain opinion in accordance with regulations''.

I am not sure whether that is qualitative or quantitative. Are there any circumstances in which public opinion may be either divided equally or be marginally against fluoridation but the health authority would nevertheless still wish to pursue that course of action for other reasons? Is public opinion the only test? If so, may I draw the Minister's attention to amendment No. 158, which, if I understand her correctly, is what she is trying to achieve? It says that this should be progressed only

    ''if public opinion is clearly in favour of such an addition''.

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Is she attracted to that amendment?

Miss Johnson: I have already said that we think that it should be done only when public opinion is in favour, and the question is how to sum up public opinion. As well as the careful judgments and difficult balances, which Members have sketched out well in their contributions, that is another judgment that may have to be taken by some strategic health authorities if there is a carefully balanced view. Whatever mechanism is used, a clear majority of people should be in favour of fluoridation.

Mr. Wiggin: One of the questions I posed at the beginning of the debate—the 90 per cent. quoted in the amendment is tempting the Minister to discuss this—was about the meaning of a clear majority. The hon. Member for Birmingham, Northfield (Richard Burden) outlined many types of consultation, for which I was grateful. The point that we are coming to, which will reappear in the next amendment, is what she means by a clear majority.

Miss Johnson: I am grateful to the hon. Gentleman for picking up on my exact words, because they were probably misleading. One reason why we have sympathy with the intention of amendment No. 158 is that we agree that the strategic health authority should not be permitted to fluoridate unless the local community is in favour. I have already sketched out the mechanisms and issues involved in reaching that conclusion.

Fluoridating water makes a difference, as many Members have already said. However, the 70 per cent. of my hon. Friend's constituents who are five years old or under and have experienced tooth decay is in stark contrast with the number in other areas of the west midlands and Crewe. The figure in the west midlands is one third of that, and in Crewe the figure is 23 per cent.

The hon. Member for Guildford (Sue Doughty) asked about some areas in Birmingham and the midlands that experience considerable problems with tooth decay, gum disease and dental health. In deprived areas, even if the water is fluoridated, tooth decay levels may be at or above the national average. That is not to say that improvement has not taken place; indeed, the situation would have been worse without it. Everybody will not be at the same level because other factors are involved.

The hon. Lady also mentioned children's centres and the role that we can play in encouraging other contributions to dental health. Those points were well made and have been taken on board. We are attempting to give young people and their families the best possible start, with a number of programmes designed to help and advance that.

I turn to the question raised by my hon. Friend the Member for Stroud on amendment No. 338. The reason for introducing the differential in that amendment is to distinguish between the Secretary of State, who is the ultimate reference point for the English health service, and the National Assembly for Wales, which is relevant for the Welsh health service.

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The Secretary of State will set the regulations for England, which is why we have introduced amendments that deal with the different position of the English and Welsh health systems.

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