My Lords, I beg to move that the House do now resolve itself into Committee (on Recommitment) on this Bill in respect of fluoridation.
Moved, That the House do now resolve itself into Committee (on Recommitment).—(Lord Whitty.)
I shall first call the noble Lord, Lord Warner, to move Amendment No. 1. I shall then call Amendments Nos. 2 to 13, which are amendments to Amendment No. 1. Proceedings on each amendment will be concluded before we move on to the next amendment. When Amendments Nos. 2 to 13 have been dealt with, I shall then put the Question on Amendment No. 1.
moved Amendment No. 1:
After Clause 58, insert the following new clause—
"FLUORIDATION OF WATER SUPPLIES
(1) The WIA is amended as follows.
(2) For section 87 (fluoridation of water supplies at request of health authorities) there is substituted—
"87 FLUORIDATION OF WATER SUPPLIES AT REQUEST OF RELEVANT AUTHORITIES
(1) If requested in writing to do so by a relevant authority, a water undertaker shall enter into arrangements with the relevant authority to increase the fluoride content of the water supplied by that undertaker to premises within the area specified in the arrangements.
(2) But a water undertaker shall not be required by subsection (1) above to enter into any such arrangements until it has been given an indemnity with respect to the arrangements in accordance with section 90 below (and any regulations made under that section).
(3) In this section and the following provisions of this Chapter—
(a) references to a relevant authority—
(ii) in relation to areas in Wales, are to the Assembly; and
(b) references to water supplied by a water undertaker are to water supplied (whether by a water undertaker or a licensed water supplier) to premises using the supply system of that undertaker.
(4) The area specified in arrangements under this section may be—
(a) in relation to England, the whole or any part of the area of the Strategic Health Authority in question;
(b) in relation to Wales, such area comprising the whole or any part of Wales as the Assembly may determine.
(5) The arrangements shall include provisions designed to secure that the concentration of fluoride in the water supplied to premises in the area in question is, so far as reasonably practicable, maintained at a target concentration of one milligram per litre.
(6) The arrangements shall be on such terms as may be agreed between the relevant authority and the water undertaker or, in the absence of agreement, determined in accordance with section 87A below.
(7) The terms may, for example, include provision—
(a) requiring payments to be made by the relevant authority to the water undertaker;
(b) specifying circumstances in which the requirement to increase the fluoride content may be temporarily suspended; and
(c) for the variation of the arrangements at the request of the relevant authority.
(8) The relevant authority shall consult the Authority in relation to the terms to be included in any arrangements under this section (in particular, terms which affect the operation of the water undertaker's supply system).
(9) The fluoride content of water supplied by a water undertaker may not be increased except in accordance with arrangements entered into by the undertaker under this section, but this shall not prevent—
(a) increases made by a third party on behalf of the undertaker in accordance with those arrangements; or
(b) incidental increases which may occur as a result of operational blending.
87A FLUORIDATION ARRANGEMENTS: DETERMINATION OF TERMS
(1) This section applies if a relevant authority and a water undertaker fail to agree the terms of arrangements requested by the relevant authority pursuant to section 87(1) above.
(2) In relation to areas in England—
(a) the relevant authority may refer the matter to the Secretary of State for determination;
(b) following such a reference, the Secretary of State shall determine the terms of the arrangements as he sees fit; and
(c) the determination of the Secretary of State shall be final.
(3) In relation to areas in Wales—
(a) the Assembly may—
(i) determine the terms of the arrangements itself as it sees fit; or
(ii) refer the matter for determination by such other person as it considers appropriate; and
(b) the determination of the Assembly or, as the case may be, the other person shall be final.
(4) Following determination under this section of the terms to be included in any arrangements—
(a) the relevant authority shall give notice of the determination to the water undertaker in question; and
(b) the undertaker shall be deemed to have entered into the arrangements under section 87(1) above on the terms determined under this section with effect from the day after the date of the notice.
(5) References in this Chapter to arrangements entered into under section 87(1) above shall include arrangements deemed to have been entered into under that section by virtue of subsection (4)(b) above.
87B FLUORIDATION ARRANGEMENTS: COMPLIANCE
(1) It shall be the duty of each water undertaker to comply with any arrangements entered into by it under section 87(1) above.
(2) Where, pursuant to any such arrangements, the fluoride content of any water is increased, the increase may be effected only by the addition of one or more of the following compounds of fluorine— hexafluorosilicic acid (H2SiF6) disodium hexafluorosilicate (Na2SiF6)
(3) Subject to subsection (4) below, water to which fluoride has been added pursuant to any such arrangements entered into by a water undertaker (with a view to its supply in an area) may be supplied by that or any other undertaker to premises in any other area (whether or not that other area is the subject of arrangements under section 87(1) above).
(4) Subsection (3) above applies if (and only if) the undertaker or undertakers concerned consider that it is necessary for the water to be supplied in the other area—
(a) for the purpose of dealing with any serious deficiency in supply; or
(b) in connection with the carrying out of any works (including cleaning and maintenance) by the undertaker concerned or, as the case may be, by the undertakers concerned, or by a licensed water supplier supplying water using its or their supply system.
(5) In this section—
(a) the reference, in subsection (3) above, to water to which fluoride has been added pursuant to arrangements includes a reference to water to which fluoride has been added by Scottish Water in exercise of the power conferred by section 1 of the Water (Fluoridation) Act 1985; and
(b) in relation to a supply of such water by a water undertaker, the reference, in subsection (4) above, to the water undertakers concerned shall have effect as references to the water undertaker and Scottish Water.
(6) In subsection (4) above, "serious deficiency in supply" means any existing or threatened serious deficiency in the supply of water (whether in quantity or quality) caused by an exceptional lack of rain or by any accident or unforeseen circumstances.
(7) Arrangements entered into under section 87(1) above shall remain in force until the relevant authority, after giving reasonable notice to the water undertaker, terminates them."
(3) In section 88 (power to vary permitted fluoridation agents), in subsection (1), for "87(4)" there is substituted "87B(2)".
(4) After section 88 there is inserted—
(1) The Secretary of State may by order made by statutory instrument provide that section 87(5) above is to have effect as if for "one milligram per litre" there were substituted a lower concentration specified in the order.
(2) An order under subsection (1) above may make different provision for different geographical areas, or for some such areas and not others.
(3) A statutory instrument containing an order under subsection (1) above shall not be made unless a draft of the instrument has been laid before, and approved by a resolution of, each House of Parliament."
(5) For section 89 there is substituted—
(1) Before taking any step mentioned in subsection (2) below, a relevant authority shall—
(a) consult and ascertain opinion in accordance with regulations made by the Secretary of State; and
(b) comply with any prescribed requirements.
(2) The steps are—
(a) requesting a water undertaker to enter into arrangements under section 87(1) above;
(b) requesting a water undertaker to vary any such arrangements in, or except in, prescribed circumstances or cases;
(c) giving notice to a water undertaker under section 87B(7) above to terminate any such arrangements;
(d) maintaining any such arrangements in prescribed circumstances.
(3) The Secretary of State shall by regulations make provision about—
(a) the process which relevant authorities are to follow for the purposes of subsection (1)(a) above;
(b) the requirements which must be satisfied (with respect to the outcome of that process or otherwise) before a step mentioned in subsection (2) above may be taken.
(4) Subsection (1) above shall not apply in relation to a proposal by a relevant authority to take the step mentioned in subsection (2)(c) above if—
(a) in relation to England, the Secretary of State so directs the relevant authority;
(b) in relation to Wales, the Assembly so determines, in each case, either generally or in relation to a particular proposal by the authority."
(6) For section 90 of the WIA (indemnities in respect of fluoridation) there is substituted—
(1) The Secretary of State may, with the consent of the Treasury, agree to indemnify any water undertaker in respect of liabilities which it may incur in complying with arrangements entered into by it pursuant to section 87(1) above.
(2) The Secretary of State may by regulations make provision with respect to—
(a) the matters in respect of which an indemnity may be given under subsection (1) above;
(b) the form and terms of any such indemnity; and
(c) such ancillary matters as he sees fit."
(7) Section 91 of the WIA (pre-1985 fluoridation schemes) shall cease to have effect.
(8) Schedule 7 to the WIA (pre-1985 fluoridation schemes) shall cease to have effect."
In moving Amendment No. 1 standing in my name, I shall speak also to Amendments Nos. 14 and 15. Fluoridation is a sensitive issue and I welcome this opportunity to debate the Government's proposals to give local communities a real option of deciding whether fluoride should be added to their drinking water. Although we believe it is right for local communities to decide whether to fluoridate their water, we have every confidence in the briefing paper on the fluoridation of water and dental decay produced by the Chief Medical Officer and the Chief Dental Officer, copies of which I have circulated to all Members of your Lordships' House.
Dental decay among children and adults remains an extremely common disease which is largely preventable. It is closely related to socio-economic status. As the briefing paper points out, from a public health perspective water fluoridation is the delivery method of choice to bring about population improvements in dental health and should be considered locally when it is desired to reduce inequalities in levels of dental decay.
There have been two recent newspaper articles by the same journalist raising concerns about fluoridation and health risks. The circulated briefing paper draws attention to the University of York and Medical Research Council reviews of evidence in this area. As the paper says, the York team found no evidence of an association between bone fractures, infant mortality or cancer and water fluoridation. The 2002 Medical Research Council review identified no particular research priority in this area. Moreover, the Chief Medical Officer and the Chief Dental Officer are to report to Ministers in the autumn on the implications of the MRC report for government policy on fluoridation, well before any local consultations could take place.
The main reason for Amendment No. 1 is that the Water (Fluoridation) Act 1985, consolidated in Sections 87 to 91 of the Water Industry Act 1991, has not achieved the policy intention of successive governments of letting local communities make decisions on fluoridation. In summary, Section 87(1) of the Act states that where a health authority applies to a water undertaker for its water to be fluoridated the undertaker "may" increase the fluoride content of the water supplied by it within that area. The effect has been to give water companies discretion over whether to agree applications to fluoridate and, on every occasion that a health authority has made an application, the water undertaker has turned it down. As a result, there have not been any new fluoridation schemes agreed since the Water (Fluoridation) Act was passed in 1985.
This, I should hasten to add, is not because water companies have concerns about the effects of fluoridation; it is because they do not feel qualified to make decisions on what is essentially a public health issue. The water industry's representative body, Water UK, has asked on repeated occasions for the Act to be amended to put water companies under a statutory obligation to accede to requests from strategic health authorities to fluoridate their water where they can show that their populations are in favour. Hence our proposed amendment requires that the water undertaker "shall" enter into arrangements with the relevant authority to fluoridate. The "relevant authority" in England would be strategic health authorities but in Wales it would be the National Assembly for Wales. This is the main change we are proposing.
We do not intend that water should be fluoridated come what may in those areas which do not currently receive naturally or artificially fluoridated water at a level capable of reducing dental decay. In fact, the enactment of the amendment may not lead to any new fluoridation schemes—that would depend on what people decided locally—but it would give local communities the choice of having their water supply fluoridated.
The remainder of the section provides details of the arrangements between the water undertaker and the relevant authority, including payment, and, as at present, the target concentration of fluoride. Proposed new Section 87A introduces provision for determination where the relevant health authority and a water undertaker fail to agree the terms of an arrangement to fluoridate. We are not expecting disagreements but it is good legislative practice to include such a provision to avoid negotiations reaching a deadlock.
Proposed new Section 87B restates the chemical compounds which are permitted to be used in fluoridating water and provides for water companies to suspend fluoridation for temporary periods due to operational exigencies such as droughts or plant maintenance.
Proposed new Section 88A introduces a regulation-making power to reduce the target concentration of fluoride in drinking water below the one milligram per litre specified in Section 87(5) of the Act. This might be appropriate if it was found that, as a result of increased use of discretionary fluorides such as toothpaste and mouthwashes, the desired reductions in tooth decay could be achieved at a lower concentration of fluoride in water.
The reason for using regulations is to provide additional flexibility in making changes of a technical nature which currently can be made only by amending primary legislation. However, because this is an important public health issue meriting debate in Parliament, we propose that the regulations are subject to affirmative resolution. The National Assembly for Wales would exercise the powers in relation to Wales and its scrutiny procedures will apply.
Proposed new Section 89 provides for consultations. As I indicated, no new fluoridation scheme would go ahead without the support of the majority of the local population determined by local consultations conducted by strategic health authorities in England and the National Assembly in Wales. It is essential that the procedures followed command public confidence. We do not consider that the present provisions in Section 89 of the Water Industry Act for publicity and consultation go anywhere near far enough. For this reason we propose to introduce a regulation-making power to cover the detailed requirements.
Taking into account the advice of the Delegated Powers and Regulatory Reform Committee we have decided that these regulations should be subject to the affirmative procedure and we will table an amendment to this effect in another place. The National Assembly for Wales will determine the content of the regulations for Wales and will no doubt consider and develop regulations that best meet the needs of Wales. Also on the advice of the Delegated Powers and Regulatory Reform Committee, we have decided that these regulations should be subject to the affirmative procedure and we will table an amendment to this effect in another place.
We intend that regulations should provide for the dissemination of the proposals through, for example, the press, radio, TV and leaflet drops, and for consultations involving public meetings, discussions on local TV and radio, helplines and websites, culminating in an objective means of measuring public opinion which ensures that the views of people from a wide range of backgrounds are represented. We will consult widely among those with expertise on the best methods of measuring public opinion, particularly among social groups which stand most to benefit from fluoridation but which do not always participate in public consultation exercises.
The proposed new Section 90 proposes that the present provisions for indemnifying water companies are made more specific through a regulation-making power. We have in mind the use of model indemnities for England in the regulations which we would discuss with the water industry. The broad objective is to ensure that the liabilities of a water company which is required to introduce a fluoridation scheme are no more weighty than those of companies without schemes for England. The regulations in Wales will be a matter for the National Assembly for Wales.
I turn now to Amendments Nos. 14 and 15. Amendment No. 14 removes the provision which would have enabled the Secretary of State to issue indemnities to licensed water suppliers. Our current thinking is that the relevant health authorities should only make arrangements with water undertakers and that the indemnities to the water undertakers would cover any sub-contracts they made with licensed water suppliers. We intend to discuss this assumption further with the water industry and, depending on the outcome, may make further amendments in another place. Whatever is decided, we will find a different drafting solution, so I shall still need to move Amendment No. 14.
Amendment No. 15 is a provision which adds Schedule 7 to the Water Industry Act to the list of provisions which are to be repealed. That schedule regularised the position of pre-1985 water fluoridation schemes in the light of the provisions of that Act. It is proposed that there will be new provision in the Bill to deal with existing schemes by converting them to the new style of arrangement. Amendments to this effect will be introduced in another place. What is certain is that the existing Schedule 7 to the Water Industry Act will no longer be required.
I remind the Committee that these amendments are being moved in response to the strength of opinion in another place on this issue and a commitment that the Government gave to do so. There is a strong body of opinion that local communities should have the right to make the choice to fluoridate their water to reduce dental decay, particularly among children. I have had many letters—as, I suspect, have other noble Lords—over the past week supporting the Government's approach on this issue and none opposing it. The Government are responding to people's concerns in a practical way. I beg to move.
I declare an interest as a director of a very small water company. I am not speaking today as a member of that board but, having been briefed by Water UK, for the industry as a whole—namely, water companies and water suppliers.
I am grateful to the Minister for his clear exposition of what is intended by the amendments. Obviously, there is a great body of opinion which wishes to have the complete fluoridation of water throughout England. However, before I speak to the amendments, I should point out to the Minister that the reason the water companies were reluctant to bring in fluoridation after the 1985 Act was because they were convinced that the health authorities had not properly consulted affected customers. I am grateful that the consultation now will be extremely wide through the press, radio, discussion groups, helplines and websites. That will cover many of the problems. It was not a case of finance or necessarily of indemnities; it was that they did not wish to get involved. The emphasis that the Minister placed on it was not quite how I understood it to have been.
The industry's position is that the legislative regime needs improving. First, decisions on and responsibility for fluoridation should be entirely matters for the health authorities and the Department of Health, subject to the following safeguards: maintenance of security of supply and, to that end, operational flexibility for the water companies, taking into account that supply zones may vary seasonally and in consequence of operational exigencies. Again, the Minister made the point that if there was a drought situation or specific local situations, there would be flexibility.
Another point is that it should be a prerequisite to the initiation of fluoridation schemes that health authorities should co-operate with each other and consult the water companies. For example, a water company could supply a very large area which was covered by two or three health authorities. It is important that that point is not missed out. If they are to have all the responsibility, they need to find out whether those who would be affected are in favour of the proposal and there has to be joint acceptance by the local health authorities.
There needs to be updated guidance on the specifications and procedures required to be achieved in relation to the construction and operation of fluoridation plant. There needs to be provision for the reimbursement by health authorities of all water companies' capital and operational costs of fluoridating water supplies. There also needs to be provision for full indemnities by the Department of Health to water companies for any liabilities that they may incur as a result of, and in any way connected with, the fluoridating of water supplies other than in respect of their own negligence, which one would not expect to be indemnified against.
That point is essential to the whole issue of fluoridation. First, I accept without question the comments in the briefings. It is appalling to think that 50 per cent of the population of this country do not own a toothbrush. From that point of view, there is a very strong case for fluoridation to avoid the really awful problems of dental decay and dreadful toothache. As the Minister said, those usually occur in areas of social deprivation, where people may regard toothbrushes and toothpaste as unaffordable luxuries.
I know that the noble Lord, Lord Balfour—
I am sorry, I am getting my Prime Ministers mixed up. I know that the noble Earl, Lord Baldwin of Bewdley, will be talking about the dangers that could result from fluoridation. We must always, in this House, avoid the law of unintended consequences. We really do not know about this. We have had experiences in the past with, dare I say, thalidomide, as well as asbestos, which were regarded as absolutely safe until way down the line.
I know there has been fluoridation in the Birmingham area for the last two decades or more, but one still does not know. There is great anxiety among the water companies and the industry as a whole as to whether, if they are to introduce fluoridation on a widespread or, indeed, a token scale, any epidemiological studies show that people in Birmingham have a higher rate of Alzheimer's disease or bowel cancer. That might satisfy some of the concerns but there is still a latent fear that, in this litigious era, the water companies could be done out of business if such problems arose.
The industry supports the principles of the Government's tabled amendments on the grounds that these meet, to a considerable extent, the concerns I have expressed. However, they need tightening up in certain respects, which is why I have tabled my amendments.
The reason for tabling Amendment No. 2 is that in order that the fluoridation provisions may be effective it needs to be made clear that they apply in full to licensed water suppliers as well as to water undertakers.
On Amendment No. 3, for the reasons I have already described, it is considered that the arrangements required to be entered into between the health authority and the water company ought to deal with all the matters listed in subsection (7).
On Amendment No. 4, again as mentioned, I believe it needs to be made clear that the health authority should be responsible for all the water company's costs of effecting fluoridation. This is for the protection of the company and its customers. If it has huge capital investments which cost an enormous amount of money, the price of water will necessarily increase, and the increase might not be fair or equal throughout the country.
Amendment No. 5 deals with the point that it is important that before initiating any fluoridation scheme, the health authority should first consult the water company on the practicalities. That is quite different from consulting the water company on the basis that it has consulted the local populace and there is a strong case for fluoridation. It is the practicalities we are concerned with here.
On Amendment No. 6, given that the existing technical guidance is now 15 years old, the industry believes that there should be a legal requirement for the Government, after consultation, to provide up-to-date technical guidance on the specifications and procedures to be observed in relation to the construction and operation of fluoridation plant. This is for safety purposes and for the avoidance of disputes over what standards should be met and funded.
Although the Drinking Water Inspectorate is now putting in hand revision of the technical guidance, the importance of having up-to-date standards is such that it should be put on a statutory basis. Chapter III of Part 3 of the Water Industry Act 1991 is the authority for the drinking water standards/regulations.
Amendment No. 7 is in the interests of security of supply and operational flexibility, already mentioned in my introduction. It is important that proposed new Section 87B(3) and (4) should be extended to take account of all the operational exigencies described in the amendment.
On Amendment No. 11, in the proposed new Section 90, if the scope of any permitted indemnity that may be provided by the Secretary of State is to be prescribed by regulations under proposed new subsection (2), then proposed new subsection (1) needs to be modified to take account of this. In this connection, on the basis that the Department of Health should take full responsibility for fluoridation, surely it should be mandatory for the department to provide indemnities to water companies.
On Amendment No. 12, following on from Amendment No. 11, I believe there should be a duty on the Government to make regulations defining the scope of the indemnities that should be provided. To use the word "may" is an option; there cannot be an option on this.
Already there is concern about the long-term effects of fluoridation, not only from the health point of view. At a dinner on Monday night, which was totally unconnected with the subject of water, someone who knew of my involvement as a marketing adviser to MAFF two decades ago asked whether I realised that fluoridation was going to cause a real problem for the growing of tomatoes by hydroponics. Hydroponics was the great thing two decades ago—tomatoes were grown solely in water. But there are concerns in the horticultural sector that adding fluoride to water could cause some problems with the fruit—tomatoes are a fruit, I am told. It could also cause problems to the hoses and pipes and all the kit involved in hydroponics. That is not part of my amendment, but these matters must be considered.
Finally, I come to Amendment No. 13. Since the revised fluoridation provisions will be dependent on regulations made by the Secretary of State, I suggest that it needs to be a precondition of water companies being required to fluoridate water supplies that such regulations should first be made. I beg to move.
I support my noble friend, at least to some degree, but I should make it clear that my support for her amendments should not be taken to imply that I support the principle in the first instance. It is only fair to point out that, should Amendment No. 1 fail, all the other amendments that we are debating cannot be called. We are in something of a procedural dilemma.
That explanation is perfectly clear, but if one supports these amendments, it might be taken to mean that one supports Amendment No. 1 as amended. I would not want that implication to be made either. These amendments have real merit if the original proposition is accepted. Therefore, they should be supported. I am assuming that we will debate Amendment No. 1 as amended at the end, so I shall confine myself simply to the two issues in Amendments Nos. 6 and 7, which are the ones that I want to support.
I must say that I am not confused. We are debating Amendment No. 2, which is an amendment to Amendment No. 1. That is a perfectly normal procedure in your Lordships' House. When that and the other amendments to Amendment No. 1 have been disposed of, we will have the opportunity to debate Amendment No. 1 as amended or as unamended. I have no doubt that your Lordships will find ways of referring to Amendment No. 1 while speaking to the other amendments.
I apologise if I have sown the seeds of confusion, as that was not my intention. I merely wanted to make plain precisely the ground on which I want to stand. I do not particularly want to refer to Amendment No. 2, but I want to refer to Amendments Nos. 6 and 7, which are grouped with Amendment No. 2.
The question of technical guidance is absolutely fundamental. In moving her amendments, my noble friend said that the present technical guidance, such as it is, is now 15 years old. We know a good deal more than we did 15 years ago, and the technical guidance may anyway need to be different from that originally devised if we are in the business of supplying fluoridated water to specific areas that may be much smaller than the water undertakers' area. Therefore, there will need to be detailed guidance on that issue.
The matter is not at all straightforward. We ought to appreciate that if fluoride is added to water for the benefit of a particular population, 99.5 per cent of that fluoride will return to the general water system. Fluoridated water will go into the system; consumers will use it in baths, lavatories and to clean their teeth and to drink. I assume that almost all that fluoride will go through the sewage works and straight into the water system—unless the Minister can give me an assurance that it can be precipitated out during the cleaning process. It will go on down the waterways.
Let us take an example. If the towns of Oxford and Reading were to decide that they wanted to have fluoridated water and the town of London did not, the town of London would get fluoride in its water—perhaps not at the full concentration, but some anyway. That is one problem that we face. It may be that the downstream towns will receive a very low concentration, but the fluoride will be present unless it can be cleaned out. Perhaps the Minister could refer to that in his response. Because of those problems, the matter of technical guidance is absolutely essential and will need very careful consideration. My noble friend has done the House, and the passage of the Bill, a favour in tabling her amendment.
Amendment No. 7 is simply a matter of what I would call good water management. In an emergency, water undertakers assist each other. If one happened to be supplying fluoridated water and another did not and there was an emergency breakdown that meant that one had to supply water to the other, it would be an impossible situation if one was not allowed to transfer to the other without having to worry about the possibility of law suits, indemnity and so on.
I particularly support Amendments Nos. 6 and 7, which do a great deal to help the matter forward. However, I make that plain without saying which way I wish to vote on the main principle, as we shall deal with that later.
It may be for the convenience of the Committee if I indicate from the outset that we have a lot of sympathy with the broad objectives of the amendments tabled by the noble Baroness, Lady O'Cathain. We have some reservations, but our attitude is overwhelmingly sympathetic. It may be convenient for the House if I indicate our likely reaction.
I am most grateful to the Minister for making that statement. Before we leave the issue, we record our thanks for that. However, I want to ask about the position of licensed water suppliers. In the government amendment, they are deliberately left out of the loop. Will that be considered, or will the Government return to the more general practical negotiations?
We are in sympathy with the broad objectives of Amendments Nos. 2 to 7 and Amendments Nos. 11 to 13. The water industry has for some years been pressing for a change in the law, as the noble Baroness said. We want to ensure that, within any constraints imposed by overall government policies, we meet the industry's concerns. We will aim to do that through the regulations enabled by the amendment and, if necessary, further amendments to the Bill, which could be made during the Bill's consideration in another place. We will consult the industry about the drafting of the regulations.
Amendment No. 2 would provide for relevant authorities—the strategic health authorities—and the National Assembly for Wales to make arrangements to fluoridate with licensed water suppliers as well as water undertakers. We consider that it would be appropriate for the relevant authority to make arrangements with a water undertaker. Where licensed suppliers are required to fluoridate any water supplies as a result of the water undertaker's arrangements, such provisions could be specified within the access agreement between the water undertaker and the licensee to fluoridate its water. We shall review that assumption in conjunction with the water industry's representatives and, if any amendments are necessary, we shall introduce them in another place. I hope that, in the light of that reassurance, the noble Baroness will withdraw her amendment.
With respect to Amendment No. 3, we recognise that water undertakers would find a standard contract reassuring, but there might be benefits in the flexibility that "may" offers over "shall". Although payment will naturally be one of the first things all arrangements will cover, there may be differences in the handling of such matters as the variations required to the arrangements. If the noble Baroness wishes, we shall consider that matter further with the water industry's representatives and, if any amendments are necessary, we shall introduce them in another place.
With respect to Amendment No. 4, we envisage that those details would be included in the terms of the individual arrangements made between relevant health authorities and water undertakers. However, we recognise again that the water industry would find reassuring the inclusion of that detail in the Bill. We shall consider the matter further in conjunction with the water industry's representatives and, if any amendments are necessary, we shall introduce them in another place.
With respect to Amendment No. 5, we agree that it is essential that the relevant authorities are clear about the boundaries of the water supply system before they embark on a public consultation. They need to know who to consult within the area for which they are responsible and, if the water system overlaps their boundaries, whether they need to involve neighbouring authorities in the consultation. We intend that that requirement will be specified in the regulations on consultation. However, we are prepared to look at this further in conjunction with the water industry's representatives and if any amendments are necessary we will introduce them in another place.
With respect to Amendment No. 6, we recognise the importance that the industry attaches to observance of the technical code of practice. We are already working on a new, updated version of the code. However, the code contains guidance which may need to be updated in the light of technical developments. Prescribing that guidance in regulations could create delays in updating the code in future. However, we are happy to look again at this in discussion with the industry's representatives. Again, if any amendments are necessary we will introduce them in another place.
With respect to Amendment No. 7, we accept the need to give water undertakers discretion to cope with unforeseen circumstances such as droughts, floods or plant breakdowns and these have been provided for in Section 87B. We have also extended the provisions in the existing Act, in Section 87(7)(b) and (c), which allow the circumstances in which the requirement for fluoridation may be temporarily suspended to be specified within the terms of the arrangements. Section 87(6) provides for local agreement of arrangements. I think that we would need a bit of persuading to go any further than that. I hope that in the light of the assurances that I have given so far the noble Baroness will be prepared to withdraw Amendment No. 7.
With regard to Amendment No. 11, we recognise the importance of the indemnities to the water industry. We do not want a water company that makes an arrangement to fluoridate its water to incur any more liabilities than one that does not. However, I think it is agreed that we cannot indemnify the companies against liabilities incurred through negligence. That may mean that we may not be able to go as far as the amendment in indemnifying "any" liabilities. Again, that is something that we would like to discuss further with the industry's representatives and if any amendments are necessary we will introduce them in another place.
We think that Amendment No. 12 is a further indication of the importance that the water industry attaches to the indemnities. My Amendment No. 1, to which I spoke earlier, uses,
"may by regulations make provision", in order to leave open the option—however unlikely it may be—of our using another means of describing the detail of the indemnities that we wish to provide. There is absolutely no question of our expecting water companies to fluoridate without indemnities, but we will look at this further in conjunction with the industry's representatives. Again, if any amendments were necessary we would introduce them in another place.
On Amendment No. 13, as I indicated, there is no question of our expecting water companies to fluoridate without indemnities or before we have made the regulations on consultation. However, I appreciate the cause of the water industry's concern. We will look at this further in conjunction with the industry's representatives. Again, if any amendments are necessary, we will introduce them. I hope that, in the light of those firm assurances, the noble Baroness will be prepared to withdraw her amendment.
What is the date today? It is 9th July. One would think that it is my birthday, but it is not. I want to say thank you very much indeed to the Government and particularly to the Minister for listening to the arguments. From reading his brief, my guess is that he already knew the sort of arguments that I was going to put forward. He matched them ball for ball. I love the new expression that he used and hope that it gains further credence in the House—"We shall look at this further with the representatives of X or Y industry, or of the schools, or of the health service, and then present further amendments". It is very gracious of the Government to do that. However, I should like to make a couple of points. I have also been told not to seek leave to withdraw my amendment until my noble friends have had an opportunity to express their views on it.
I am afraid that the Minister did not listen to my opening comments when I gave my reasons for tabling the amendments. I said that companies would expect to be indemnified,
"other than in respect of their own negligence".
That is a sine qua non; there is no question about it. No one should ever be allowed off that hook. If people are negligent they will just have to carry the can.
I noticed that the Minister needs a bit of persuading on Amendment No. 7. I think that I will need a bit of persuading to withdraw it. I shall see whether I have been persuaded in the course of the next debate. At this point, I believe that other noble Lords wish to speak to the amendments.
I am pleased that the Minister made those comments; they are at least a starting point. However, I should like to respond to the points made by the noble Lord, Lord Dixon-Smith, particularly his worry that too much fluoride will accumulate in the water. I believe that it is very important for him to appreciate that there is absolute control over water fluoridation in every area where it has been introduced. The level is never allowed to rise above one part per million. I cannot see why there would be any change to that.
I seek to assist the Committee. My understanding is that if the noble Baroness, Lady O'Cathain, were to withdraw her amendment, we would then deal with the amendments tabled by the noble Baroness, Lady Miller. After that we would be able to consider the Minister's Amendment No. 1. I do not believe that noble Lords wish to have a debate on the principle and issue of fluoridation three times.
I am not speaking about the general issue. However, I think I should say now—while we are speaking to Amendment No. 2, and after the noble Lord, Lord Dixon-Smith, spoke specifically to the point—that it is a misconception to believe that fluoride levels in the Thames will continually build up. Although that is only one of many minor points, I think it relevant to what has been said in relation to this group of amendments. It is important to realise that in all the years that fluoride has been in water, the maximum level has always been set at one part per million. There has been no change to that. So although the noble Lord says that we need to update all the arrangements, research has not demonstrated the need for change.
I think that I should be allowed to attempt to clear up the confusion that I appear again to have caused. I did not mention one part per million, and I certainly did not wish to imply that one might ever find oneself with water with more than one part per million of introduced fluoride. I should add that there are some natural water sources in which the level is considerably higher than that.
That said, my concern was slightly different. My concern was that upstream communities could vote to introduce fluoride and downstream communities would have fluoride in their water whether they voted for it or not. It may well be at much reduced concentrations, but the fact is that it would be there. That could be avoided if the fluoride—the Minister was not debating the principle, so he probably did not want to address this issue—was removed during the water cleaning process which such water would undergo before being returned to the watercourse. It is an issue, but it is nothing to do with the one part per million.
I think that at the moment we are debating the technical amendments tabled by the noble Baroness, Lady O'Cathain. We have time to debate the one part per million or the 10 parts per million or whatever it is when we debate the Minister's main amendment, Amendment No. 1. I wonder whether the noble Baroness will kindly respect that.
At the moment we are debating the second grouping of amendments. Is that not correct? We are debating Amendments Nos. 2, 3, 4, 5, 6, 7, 11, 12 and 13. That is what is before us at the moment. Therefore, I do not understand the point made by the noble Baroness. This is Committee stage. We could debate the matter backwards and forwards all night if we so wished. I do not so wish, but the point which my noble friend Lord Dixon-Smith reiterated about fluoride build-up makes one imagine that we are taking water straight out of the river and drinking it. All drinking water is treated before it reaches the consumer. Where I live in Oxfordshire the chlorine content of the water is so strong that I have to fill the kettle and leave it to stand over night or I could not drink the tea made with that water. There is no doubt that water is treated before it reaches the consumer.
The discussion between the noble Lord, Lord Dixon-Smith, and the noble Baroness, Lady Gardner of Parkes, exemplifies why the public may wish to become involved in any consultation on whether to fluoridate water.
Were the amendments that I have tabled to be accepted, I would not have any problem with the Government's Amendment No. 1. Were they not to be accepted, I would have a problem with Amendment No. 1, which is a technical amendment to which we shall return later. Consultation with the public is absolutely key to the matter. The government amendment has been tabled at a very late stage which precludes much discussion on it. We shall have to cram it all into a couple of hours this afternoon.
I have grave misgivings about the drafting of Amendment No. 1, notwithstanding what the Minister has just said about public consultation. I say, "Lucky Wales" with its elected Assembly with which the relevant decision will rest. However, in England the strategic health authorities are not well placed to undertake any kind of public consultation. It is not part of their main job; they are not experienced in it and the public are not used to strategic health authorities undertaking public consultation. In contrast, elected local authorities undertake public consultation all the time. They have experience of dealing with very difficult issues such as local planning issues when dealing with local plans. They are ideally placed to undertake public consultation. If the public in a particular area are not happy with the way in which a local authority conducts itself, they can vote it out of office. That does not apply to a strategic health authority, which is appointed by a Minister.
Strategic health authorities have a vested interest in slanting public consultation—I am not saying that they would—in one direction. Of course, strategic health authorities believe that fluoridation is a good thing. The many letters that I have received on the subject from the medical establishment suggest that that feeling is widespread. I do not want to challenge that, but I believe that the public have a fundamental right to do so for the following reasons. Water fluoridation is a step in a different direction where informed consent for medication is no longer required; it just arrives through one's tap whether one likes it or not. One cannot opt out of it. That is a fundamental change.
I have no doubt that if strategic health authorities had the funds and the time, they would approach the issue of children's tooth decay from a different angle. We have heard that often children's teeth are in a worse state in areas of greater deprivation. I believe that, if strategic health authorities had sufficient funds and time, they would devote more attention to the diet of pregnant mothers, the promotion of breastfeeding, suitable diets for babies and young children and doing something about vending machines in schools and the consumption of fizzy drinks and sweets. I accept that those are all long-term issues. However, once fluoridation is introduced, the incentive for strategic health authorities to do something about those other issues, which result in many other health problems, is much reduced as one of the obvious factors resulting from a bad diet has been removed, and the expense that goes with that for the relevant strategic health authority.
My amendment seeks to ensure that the Secretary of State,
"shall ensure sufficient funding is available for a meaningful consultation to take place".
It is far from clear to me who will pay for it. As we know, health authorities are strapped for cash as it is. Will they spend an awful lot of money on consultation, the answer to which they are already convinced should be yes? I do not believe that they will do so unless the Secretary of State ensures that that is done.
Nothing in the Bill suggests how public opinion would be measured at the end of such a consultation process. The GM debate reveals that the Government do not know how outcomes of consultation should be measured. I do not believe that they have produced a formula. The Minister will tell me that it is for the independent steering group to do that. He will also say that it is for strategic health authorities to determine how to measure public opinion. But I consider that we need to state on the face of the Bill that public opinion is clearly in favour of the change that we are discussing; otherwise, the matter is unclear and strategic health authorities can go ahead and public consultation will count for nothing. I beg to move.
It might be convenient for me to say at this stage what I would have said on the original new clause. I believe that we are in a state of confusion about that. I should have preferred that this very important matter involving compulsory medication was dealt with in a Bill rather than a new clause to a Bill which is reaching the end of its passage through this House. Then we could have had a proper Committee stage, a Report stage and a Third Reading. That was the proper way for this measure to have been introduced. It is much more important than people realise.
In the speech that I would have made, had we been having a Second Reading, I was going to raise the question of consultation. I would have asked a number of questions. What sort of consultation is it going to be? Are there, for example, going to be local referendums? If so, who will arrange them? By whom will they be conducted? Will they be conducted under the auspices of the Electoral Commission and, if not, how is strict fairness to be achieved? As the noble Baroness pointed out, in any consultation procedures we need to be sure that fairness is achieved. What facilities will be given to opponents of fluoridation to state their case? Will equal amounts of public funds be made available to them as to the supporters of fluoridation? Will health authorities be under a restriction as to the use of taxpayers' money to promote fluoridation when opponents may not have such access to public funds? Indeed, if there are to be referendums, how will voting be conducted and, as I say, by whom? Those are important questions. I do not know whether the noble Lord intends to answer them now or at a later stage, but I hope that he will be able either to satisfy the noble Baroness as to her amendments, or, if not, that they will be put to a vote. It is extremely important, indeed essential, that if debate is to be carried out it is done on a proper basis—a basis that people can understand and in which they feel able to take part in.
I support the previous speakers on the points they made and the amendments tabled by the noble Baroness. It is important that this should be decided by the elected local authorities. As the noble Baroness said, it is more than a simple matter of fluoridation and healthcare. Tessa Jowell, as Minister for Public Health some years ago, was sympathetic. The thinking then was that it should not be the responsibility of health authorities, with the endemic pro-fluoridation culture which is hard to get away from, but the elected local authorities. I hope that the Minister takes the point seriously.
It is important to involve all shades of opinion in any consultation process. We had a very good principle on the York systematic review in which I took part. There was an advisory panel overseeing the whole process, drawn explicitly from supporters and opponents of fluoridation. That meant that both sides of the argument could be put. Any bias was spotted and corrected as we went along, and neither side was at a disadvantage at any stage of the process. I have reason to believe, having been in correspondence with him, that the Chief Medical Officer may be sympathetic to the view that it is important to include all shades of opinion in the consultation process, both in terms of putting forward their points of view and in drawing up the necessary questions and agenda, which are too readily set by the pro-fluoridation people.
I had intended to say later, and shall say now, that in an area which, in the words of one mainstream journal,
"has probably brought out as much extremism as any other issue in the modern history of science"— on both sides—and where,
"hardly any individual interested in the issue . . . can be classified as neutral", even-handedness is crucial at every stage. I hope that the noble Lord will give the matter serious consideration.
I begin by declaring an interest as a former member of the British Fluoridation Society and an active supporter of its work. I am also an adviser to the Birmingham and the Black Country Health Authority.
Perhaps I may respond to the points made by the noble Baroness, Lady Miller. She strayed into issues in relation to the principle behind the debate. I regret that we have not been able to have a debate on the principle before coming to the detailed amendment. I do not think that this has been a very sensible approach. We find ourselves extremely frustrated in talking about the nitty-gritty of consultation without coming to a view on the whole issue of fluoridation. It is not a very sensible way to proceed.
Perhaps I may respond to the point made by the noble Baroness, Lady Miller, about strategic health authorities. She said that they should concentrate on breast-feeding and diet and other ways to improve oral health in contrast or in substitution for fluoridating the water. She went on to say that areas where water is to be, or has been, fluoridated might not take other action to improve oral health.
I thank the noble Lord for giving way. I think he will accept, if he looks at the record, that I said that those would be the long-term issues but that fluoridating water might not encourage a strategic health authority to take energetic steps in that direction.
I am grateful to the noble Baroness for that clarification. But if we take the City of Birmingham authority, which fluoridated the water about 40 years ago, we see that the public health dentistry programme in that city and in the Black Country is probably one of the most progressive in the country as a whole. The fact that it has taken a proactive role in promoting fluoridation indicates that it is dedicated to the dental health of children. Not only does Birmingham have the advantage of fluoridation; we also have very strong dentistry provision and a very strong public health dentistry service. I do not accept the argument advanced by the noble Baroness.
On the issue of consultation, the noble Lord, Lord Stoddart, and the noble Baroness, Lady Miller, are right to stress that consultation is very important. But we have heard from my noble friend that affirmative regulations will be laid as regards the detail of that consultation.
As to the question of whether local authorities or the NHS should be responsible for consultation, the NHS is the public health authority in this country. If local government had a broad responsibility for public health, I could understand the point that the noble Baroness makes. But it is the health service that has responsibility for promoting and improving the general health of the population locally. Surely it follows that it should be the National Health Service itself which conducts that public consultation.
It is not as though the NHS is without experience in conducting consultation. It does so time and again on the major reconfiguration of services and on restructuring. It has a long history of consultation. It is subject to judicial review if it gets it wrong. I really do not think it would help if, on this important public health measure, we suddenly said that we do not have faith in the NHS to conduct public consultation properly and that we should hand it over to local government. I believe that in this area we should trust the NHS to do a proper job.
The areas that I know best, in the north-west of England, are the very areas that are not fluoridated and where there is without doubt concern, particularly in regard to child health and child dental health. These issues have not been improved by dietary interventions or even through interventions in terms of better maternal health. Therefore, one looks at long-standing issues such as the high expense to the National Health Service of children with dental decay. Those who are under five need a general anaesthetic before they can have teeth taken out. In Manchester, 1,500 such operations are carried out every year, and there is a waiting list of about 500. At the Liverpool dental hospital, the figure for general anaesthetics for children under five is 1,300. The cost is enormous. We could be doing many more operations or carrying out much better interventions if we did not have this expense.
We are dealing with a specific amendment in this instance. The three amendments tabled by the noble Baroness, Lady Miller, are specific to questions of funding and public consultation. I suspect that the noble Lord is making his speech in response to Amendment No. 1 and the general debate on the principle of fluoridation.
I beg the pardon of the House. I was coming to consultation. Patients' forums, and the neighbourhood forums that we have set up in the North West function as a useful way of consulting people. There is no doubt that that is a helpful approach. There are also forums looking specifically at sections of the population such as ethnic minority families where the incidence of dental decay is high—particularly among Chinese children.
I shall seek to deal with the amendment on public consultation. Part of the confusion on this amendment arises because it is not an amendment to the Bill but, clearly, that is what it should be. I say that with the assurance of someone who, in 1985, introduced the Water (Fluoridation) Bill. I and my Minister for Health at the time, Ken Clarke, took it through all its stages. I am not sure whether the noble Lord, Lord Stoddart, was one of the opponents of that legislation. He signals that he was. I thought that I had remembered correctly—I still have the scars. I believe that possibly a record was reached on the length of speeches made then.
It is a little difficult to deal with the issue of public consultation before we have dealt with the principle of what we are doing, and therefore I believe that the whole Committee is in some difficulty on that. Although I understand what has happened, frankly I consider it to be a curious way to get the legislation through. I am not at all sure that it will prove to be the best way because one reason we are dealing with this legislation is that we say that the old legislation did not work. But we shall see.
I agree emphatically with the noble Lord, Lord Hunt, about the issue of public consultation. We are both Birmingham Members, or part of the Birmingham Mafia, so perhaps that is not totally surprising. However, I am not at all sure that I want local authorities—certainly some of the local authorities that I lived under—to organise the public consultation on this matter. We are dealing with health authorities. They are the public health authorities. They have the expertise; they are aware of the arguments; they are able to give the facts; and, above all, they are able to give the advice. People look to health authorities for that expertise and advice.
I should much prefer the public consultation to be organised by public health authorities and not by local authorities. Local authorities have quite enough to do. Personally, I am fairly sceptical as to whether they do it fantastically well, and I certainly do not want to place another extraneous job and duty upon them. I believe that that is what health authorities are there to do and I back the Bill so far as concerns that matter.
I support the noble Baroness, Lady Miller, in her first amendment—Amendment No. 8. Perhaps the noble Lords, Lord Hunt and Lord Newton—I am sorry; the noble Lord, Lord Fowler—will not mind my saying that, along with that of the Birmingham Mafia, my water has also been fluoridated for 40 years. I live in Worcestershire and am in the Severn Trent area. I totally oppose fluoridation, but I shall come to that issue later.
If we are to have fluoridation, we need to have informed consent. In order to inform people properly, the necessary funding must be available. The noble Lord, Lord Stoddart, made clear the provisions that are required and I heartily endorse what he said. Like other noble Lords, I am sorry that this amendment has been tabled in this way and that our debate on it is so truncated. It is a very bad way to proceed, especially when the Minister and all his advisers know what a contentious subject this is.
Although I oppose Amendment No. 1 for reasons that I shall come to before very long, I believe that these Liberal Democrat amendments will make a bad amendment slightly less bad. I still doubt that a majority has any moral right to compel a minority to ingest a contentious compound through its drinking water. But at least the amendments would ensure that fluoridation was not being imposed against the will of that majority. Frankly, I do not trust the NHS to do a proper job of reflecting public opinion.
I strongly support the idea of the National Health Service carrying out the consultation, and I strongly oppose Amendment No. 9, which suggests that local authorities should do it. Many points have been raised, but one that has not been made is that this issue would become a manifesto commitment for local authorities. We could end up with fluoride being put in and taken out of water time and again, and the situation would be hopeless for both the local authorities and the public.
Perhaps I may add a small word on this matter, and I apologise for delaying the Committee further. The issue is not how one consults the public. It is very easy to bombard the public with information and it is equally easy to bombard them with disinformation, if I may say so. The real issue is how one determines the view of the public. I believe that that point was made by the noble Lord, Lord Stoddart.
I want to say only that probably the biggest public consultation of all—I believe I can say this in this House where we are not elected—is a general election. From observation over many years, I believe we would all say that general elections occasionally throw up the most extraordinary results. But at least it is a public determination and one knows exactly the view of the public. It may be extraordinary but one knows their view. If that type of process does not take place, there will always be an element of doubt.
Perhaps I may ask the noble Baroness a detailed question on her Amendment No. 9. Does she envisage that a local authority would have the discretion to decline a request made to it by a strategic health authority? It seems to me that that is the way the amendment reads. The request can be made but there is nothing in the amendment to say that the local authority must comply with the request.
Before the noble Baroness responds, perhaps I may add one or two questions. I agree with all noble Lords who have said that we have got into an awful mess by dealing with the issue in this manner. However, I have a specific question about Amendment No. 10, which seeks to insert the words,
"if public opinion is clearly in favour of such an addition".
Is the noble Baroness referring to a majority of the public—that is, more than 50 per cent—or does she have in mind a particular way of judging public opinion? Does she envisage that a target must be reached before public opinion cuts in? That is a matter to which I shall refer later.
I support the noble Baroness's Amendment No. 8 because I believe that whoever undertakes the consultation—whether it is a health authority, a local authority or whoever—will definitely need to have sufficient funding. Perhaps I may also ask the noble Baroness the Minister—indeed, I shall ask the noble Lord when we speak to Amendment No. 1—whether the Government have considered having a referendum, involving one person/one vote. How far will this matter go? If it is of help to noble Lords, my local newspaper, the Leicester Mercury, has run a nightly article throughout this week. According to the responses that it has received from its readers, 94 out of 100 are opposed to the inclusion of fluoride in water. Therefore, one should not assume that everyone supports fluoridation.
I shall give other figures later when we discuss the detail of this issue. However, I want to know at what level the consultation will cut in, what percentage will be involved and whether the exercise will obtain just a general view, as the noble Baroness inferred during the GM debate. If it is to be based on the GM issue, then I should be very anxious on my own account.
I support the noble Baroness's amendment because the health authority would already have made up its mind. It would promote the question. At least the local authority would be impartial. A local authority is also democratically elected and the people know who they are dealing with. My experience of health authorities is that, when they hold consultations, they usually do so at a time of day when people cannot be present and, invariably, no one turns up for the consultation. Therefore, I am opposed to fluoridation and I hope to speak to Amendment No. 1. But certainly I believe that this amendment would improve that amendment a little if it were eventually agreed to.
I hope that I shall be able to clarify some of the issues for noble Lords on some of these amendments. With regard to Amendment No. 8—the money item—I appreciate the noble Baroness's concern to see that consultations are adequately funded. However, I believe that she may accept that it would be contrary to the general policy on funding in the NHS to try to ring-fence elements of an SHA's budget. Certainly the Government are committed to shifting the balance of power in the NHS downwards to SHAs and PCTs. We feel that they must be free to determine their own spending priorities.
Indeed, this provision in relation to fluoridation concerns local choice and local priorities. Nevertheless, in the regulations we shall set down the procedures that the SHA has to follow in undertaking consultation. As I said earlier—I do not wish to detain the Committee by going through what I said in the earlier part of my remarks on Amendment No. 1—the regulations will deal with the dissemination of the proposals to fluoridate. We will use the press, radio, TV and leaflet drops. There will be consultation involving public meetings, discussions on local TV and radio, help lines, websites, and there will be an objective means of measuring the public opinion which could have a basket of indicators. I shall say a little more on that. I do not believe, in the context of the regulations, that there is any chance of strategic health authorities doing that in a hole-in-the-corner manner.
While I recognise the pressures on funding in the NHS, dare I remind noble Lords that over the years 2003–04 to 2007–08 expenditure on the NHS will increase on average by 7.4 per cent a year over and above inflation. That is a total increase over the period of 43 per cent in real terms. By 2007–08 we shall be allocating £84 billion to the NHS and near £2 billion of that sum will be spent on dentistry. So strategic health authorities with high levels of dental decay in their population are likely to be attracted by long-term savings in dental treatment offered by fluoridation. There are some incentives for them to find the money for the consultation processes.
On Amendment No. 9, we certainly want local authorities to play a full part in the consultation, but essentially this is a public health matter, as many noble Lords have said. We believe that the matter has to be owned by the health service. That is not to under-estimate the contributions that local authorities are capable of making at all stages of the consultation process. It would be surprising if something like this consultation was taking place in a particular local authority area and it stayed shtoom and did not involve itself in the process of consultation at all. As I have said, in the regulations we shall give the details of how they could help publicise the proposals, organise public meetings and help with the measurement of public opinion. There would be nothing to stop local authorities being fully engaged in that process.
We intend that the regulations on consultation will require strategic health authorities to seek the views of the local authority. That will ensure that local authorities in effect have a statutory role in the consultation process. I hope that in the light of that assurance, and the kind of assurances that I have given, the—
I have listened closely to what the Minister has said, but I cannot be assured by him saying that the regulations will include proper methods of consulting the general public. Nothing in his speech tells the Committee that all the information will be impartial and that there will be opportunities for opponents to put their point of view with the aid of public money and public facilities. He has not answered my questions as to whether there will be referendums and, if not, why not, and if there are to be referendums who will supervise them. A whole range of questions need to be answered. If they cannot be answered at this stage, I sincerely hope that they will be answered when the Bill goes to the other place. Otherwise, the whole business will be entirely unsatisfactory and the public will be completely and utterly conned by the consultation process.
I believe that if the noble Lord reads Hansard tomorrow he will see that I spelt out in some detail what kind of territory will be covered in the regulations. He may recall—perhaps he missed this point in my opening remarks—that I said that the regulations would be subject to the affirmative resolution procedure. So there will be plenty of time for the noble Lord to put his points on this issue when the regulations are produced—
I am much obliged to the noble Lord for giving way. I have heard exactly what he said, and I am pleased that the regulations will come forward by affirmative resolution. But he must know that even if there is an affirmative resolution, it cannot be amended by either House. Therefore, the regulations will be put before us for acceptance or rejection, but not for amendment. I am trying to ensure that the Government are aware that there are strong feelings about what the regulations should contain and that the public should be properly and fairly consulted before any decision is taken.
I am not sure what more I can say to reassure the noble Lord on the processes to be carried out in this area. I am not sure that I do much service to the Committee by continuing along this path.
Perhaps I may move to Amendment No. 10. Our reaction to the amendment is that we have much sympathy with the intention behind it, that no strategic health authority will be permitted to fluoridate, unless the local community is in favour. That will be central to the regulations that I said we shall draw up on consultation and assessing public opinion under Section 89.
On the obvious concerns of the noble Baroness, we shall also consider whether the need for an SHA to show that the population is in favour should be included on the face of the Bill. We recognise the importance of the methods used in assessing public opinion. I have tried to emphasise that. As I said earlier, we shall consult widely on this matter, on the best basis of carrying out the consultation and on the best way to measure public opinion. We can use issues like well structured public opinion surveys; we can talk to the Electoral Reform Society, the Local Government Association and the professional bodies concerned with public health and dentistry. We are resolved to combat social exclusion by means of reaching people who do not normally contribute to opinion surveys.
It is worth bearing in mind again that the people who are suffering from dental decay most severely are people in lower socio-economic groups. In the public consultation and public determination process, we need to work towards a kind of basket of indicators that is likely to provide us with a good picture of people's opinions across the socio-economic groups. I emphasise again that we shall use leaflet drops, telephone help lines, and all the wonders of information technology to help us to tap in to people's opinions. I hope that in the light of that the noble Baroness will be willing to reconsider moving her amendment.
Before the noble Lord sits down, perhaps I could say that he has not addressed the point that was made by the noble Lord, Lord Stoddart. Opinions are formed by opinion formers. We have all been bombarded by letters from a huge number of health authorities and the Minister said that he had not heard any opposition to fluoridation. I have. Perhaps people think that I may be more receptive to some opposition. We have to hear both sides of the story. If the health service is promoting its attitude to fluoridation, the other side must be funded to promote its side, so that people can have an even view of the matter on which to make up their minds. Will the Minister kindly address that point?
I am drawing a deep breath. I have already said that there will be public funding through the statutory health authorities for the process of consultation. We have said at length what those processes will be. There will be plenty of opportunity for those who oppose the idea of fluoridating water in a particular area to have their full say in the process. I would be very surprised if the noble Lord, Lord Stoddart, in his area, remained silent while such a process was taking place there.
Perhaps I may take the noble Lord back to the point made by the noble Countess, Lady Mar. If I recall correctly, the Minister said that £2 billion—anyway a large sum—was allocated to the health authorities. That does not mean that money is available to those who might want to put a contrary view. The noble Baroness, Lady Miller of Chilthorne Domer, is trying to make sure that sufficient funding is available so that those with different views can make their cases heard.
Although I have listened carefully to the noble Lord, he has not satisfied me as an individual that the money allocated to the health authorities would be distributed to groups with contrary views. That is where the dilemma lies.
Surely the £2 billion is not actually for the consultation, but is solely for dentistry. Suddenly that figure gets around and is in the same discussion about consultation, so please let us get that off the record.
Let me put the matter beyond doubt: there will not be £2 billion for public consultation. I was saying that by the time we get to 2007–08, something like £2 billion a year will be being spent on dentistry. So those strategic health authorities in which there are high levels of dental decay will have a vested interest in ensuring that there is a proper public debate about this particular issue.
I thank all noble Lords who have spoken in the debate. I am agnostic about fluoridation of water; I am simply concerned with these amendments to ensure that the non-agnostic public, who probably will not take a strong part in the matter, have a proper opportunity to put their views.
I believe that the Government can understand—and have said so on occasions, although I cannot quote when—that a body should not be judge and jury of an issue. If a health authority is a strong promoter of adding fluoride to water, it certainly is not the body to carry out the consultation.
Secondly, I appreciate the noble Earl—
If the noble Baroness adopts that principle, one would reach a situation in which the strategic health authority would not take any decisions at all because she would say that it could not take an objective view. The strategic health authority and the primary care trust are the public health authorities in this country. It is their job to take decisions.
The difference is that informed consent to medical treatment has until now always been the norm. The move away from that makes this a sensitive and different issue and the reason why another body or bodies should conduct the consultation.
I am grateful to the noble Earl, Lord Howe, for pointing out that in Amendment No. 9 it might have been better to use the words "may instruct". I guess that it was my natural liberal tendencies that made me use the word "request" because it sounded more polite. I accept his point that that wording would be stronger.
I cannot better the arguments of those noble Lords who have said that Amendment No. 1 would be a much better amendment were these amendments to be on the face of the Bill. I have listened carefully to the Minister's reply. It may well be that all the points he makes are in regulations. However, that certainly does not get around the judge and jury point. I believe that when we feel something strongly, it should be on the face of the Bill. For that reason, I wish to test the opinion of the Committee.
moved, as an amendment to Amendment No. 1, Amendment No. 9:
Line 147, at end insert "request the elected local authorities within its area to"
I intend to move Amendment No. 9, because I should like to think further about the helpful suggestion from the noble Earl, Lord Howe, that local authorities may be instructed within the area. I shall bring back the amendment on Report. I beg to move.
I would not wish to intrude on the work of the Committee by in any way embracing the role of a Speaker, but in fact the noble Baroness had two options: one would have been not to move the amendment; the other, which she has quite properly chosen, is to have moved it, in which case she is quite right—in those circumstances, leave to withdraw needs to be sought.
As might be anticipated by those who know me, I rise to oppose the amendment. As I said earlier, I have lived in the Severn Trent river authority catchment area since before it started to fluoridate the water supply 40 years ago. My daughter, born 40 years ago, has no dental caries, but my granddaughter, who has never lived in an area where the water supply was fluoridated, has dental fluorosis. Her teeth are affected. I wonder what has happened to her bones and other organs.
I very much appreciate what the noble Baroness has said.
I am not unsympathetic to the plight of children who have dental caries. For five years during the mid-1960s, I worked in the casualty department of my local hospital. Seeing tiny children whose milk teeth had not yet all erupted coming in for total dental clearances was not a pleasant experience. Their screams of terror before the anaesthetic took effect still haunt me. The sight of a mouthful of blackened stumps where there should be shiny white teeth was awful. However, I am not satisfied that mass medication as proposed by the Minister is the right answer.
We have been told that fluoride occurs naturally in some water supplies, and it does. It occurs as a relatively insoluble calcium fluoride. I understand that in most water supplies it occurs at levels of about 0.01 to 0.03 parts per million. At slightly higher levels, it is toxic. For example, in India, where levels of between 0.7 and 13 parts per million occur, large numbers of the population are crippled by skeletal fluorosis by the time they are 40.
The amendment authorises health authorities to request water authorities to put into our water supplies hexafluorosilicic acid, or disodium hexafluorosilicate. That chemical is a waste product of the fertiliser industry. Its environmental toxicity was first recognised in the early 1950s in the US. In Florida, the creation of multiple phosphate plants in the 1940s caused damage to vineyards and citrus groves. A former president of Polk County Cattlemen's Association said:
"Around 1953 we noticed a change in our cattle . . . We watched our cattle become gaunt and starved; their legs became deformed; they lost their teeth; reproduction fell off; and when a cow had a calf, it was affected by this malady or was stillborn".
The following report appeared in a 1969 article in Good Housekeeping:
"The blight had affected cattle too. Some lay in the pasture, barely able to move. Others limped and staggered on swollen legs, or painfully sank down and tried to graze on their knees . . . Ingested day after day, the excessive fluoride had caused tooth and bone disease in cattle, so that they could not tolerate the anguish of standing or walking. Even eating and drinking was an agony. Their ultimate fate was dehydration, starvation and death".
Environmental damage is known to occur at exposures of as low as one part per billion. Here we are talking about putting one part per million in our water supplies. Eventually, environmental legislation forced the agrochemical industries to put scrubbers in their chimneys to strip particulate and recovered compounds from waste gas. Every time I think of scrubbers, I think of the noble Baroness, Lady Trumpington, when I asked her a question many years ago.
The recovered compounds include hexafluorosilicic acid and disodium hexafluorosilicate, which are very toxic compounds.
As recently as 2000, Dr J William Hirzy, senior vice-president of the US Environmental Protection Agency, said of these chemicals:
"If this stuff gets into the air, it's a pollutant; if it gets into the river, it's a pollutant; if it gets into a lake, it's a pollutant; but if it gets into your drinking water system, it's not a pollutant. That's amazing. There's got to be a better way to manage this stuff".
Are we content to be the sink for a waste product of the chemical industry? The safety data sheet for hexafluorosilicic acid, produced by Rhone Poulenc of Ghent, states:
"Do not let this chemical enter the environment . . . Dispose of this product as a hazardous waste. Consult the supplier to see if he will take it back. [It] causes burns. Hazardous reactions may occur on contact with many chemicals".
These compounds are listed as poisons in the Poisons Act 1972.
In 1995, a spokesperson for the Department of the Environment wrote:
"There would appear to be no standard for the discharge of fluoride to the environment . . . but it is regarded as a dangerous substance under the EC Dangerous Substances Directive and as such pollution must be reduced . . . Research is to be carried out to define acceptable limits for fluoride [for discharge to sewer and in treatment processes] in the future, but when such work would be complete and published is indeterminable".
Dental fluorosis is believed to affect an average of 48 per cent of children in fluoridated areas. I believe that that also applies to Birmingham. Since the beginning of the 20th century, fluorosis has been observed in patients suffering hypothyroidism. Do we imagine that the fluoridated water that we ingest leaves its fluoride on our teeth and has no further effect on other parts of our anatomies? About half the fluoride we ingest is accumulated in our bones. They may at one stage get stronger, but then they become brittle. No long-term research has ever been conducted into the systemic effects of long-term exposure to compounds of fluorine. Certainly there has been no attempt by our National Health Service to establish the levels of fluoride in the bodies of people who have lived for many years in fluoridated areas.
As well as being concerned about the effects of long-term exposure of the human population to fluorides, I am concerned about the ethics of mass medication. I am concerned about the effects of watering farm livestock—a milking cow drinks 30 gallons of water per day—with medicated water. I am concerned about the effects of pouring billions of gallons of water into our sewers and watercourses daily, with the resultant contamination of the environment.
We know that we are talking about a very toxic chemical. One part per million sounds a very small amount. However, we must take into account the fact that many people will use toothpaste with added fluorides, that many foods and drugs contain such compounds, and that for those who live in industrial areas, manufacturing processes may result in airborne pollution. Some may be exposed to quantities much higher than would be considered safe for the taking of drugs, which are subject to rigorous tests under clinical conditions. All safety studies on fluoride to date have been conducted using pharmaceutical grade sodium fluoride, not industrial grade silicofluorides.
I could say much more on this matter, but I will not. I rest my case.
Having served with my noble friend for two or three years, I know perfectly well that she can speak for herself, and she most certainly will. The noble Countess confused me with the noble Lord, Lord Newton, and I would like to tell the Countess of Margate that I in no way regard that as an insult—
I thank the noble Lord for giving way. I apologise profoundly for mistaking his name. Perhaps the noble Baroness, Lady Trumpington, remembers a question about dioxin, which she answered when she was on the Front Bench on this side, and that she made a big joke when I asked her about scrubbers in chimneys.
I really will allow my noble friend to reply to that. I am afraid that the joke is entirely beyond me, and I suspect beyond my noble friend as well.
I intervene to return for a few minutes to the question of fluoridation because I have a slight feeling that we have been here before. In 1985 we introduced the Water Fluoridation Bill, which my noble friend handled so ably in the House of Lords—
I would like that to be put on record as well. I should perhaps have done it earlier. My noble friend will remember that that Bill was very fiercely debated, and I know that some opponents of it are still in the House.
We should perhaps recall why we introduced that Bill. It came directly from the judgment of Lord Jauncey in the Strathclyde case, which ruled that in Scotland fluoridation was ultra vires. The judgment did not challenge the safety of fluoridation, but rather the power of authorities to be able to use it. As a result, fluoridation in Scotland was ended. It also cast doubt on the position elsewhere in the United Kingdom. We sought to clarify the matter and effectively revert to the position as we had always thought it to be. We gave health authorities the power and responsibility to propose fluoridation in their own areas because we felt, and I still feel—the point was made by the noble Lord, Lord Hunt, on a previous amendment—that they were the most competent bodies to determine local health needs. It seems to me that that is what health authorities are about. Because some water authorities have challenged that, we are in the position we face today.
The Minister was fairly kind about the attitude of the water companies. My noble friend put their case in the most sympathetic way possible. I wonder whether, with a little more courage, the water authorities might not have been able to do more than they did. Irrespective of where fault lies, I am sure that the Government are now right to put the issue beyond all possible doubt.
The arguments on fluoridation are not remotely new. It was first proposed in the 1930s and introduced in North America in 1945. Two arguments have been made against it. The first is that it challenges the freedom of the individual. There is no doubt that, if fluoridation is carried out in a particular area, there is no choice about the water you drink. The same arguments of liberty were put on issues such as seat belts and crash helmets. There is a balance, and it is for everyone to make up their own mind. In my view, the good to be done outweighs any argument of individual liberty. That is the case here.
The second argument relates to whether fluoridation does good and whether there is any danger in it. On the issue of safety, I do not intend to go into all the arguments. As in the 1980s, I am entirely persuaded by the evidence and views of the Chief Medical Officer, the Chief Dental Officer and the British Dental Association. That is where I stand.
On the good that fluoridation does, perhaps I may refer to the West Midlands where I had a constituency for almost 30 years. The evidence from there seems overwhelming. As in so many other matters, Birmingham leads the country in this respect—at least I have the noble Lord, Lord Hunt, on my side on that issue. Like all Members of the Committee, I have received a number of representations. One letter from the West Midlands was from Dr Nigel Carter, the chief executive of the British Dental Health Foundation. He says that, from his personal experience, having practised on the borders of fluoridated Birmingham and the then non-fluoridated Sandwell at the end of the 1970s, it was possible to tell whether children were from a fluoridated or non-fluoridated area just by the condition of their mouth. While children from Birmingham were virtually decay-free, those from Sandwell often had multiple cavities and suffered many extractions. Dr Carter says that he is pleased to say that, following fluoridation of Sandwell's water in 1987, children in the area have moved from near the bottom of the dental health league to the top 10. That is significant evidence.
Strangely, that evidence was confirmed by the leader of Sandwell Borough Council, who pointed out that Sandwell has some of the most deprived wards in Europe where one would expect children's dental health to be correspondingly poor. Yet, after fluoridation, Sandwell ranks among the best. Again, John Charlton, the chairman of University Hospital Birmingham, says that water supplies in Birmingham have been fluoridated for almost 40 years and, as a result, dental health in Birmingham is among the best in the country. The letters go on and on.
My favourite letter is from one of my oldest political opponents in Birmingham, Sir Richard Knowles—Dick Knowles—whom the noble Lord, Lord Hunt, will know. He says that the ability of the upper House to straighten out legislation has been the main reason why, in a lifetime of politics, he supports a bicameral system. I hope that the Government Whips are listening to that support for our system. He says that 86 years ago he was born on a farm where natural fluoride existed in the local water, which is one of the reasons that his own teeth are so good. According to Sir Richard Knowles, the teeth of children in Birmingham are in better fettle than anywhere else in our country.
With that evidence of success, it seems that the challenge is to go further. Surely, dental decay is a disease that is largely preventable. But, despite substantial improvements in dental health over the past 30 years, there remain many areas of England where there are considerable numbers of children with the disease, which can cause pain and infection. That is the challenge that the Department of Health and this country face. There is an overwhelming case for more action. I support wholeheartedly the amendment.
Several issues must be examined in this debate. The main objections in principle are ethical and scientific. The noble Lord, Lord Fowler, accurately described the situation concerning children in Birmingham. I have no doubt that the condition of their teeth has improved; I do not contest that. However, there are other ways of securing good teeth; for example, what was the effect of the withdrawal of school milk on the condition of children's teeth?
We are talking about the risk to adults. For example, what effect does drinking fluoridated water have on older people whose bones are weak? What is the effect of using fluoridated water in washing machines and dishwashers? The noble Countess, Lady Mar, asked about farm animals. Those questions must be answered to the satisfaction of Members of the Committee and the community.
The ethical dimension is one of civil liberties, as mentioned earlier. There is a principle of informed consent to medical treatment as an individual. The Patient's Charter restates the patient's right to give or withhold consent to treatment, as does the EU Convention on Human Rights and Biomedicine 1997.
To some extent, the scientific arguments have been put. I do not want to speak for too long, as many Members of the Committee wish to participate. Already in this debate the York committee's report has been prayed in aid of fluoridation. I agree with the noble Lord, Lord Fowler, about health authorities, medical officers and others who have long advocated fluoridation. However, I am concerned that, as a result of the York scientific committee on the subject, the chairman, Professor Trevor Sheldon, has considerable worries about how the York report has been interpreted.
I shall quote from an open letter from Professor Sheldon, a scientist of the highest integrity, to interested individuals and scientific bodies about his concerns over how his research was interpreted. He says:
"In my capacity of 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, 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. 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%, is far from 'massive'.
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. The review did not show water 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. There was little evidence to show that water fluoridation has reduced social inequalities in dental health".
We can argue about that one way or the other, because I am not entirely sure that I agree. It continues:
"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. 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. 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".
Professor Sheldon was the head of the research team conducting the York University research. I am not saying that he is totally right, but I would like the Minister to address those points in his reply and tell us whether what Professor Sheldon says is important to the debate that we are having on this final form of the legislation.
Before the noble Lord sits down, I would like to say that, although he speaks from the Front Bench for this party, he is not speaking on behalf of the party. Many of us would certainly not go along the line that he is taking. I have always taken the view that if we put chlorine atoms into the water, fluorine atoms will not make much difference, but that is a fairly unscientific scientific remark. I dissent from my noble friend Lord Livsey of Talgarth on this matter and will vote for the Government.
That changes the whole picture. Having taken this Bill through this House originally, anything I have to say is superfluous. I hope the Committee listened carefully to my ex-boss, with whom I did not always agree, but he made a magnificent speech on this occasion. Typical, typical Liberal, sitting on the fence as usual. I wonder whether the noble Lord, Lord Livsey of Talgarth, carefully read the whole of the proceedings for the last time the fluoridation of water Bill was in this House. If he had, he would have found the answers to many of his questions. The noble Countess, Lady Mar, should return to the goat's cheese again.
Time and again, the Prime Minister has declared passionately that he wants Britain to be at the heart of Europe. If Mr Blair is really determined that Britain should be at the heart of Europe, the very first thing he should do is to order this amendment to be torn up and thrown into the dustbin. Of the 18 countries in western Europe, some of them within the European Union and some outside it, no fewer than 15 have totally rejected fluoridation. Some of those had experimented with fluoridation only to abandon it when they concluded that the disadvantages and dangers outweighed any possible benefits. That counters the assertion made by the noble Lord, Lord Fowler, that we have been here before, because when he introduced fluoridation, rather more western European countries practised it. Time has moved on and many of them have changed their minds.
Indeed, exactly three months ago today, on 9th April 2003, the Swiss canton of Basel-Stadt—the home city of the splendid Wimbledon men's singles champion—abandoned fluoridation after 41 years. Among other reasons for the decision was that there was no evidence that the incidence of caries in the area had been reduced.
I shall read to the Committee a list of countries that have rejected fluoridation: Austria, Belgium, the Czech Republic, Denmark, Finland, France, Germany, Iceland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Sweden and Switzerland. Only three countries out of the 18 still practise fluoridation—this country, in part, the Republic of Ireland, although not Northern Ireland, and, to a minor extent, Spain.
The total population of countries where some fluoridation takes place is 98.5 million. The total population of countries and regions that shun fluoridation is 286 million. In the latter figure I have included Northern Ireland, but excluded La France d'outre Mer, which, although technically part of France and the EU, is in reality not part of western Europe.
If we assume that the ratio of doctors, dentists and other medical professionals to the population as a whole is roughly the same throughout western Europe, it follows that there are approximately three times as many medical experts living in non-fluoridating countries as in partly fluoridating ones. Unless we believe that, quite unlike their British counterparts, continental medical experts are timid and frightened of raising their heads above the parapet, which is an unlikely scenario, it figures that a minimum of 75 per cent of medical experts throughout western Europe are at least hostile to fluoridation or, at best, doubtful that its alleged benefits outweigh its disadvantages and possible dangers.
Sweden, for example, has been a country greatly admired by members of the British Labour Party over past decades. Sweden is a highly efficient, highly safety-conscious country, yet it outlaws fluoridation. It is a criminal offence to add fluoride to the water supply in Sweden. I invite noble Lords on the Government Benches and, indeed, some on the Opposition Benches to ponder that.
I have not even started on the libertarian objections. For the time being, I shall not do so, because I know from experience that libertarian arguments cut little ice with many on the Government Benches and quite a few on the Opposition Benches. However, the weight of expert medical and environmental opinion throughout western Europe must surely give noble Lords food for thought.
I declare an interest, because I have not got a single natural tooth in my head. That has nothing to do with fluoride one way or the other, but to do with reading books while riding bicycles.
Having declared that I have no interest in that way, I must say that I am totally on the side of the noble Countess, Lady Mar, which I usually am when she speaks in your Lordships' House. I am also speaking on behalf of the Green Party. We think that mass medication is wrong and that mass medication of poisons is especially wrong. The jury throughout the world is out on the medical effects of fluoridation, and this is by no means as open and shut a case as the pressure groups that have been bombarding us would have your Lordships believe. This is a bad amendment and we should reject it.
I shall refer briefly to a couple of points before moving on to consider the scientific evidence for fluoridation. I apologise, because there was something that I forgot to say earlier. I would like to ask the Minister, who may write to me afterwards if he wishes, what provision is made for any areas which, after some years of fluoridation, wish to change their minds and stop existing schemes. If that is already provided for and I have misread it, I can leave it, but I was going to make the point that it is already an issue up in the North West. I hope that there are mechanisms for expressing and giving effect to change in local opinion.
I would like to preface my remarks with just a repeat from our earlier debate. I stress once again that it is a mistake to believe, sadly, that the dental lobby or the Government or health authorities give always impartial information in this controversy. Some of that will become apparent as I speak.
I have probably put in as much time on the recent scientific arguments over fluoridation as anyone. I asked the Questions in your Lordships' House which led, when I was supported by Sir Iain Chalmers of the UK Cochrane Centre (for evidence-based medicine), to the setting up of the systematic scientific review of the evidence world-wide at the University of York, which reported in 2000 and on whose advisory panel I sat for nearly a year. Since then I have been involved, unfortunately, in numerous debates arising from the spin that has been put on that report. This has kept me in close contact with the senior independent scientists who took part in the review process—and by independent I mean not affiliated, professionally, financially or emotionally, to the pro- or anti-fluoridation lobbies. Always I have taken care to write or say nothing that they would consider scientifically unsound. I say all this, my Lords, because I recognise how difficult it is to be heard to criticise the big and respected organisations such as the British Dental and Medical Associations. But criticise them I must.
First, however, a word about scientific reviews. The problem with the traditional review or inquiry, and there have been many on fluoridation, is that you do not always know what studies the chosen "experts" have selected to look at, or why, how reliable those studies are, what might have been omitted, how much they have relied on other people's views, and indeed what the affiliations or preconceptions of those "experts" might be.
In contrast there is the much rarer and more thorough systematic scientific review, which to their credit the Government set up in the case of fluoridation. In this, a specialist review team searches the world literature, relying only on primary studies and not on the past opinions of others, according to established criteria, which ensures as far as possible that nothing is missed, and that everything relevant is assessed and graded for reliability. With the York review this was all conducted publicly on a website which invited contributions from around the world; it was openly peer-reviewed; and the whole exercise was overseen by a panel which, as I said, was carefully chosen to represent opponents as well as proponents of fluoridation, which ensured, as I can testify, that biases were recognised and allowed for.
I make this point to illustrate the difference between what is known as "eminence-based" medicine and "evidence-based" medicine. I am disappointed that the Chief Medical and Dental Officers' briefing paper did not bring out this distinction as a guide to understanding where the most reliable evidence is to be found. Of course traditional reviews have their uses; but they are open to inconsistency, selective presentation, and influence from the prevailing scientific culture, in a way that systematic reviews are not. And thus it is quite possible for a systematic review to produce an answer that contradicts what previous less rigorous reviews reported.
This—this is an answer to the point that the noble Lord, Lord Fowler, made about there being nothing new since 1985—is what has happened with York, though you would not guess it from the briefings we have all received from the big campaigning organisations. York, for all the lip service paid to it, was a considerable shock to the dental and medical communities who have promoted fluoridation so long and loud, and it has been misquoted, misrepresented and downplayed ever since. I was particularly pleased to hear the quotation used by the noble Lord, Lord Livsey of Talgarth. He might have added that, in a later letter, Trevor Sheldon included the British Medical Association on the list of miscreants who had spun the report. Damage limitation has been the name of the game, as also—here is an analogy—with hormone replacement therapy which was recently shown by high-quality studies to be harmful to the heart, not protective as everyone thought on the basis of previous inferior research which, interestingly, the senior reviewer at York tells me was actually of better quality than we have for fluoride. That, my Lords, should give pause for thought.
York could not find one good-quality study in 50 years of the world literature. This meant, and it said so clearly, that it could conclude nothing with confidence: not effectiveness, not safety, not harm, and certainly not the hoped-for reduction in inequalities in dental health for which the evidence was weakest of all. It found varying degrees of probability across the questions it addressed, depending on the quantity and quality of the evidence: the less reliable, the more likely the conclusion could be wrong—an obvious point that has eluded many commentators. My distinguished colleagues from York assure me that no prescription drug would get a licence on evidence like this. Most probable—York was careful here to say "suggests", not "concludes" or "confirms" which is how pro-fluoride groups have changed the wording—is a reduction in caries, which might be of the order of 15 per cent (dentists used to claim 50 per cent or more). York stressed that it would need better-quality studies to be confident of this finding. An unexpectedly high level of dental fluorosis, or mottling, also looks probable.
What about safety? We read in our briefings "Water fluoridation is safe"; "there is no evidence that fluoride causes bone disease, cancer, birth defects". I refer your Lordships to Section 8 of the York report, on page 48: 14 analyses from studies found an association with bone fracture. In Section 9.6, page 58, nine analyses found an association with cancer. In Section 10, pages 59-61, there are similar associations with Down's syndrome, all-cause mortality (including infant mortality), and mental functioning. No evidence, my Lords? No evidence?
Let me complete the picture. These associations were weak, because the few studies were of poor quality. And there were a roughly equal number of poor studies that found no association. So the picture is mixed: there is "no clear association", in York's words. But this is not the same as "no evidence": a phrase too often used recklessly, not least by the President of the Faculty of Public Health and others in a letter in yesterday's Times, which some of your Lordships may have seen. The implications for policy and research are quite different. This is why York recommended further research in three areas of possible harm (not two, as the CMO and CDO's paper wrongly states; their briefing is not a sound guide to the research needs that have been identified).
These are not quibbles. To those who would dismiss them I would say, "Do you want your policy to be based on good science, or not?" Because if you do, then you still have work to do. If you do not, you have no business promoting it to the public. To claim water fluoridation is safe is as scientifically indefensible as to claim that it causes hip fracture or excess mortality. At this stage of the evidence, we simply do not know.
I ought to quickly mention the Medical Research Council, which was asked to make research recommendations in the wake of York. Unfortunately, among much helpful work, it muddied the water by second-guessing some of the findings, without York's care or rigour, and came up with the erroneous statement that York had "confirmed" fluoridation's effectiveness, which has been much quoted as an MRC finding. I have, in fact, placed a detailed critique of this report, endorsed by the senior reviewer from York, and of another recent report by an all-party group, in your Lordships' Library.
It has been a learning experience for me, my Lords, having come in a few years ago as an outsider to the scientific process, to observe how even the most eminent participants find it hard to abandon old beliefs when they are shown to be unsupported, and how unvalidated comparisons in dental health between the fluoridated West Midlands and other areas continue to be advertised. The noble Lord, Lord Fowler, was, unfortunately, as guilty of that as many other people. They are not, I am afraid, when it comes to such issues, good science and nor are league tables. The other side, if you want to play that game, can trade you league table for league table. I will not start now. It is the good studies that are needed, not the uncontrolled comparisons. If there had been any good science supporting that, it would have been found by the York review: it was not, and it did not even meet its admission criteria.
Without good science, I cannot account for it. Observers were not blinded to the status of the people whom they looked at, so that they knew whether they were fluoridated or not when assessing the decay. There is a lot of variation in assessment of decay, well described in the dental literature. There was no controlling for sugar consumption in different areas. The science in that area was a mess. That is why one cannot make firm assumptions however clear the observations seem to be to people on the ground. I am sorry, but in this instance one has a right to ask for good science, as I said before.
I was going to go on to say that in many ways the question of abandoning beliefs is no different for many of us. In answer to what the noble Lord said, it is the enthusiasm, to some extent, I could say, of the crystal healers who say, "Who needs proper science? We can see that it works and we know that it works so we do not need to do any proper studies". In addition to this, some pretty disgraceful things have been written by people in positions of power and responsibility who should know better. I just want to mention a couple because some of them will be things that your Lordships have seen. In May Sir Iain Chalmers, Professor Sheldon and I had a letter published in The Sunday Times in which we made some of the points from the York report that I have made this afternoon. Alongside our letter was one from a representative of the British Medical Association supporting fluoridation. Her opening sentence read:
"Every major independent and government expert committee . . . has concluded that water fluoridation is one of the most effective ways of reducing tooth decay".
Since this is demonstrably untrue in the case of the largest and best, York, and the most recent, the Medical Research Council—I know these two reports well enough—I challenged her three times to substantiate this from the reports themselves, or else publicly retract a statement which will have misled thousands of readers. In three replies she simply defended the BMA's support for fluoridation; only in her final letter did she address my point with the words that her Association,
"interprets the York report as further evidence that water fluoridation . . . [etc. etc.]"— a very different matter from what she had publicly claimed. She gave her position, by the way, as Head of Science and Ethics.
I cite this, my Lords, as an example that can stand proxy for much that has been said and written after York: reckless, and in my view an abuse of a privileged position. The main offences have been lack of scientific rigour and selective presentation of evidence. What you are not told in briefings is often just as important as what you are. Other examples have come through the post recently, notably a briefing yesterday—I believe one of your Lordships quoted this—from the Chief Executive of something called the International Dental Health Foundation, who has clearly never read the York report but has convinced himself that it "totally refuted" any adverse health claims. No wonder some local communities vote for fluoridation when fed material like this by people with degrees after their names.
I wish there were time to dissect the BMA's current parliamentary briefing, which is one of the most scientifically disreputable documents I have seen on the subject. But there is not. Nor, alas, is there time to go into the other elements of the fluoridation controversy—which other noble Lords have covered—which are no less important than the science. I would simply, as a way towards finishing my remarks, invite your Lordships' attention to one short paragraph on the second page where the BMA, drawing a parallel with the iron and calcium that doctors give to children who are deficient, says:
"Fluoride as a deficiency should be treated no differently".
This is about the only part of the briefing I agree with. Leaving aside that fluoride deficiency is not recognised by the Department of Health as a condition, fluoride could indeed be given like iron or calcium: tailored to individual need, in a controlled dose, for a limited period, monitored, always respecting the patient's right to refuse treatment. That is how medicines and supplements are given. This would indeed be the way to give fluoride.
But consider fluoridation, my Lords. It is given indiscriminately—forget the notion of "targeting", which is simply not possible via the mains water supplies (Czechoslovakia and Switzerland stopped fluoridating partly because over 99 per cent of fluoridated water misses its "targets")—to populations many of whom do not want it and cannot benefit from it, without the normal procedures of individual informed consent, which is a hallowed principle, as we heard, of medical ethics enshrined both in the Patient's Charter and the European Biomedicine Convention, without any medical licensing procedures—that is an odd area—by an uncontrolled dose (you get however much you drink or cook with), and for a lifetime. It is the most peculiar medical treatment of our times—which is perhaps why few countries practise it—one which common sense and caution suggest would need the very highest standards of evidence for safety and efficacy.
If proponents want to promote it on evidence which is substantially less good than for a drug prescribed one-to-one by a doctor who knows your history, and in the full knowledge that the two most recent scientific reports have highlighted the need for more research because we do not know enough about its effects, then this is enthusiasm run wild. Fluoride is already given to over 5 million people, which on the most recent figures is probably more than are taking any other drug. For the sake of the further millions who may be at risk from this measure, and on grounds both of medical ethics and good science, I urge your Lordships to reject an amendment which, given the unshakeable conviction of one party to this debate, is likely to bring this situation much nearer.
First, I express an interest as an ex-physician with a scientific bent—in case it is unclear where I am coming from with my comments. We have all been inundated with a large number of letters of support for fluoridation. Personally, I have not had any letters against. As has been suggested, the weight of letters alone is hardly a reason for agreeing. But in this case I find myself in the unusual position of agreeing with the majority.
There is not a great deal that is new that is not already in much of the literature which most noble Lords received. I believe that the evidence for benefit seems strong. I, too, now have had the opportunity to read the York study, largely after being prompted by the noble Earl, Lord Baldwin. I am rather more reassured than he is, having read it fairly quickly but, I think, thoroughly. There does not seem any doubt that areas of the country where fluoride has been introduced have, by and large, reduced the incidence of caries. Where fluoride has been withdrawn—as it has been in one or two places—the incidence has risen.
We may argue—certainly the York report argues—that the evidence varies from place to place and that some evidence is not terribly strong. But all the evidence points in the same direction; it all seems to say the same thing. On page 43—
My Lords, perhaps I may correct the noble Lord. While the probabilities are as he said, in fact, the range included a possible disbenefit. They did not all point in that direction. The fact that they were all open to possible bias does not help the case in adding studies to it. I hope that the noble Lord noted the word "suggests" and not "concludes". I go with him; it looks a probability. But the question is: is a probability of that degree enough? Perhaps we differ.
My Lords, there have been a very large number of studies, most of which were discarded in the York study because they did not meet certain criteria of reasonable evidence. On page 14 of the report, there is a series of results from about 12 studies, all of which show the same thing—that is, there is benefit. Presumably, those were selected because they seemed to be relatively unbiased.
One of the problems is that it will not be possible to do a gold standard double blind trial in this type of situation where large populations are involved. We cannot get that. We may obtain increasing amounts of studies which lend weight to the proposal; I believe that we have a rather large number in that direction.
I should touch on one aspect which has not been mentioned. Children with caries often require a general anaesthetic for treatment. While general anaesthetic for children is fairly safe, there are clearly determined risks. Every so often one reads of a disaster from dental anaesthesia. So preventing even the rare occurrences alone seems a valuable, worthwhile aim. There is also some evidence—not strong; certainly not enough to produce it as strong evidence—suggesting that chronic mild infection in the mouth predisposes to chronic ill health. For example, it may predispose to heart attacks. The evidence is not strong but there are hints and people are looking at chronic infection in the mouth. A healthy mouth is worth while, provided that fluoridation itself does not cause commensurate harm, as the noble Earl suggested. Again, however, all the evidence favours no measurable risks.
I went through the York report looking for the evidence. Perhaps I may quote some statements from the report:
"Using a qualitative method of analysis, there is no clear association of hip fracture with water fluoridation . . . A meta-regression of bone structure studies also found no association with water fluoridation . . . There were 26 studies of the association of water fluoridation and cancer".
Eighteen of these were thought to produce rather poor evidence and were not counted, but eight provided very reasonable evidence. The report continues:
"There is no clear association between water fluoridation and overall cancer incidence and mortality. This was also true for osteosarcoma and bone/joint cancers. Only two studies considered thyroid cancer and neither found a statistically significant association . . . Overall, no clear association between water fluoridation and incidence or mortality of bone cancers, thyroid cancer or all cancers was found".
To my mind, for a study to quote in that way was not bad evidence.
Does the noble Lord agree with my point that no clear association, which is what I said that York had found, is not the same as no evidence, which is what people are saying in our briefings? That is where we go wrong; that is, in the suggestion that there are no studies which suggest it. They go both ways and it cannot be said that there is cancer any more than it can be said that it is safe. I think we are probably at one on that, but it is not the same as saying that there is no evidence.
All the studies quoted did not show evidence of an increased risk. That is all that one can say about them.
The proposal before us does not seek to thrust fluoridation on people by government diktat, but to allow local communities to have access to fluoridation if that is what they agree they want.
I spoke in the debate on the Water (Fluoridation) Act 1985. In all my years in this House, I have never known quite such a bitter issue. Fortunately our debate today has not been so bitter; it has been good natured. I think that the noble Earl, Lord Baldwin, was not present on that occasion, but I have crossed swords many a time with the noble Earl on this issue. Indeed, he was furious when once he sent me a document and I quoted from it. He then wrote to say that I had picked out the only bit that supported fluoride, which of course I had done.
As with all other noble Lords, I shall declare my interest in supporting the argument for the fluoridation of water. For a long time I was a dentist in general practice. In my early days in London the standards of dental health in my part of the city were very low, although they had improved greatly by the time I left practice. However, in those early days, children would come to the surgery, crying in pain. General anaesthesia was the only way to deal with the problem. In his comments earlier, the noble Lord, Lord Chan, mentioned how this is still the situation in the North West.
However, today there is an added problem. Those children who require extractions performed under general anaesthesia no longer can have them in the dentist's surgery. On safety grounds the operations must be performed in hospital. While that is desirable for safety reasons, it means long waiting lists so that children who are in such terrible pain are now waiting much longer to have that pain relieved.
I believe that there is a very strong case here. Fluoridating the water would help the underprivileged and would lessen inequalities. People who come into the dentist's surgery in that state may have never owned a toothbrush or even thought about their teeth. They are totally unaware of what to do until their child wakes up screaming in agony, perhaps with several dental abscesses. To compare conditions in the kind of deprived area I am describing with those in Switzerland, with its high standards in medicine, dentistry and hygiene, is really not to make a valid comparison.
I should like to make just a few points because I have made them so many times over the years that no one wants to hear them again. It is now 18 years since that last major debate in 1985, but it is 39 years since water fluoridation was introduced in Birmingham and, in 1964, in Canberra, Hobart and Townsville in Australia. If there was a serious health risk I believe that a pattern would have shown up. People living in those fluoridated communities would be showing a different health pattern from those not living in a fluoridated area. The one significant difference is the state of their teeth. There is no evidence at all from Sydney, which more recently changed to fluoridated water, that people contract more cancers than those living in Brisbane, now the only unfluoridated capital city in Australia.
There is plenty of evidence, however, to back up what was said about the patient from Sandwell in Birmingham. If a child or young teenager with terrible teeth visits a Sydney dental surgery, the dentist knows that the child has come from the bush where the local water supply has been used, and so has not had the benefit of fluoride. He will know in one minute that that child has not been brought up in an area with fluoridated water.
Yes, but since she made the point about not seeing patterns, in the first place, patterns do not spring out at you. They need to be revealed by careful epidemiological studies: witness smoking and cancer. Secondly, when patterns do emerge—higher infant mortality has emerged there; we have no idea whether there is anything in it—and the pattern is presented to the authorities, as I or my colleagues have done, we are told that fluoride has not been looked at because it is not under suspicion. So you are in a no-win situation.
I cannot accept the argument of the noble Earl. I believe that there have been very detailed studies of health situations in all parts of the world. Australia is very efficient about studying its health trends. If there were differences over 40 years—we are talking here about two full generations of people who have been born and brought up with fluoridation—surely the evidence has lengthened as the years have gone by. It would not be possible to test all those millions of people simply out of interest, but they represent a test in themselves: the fact is that there is no difference in their health patterns from those of others.
I turn to the Strathclyde case mentioned by my noble friend Lord Fowler. Again, it proves the point from a dental perspective. When fluoride was added to the water supply, rates of decay reduced. When it was taken out again, rates of decay went up. We have seen much on the health scares about brittle bones and cancer. Indeed, the noble Earl, Lord Baldwin, has often highlighted them to me. Again, however, the York study does not support them.
It is very important that the right to fluoridation must be established as a statutory obligation. Over the years, the water authorities that I have spoken to have always said that they would not fluoridate unless it was made obligatory because they did not want to face the cost, the difficulties created by people who oppose it or the possibility of litigation, a point raised earlier by my noble friend Lady O'Cathain. So it is important that the amendment should make the point very clearly.
Earlier today I spoke to a Member of Parliament from the Birmingham area. He said that the one thing on which he hoped the Government would give an assurance is that no referendums should be held in areas where the water is already fluoridated. People would be very upset if they thought there could be a risk of losing their fluoride. I noticed that, in opening, the Minister said that this amendment and the regulation would cover only areas which do not currently have fluoridated water. I am seeking his assurance that the amendment would not in any way allow regression in terms of referendums.
Consultation is a different matter, of course. The Minister made the point in his speech that there may be circumstances in which it may be sought to reduce the proportion of fluoride in the water. All those points are covered in his amendment. But as I have said, the one matter that worries me is whether referendums are to be held in areas which currently have fluoridated water. I support the amendment.
I sense—and rather hope—that the debate will soon draw to a close. I shall be extremely brief and concentrate on only one point. Several noble Lords have said or implied that the addition of fluoride to water supplies constitutes "mass medication". In fact, the fluoride used is the chemical salt of a naturally occurring element—fluorine—which is present at a higher level than one part per million in the ground water of some areas of the country, the best known being the area around Hartlepool, with no demonstrable adverse effects on health other than the minor cosmetic effect of dental fluorosis among a small proportion of the population.
Exactly the same applies to the fluoridated areas of the country, particularly Birmingham. This suggests that the effects of artificially and naturally occurring fluoride are similar. But, to satisfy the noble Earl, Lord Baldwin—whom I admire greatly for his stalwart efforts to defend his corner, but he has not convinced me—and people who think like him—
Perhaps I may enlighten the noble Lord. The uncertainty—and there is scientific uncertainty—around precisely that point is being laid to rest by a study which the Medical Research Council has just commissioned to see if naturally and artificially fluoridated water are the same. It is not known—it is accepted that there is doubt—and that study is getting under way.
Perhaps I may make two small points based on information from the field in the north. Up until 1989, children in Huddersfield had the benefit of fluoridated water. As a result, from the dental records it would appear that children as young as three did not have caries. One study showed that three year-olds in Huddersfield had less than half as much tooth decay as children in non-fluoridated but otherwise similar areas such as Dewsbury. As a result of fluoridation, children in Huddersfield had less toothache and less need for a general anaesthetic to have a tooth extracted.
Today, children living in Huddersfield no longer have the benefit of fluoride in the water. As a result, according to dentists, the average number of decayed teeth in children under five is 4.6, a definite increase. That is one piece of evidence from the field.
The other piece of evidence comes from Shropshire and North Stoke, or Staffordshire, again in the north. In Shropshire there is fluoride in the water. In North Stoke there is no fluoride in the water. The number of affected teeth in North Stoke is 2.13 as opposed to one in Shropshire.
Only 10 per cent of England has fluoridated water; so it is not as though it is the whole of the country. My plea is for the Government to give an opportunity to those parts of the country where there is high dental decay to make up their minds about fluoridation because there are definite benefits.
I support the amendment. Noble Lords would expect that of me coming from Sandwell, which has done extremely well under fluoridation. I hope very much that the amendment will be agreed to.
The amendment is necessary to correct a flaw in the existing legislation. It would ensure that water companies are required to fluoridate when asked to do so by health authorities or other health bodies after due consultation. I understand that the amendment has the support of Water UK, the organisation that represents the whole of the UK water industry.
Despite an overall improvement in dental health over the past 30 years, tooth decay remains a significant public health problem in many parts of the UK. In socially deprived areas such as Sandwell, in non-fluoridated communities as many as one in three children under the age of five will have one or more decayed teeth extracted.
Dental decay is also a problem for adults. In 1998, 46 per cent of adults in England had active tooth decay and 6 per cent had six or more decayed or unsound teeth. In both children and adults there are major inequalities, with a far greater problem of decay in the poorer sections of the community. The addition of fluoride into water supplies could dramatically reduce the levels of tooth decay and give children a decent and pain-free start in life.
In spite of the many myths surrounding water fluoridation, it is safe. None of the medical research organisations has found evidence to support claims that fluoride at the level suggested—that is, one part per million—causes cancer, bone disease, kidney disease or birth defects.
It is true that fluoride can be made available via other mechanisms. However, they all require ongoing positive personal action by the individual concerned and, in the case of younger children, by a parent. Some also require action by a dental professional. In other words, to be effective they need people to alter their behaviour and sustain that behavioural change. Therefore such other techniques are not practical as public health measures.
Water fluoridation delivers greater reductions in decay than toothpaste and other techniques and reaches the whole population rather than only those who adhere to a regular cleaning regime using fluoride toothpaste. It is also quite a cheap method. Water fluoridation costs around 50p. per person per year. This compares to a year's supply of toothpaste which costs around £10. So there are important reasons why we should consider water fluoridation as the preferred method of preventing tooth decay on a population basis and improving the health and welfare of poorer communities.
I base my observations on my experience as chair of the education committee and leader of the Metropolitan Borough of Sandwell for the past 24 years. Sandwell's water supplies were fluoridated in 1986. Before then, the dental health record of Sandwell's children was among the worst in the country. Since water fluoridation was introduced in Sandwell, tooth decay rates have declined dramatically. The average number of decayed, missing or filled teeth per five year-old child fell from 2.55 in 1985 to 0.92 in 2001. It is now below the Department of Health target. All this was achieved through the hard work and commitment of John Charlton—to whom the noble Lord, Lord Fowler, referred—and his team and the BDA. My only regret is that water fluoridation was not available when I was young, otherwise I would not have to make my speech with false teeth.
I add my support to the amendment. I wish to make two basic points. First, tooth decay is still a very significant public health problem in many parts of the United Kingdom. Secondly, I am persuaded that water fluoridation in areas of high need will provide significant benefits in dental health.
Since I was ordained more than 30 years ago, I have lived and worked in the cities of Birmingham, Bradford and now in Newcastle. In Birmingham and Newcastle, water has been fluoridated for more than 30 years. In Bradford it has not, and it shows. We have already heard that dental health in Birmingham is among the best in the country. That means significantly less pain from toothache and abscesses; fewer days lost from school and work; and less need for emergency dental treatment. But in other parts of the country tooth decay remains an intransigent public health problem, and it is very strongly associated with child poverty.
I am told that the national target is that five year-olds should have an average of no more than one decayed, missing or filled tooth. Birmingham and Newcastle, both fluoridated, approach that target. Sadly, Bradford and other cities which do not receive the benefits of fluoridated water, have almost three times that figure.
It is important to consider what the cost would be of failing to fluoridate. A large number of children, especially from the poorer and more deprived communities, will continue to suffer avoidable pain and will have persisting poor dental health all through their adult lives. It is sadly true that the poorer the groups, the higher the levels of disease.
I cannot think of another measure that could be introduced so economically and yet produce such a health gain for so many. The cost of not fluoridating is paid for by the continuing suffering and poor dental health of some of the most vulnerable groups in our society. I am left asking why a child born in a poor family in Birmingham or Newcastle should be able to receive the benefits of fluoridation but not one born in similar circumstances in the city of Bradford.
I support the amendment in seeking to ensure that when communities both need and want their water supplies fluoridated, they can expect the water supplier to comply with their request.
I am one of those very dangerous people—a convert. Twenty years ago I was a member of the East Sussex area health authority and I remember very distinctly a very strong emotional debate in the town hall on this subject. The arguments were impressive, and I voted against fluoridation. I voted against it for technical, cost and emotional reasons. In the intervening years, I have grown older and wiser and have come to the conclusion, as has the right reverend Prelate, that it is negligent not to give the local population the choice of whether to have fluoride in their system.
One of the impressive things about this debate is the position taken by the dental profession, a point which has not been made tonight. The profession has been consistent in promoting, in a very intelligent way, a way of reducing dental caries. That is both honourable and surprising. It is surprising because it works against dentists' professional financial interests. It is honourable because it is the right thing to do in the public interest.
The noble Lord, Lord Monson, questioned whether fluoridation helps people in deprived areas. I looked at a study the other day which showed that in the 1980s, children in the most well off areas had the best teeth—not surprisingly. In Stourbridge, 74 per cent of five year-olds were completely free from decay. In the centre of Dudley, which had relatively high levels of deprivation, only 49 per cent of children were free from decay.
In the 1990s, Dudley's water, as we have heard, was fluoridated, and things changed dramatically. In Stourbridge, whose water was not treated, the number of children free from tooth decay dropped to 65 per cent, whereas in the centre of Dudley where the water was fluoridated, the proportion rose to 69 per cent. That is pretty impressive stuff. The turn-around was very dramatic. Children in the most deprived part of the borough now have better teeth than those in the least deprived part. In areas of deprivation where water has not been treated—we have heard of pockets in London, Manchester and Liverpool—levels of tooth decay have remained stubbornly high.
The noble Lords, Lord Chan and Lord Turnberg, talked about anaesthetics, which is an interesting point. It is hugely costly. In the Manchester dental hospital, three general anaesthetic sessions are carried out every week to remove painful, rotten teeth from children, some as young as two years old. Last year, a total of 1,500 general anaesthetics were given to children for tooth extraction. I take the point of the noble Lord, Lord Turnberg, that anaesthetics today are much safer, but I think those figures are quite appalling. In a relatively rich, civilised country, it is a disgrace that when we have the means to prevent terrible suffering, loss of school days and use of skilled professional time in this respect, we do not do something about it.
The right reverend Prelate referred to costs. In the past, one argument put by the water undertaking was that the costs were very high. I understand that fluoridation costs are around 50 pence per person. Does that figure include capital costs or is it simply running costs?
Ignoring the cost of anaesthetics, I understand a simple filling costs the NHS £10 per person. On the face of it, in financial terms fluoridating the water supply really must make sense. There are alternatives and they have been explored tonight, but the difficulty is that they require sustained behaviour change.
I was responsible—no. I was about to say that I was responsible for AIDS and HIV. When I was a Minister, my portfolio included responsibility for HIV and AIDS. Time and time again, I wrestled with the fact that although the information was out there and people understood how they could contract HIV, the difficulty was in achieving and sustaining a change in behaviour. If we are talking seriously about oral health, getting children to take tablets every day or to return to the dentist for coatings or varnishes will not work. It is much better to fluoridate, especially with the sort of communities we have been discussing.
The Government's proposals are sensible. I like the idea of choice, provided, of course, that there is consultation and all the due processes are followed. I like the idea of geographical selectivity and discretion. It is absolutely right that strategic health authorities should be in charge of this process because, as the noble Lord, Lord Hunt, said, they have the proper advice, the research base and the scientific evidence.
The stumbling block in the past has always been the reluctance of the water authorities and, latterly, the water companies. I understand from the Minister that negotiations are still taking place with the water undertakings, which is very important. If they want a degree of comfort—although I am not sure it is necessary—I hope the Government will do all they can to provide it.
We have heard a lot tonight from the noble Earl, Lord Baldwin, whom I respect hugely. He is so thorough on this subject when it comes to looking at the research. He mentioned Professor Sir Iain Chalmers and Professor Sheldon, whom I know well and respect. But there is one thing I would like to say. I work a bit with the scientific community and whenever a report is produced scientists always recommend further research. I can understand why. They have extremely lively, inventive minds, and they want to progress further. But the noble Earl, Lord Baldwin, is right. We want to be more sure about some of the science.
I am sorry to interrupt the noble Baroness, but she has spoken about nothing but teeth. We are ingesting fluoride—I ingest it when I am at home—and it goes right through the system. Is she aware that in 50 years there has never been a full chronic health study on humans who have been treated with fluoride?
I understand that point, but we do not know how quite a lot of the medications that we use work—I am thinking of aspirin. Nobel Prize winners have sought the reasons why aspirin works. Sometimes we have to go forward without having the total research base. I take what the noble Lord, Lord Turnberg, said. In the end, one cannot know absolutely everything.
I agree entirely that we will never know everything. I have had my own experience with organophosphates. The noble Earl, Lord Howe, who is sitting on the Opposition Front Bench, told me at one stage that there was no evidence that organophosphates were not perfectly safe. We now know differently.
I have to remind the noble Baroness of the dictum that the absence of evidence is not evidence of absence. If one does not look for problems, one is not going to find them. There is a cycle involved.
I am not recommending that we do not do further research, but there are occasions when one must go forward with something without knowing the absolute reasons why. I was very interested in the paper that we received from the Chief Medical Officer and the Chief Dental Officer. They point out—and I believe that it is right—that we have more than 40 years experience in England of artificial fluoridation, but there are generations of experience in some communities of natural fluoride levels matching those used in water fluoridation systems. No evidence of harm has been demonstrated in areas of England with natural fluoride of around one part per million.
It hurts me to say this—it is very painful—but I totally support the Government in what they are trying to do.
As the noble Baroness mentioned me by name, before she sits down will she say why children in the industrial cities of France, Germany, Belgium, Sweden, Portugal, the Netherlands and so on do not seemingly have the dental problems to which she referred? Why are medical establishments in those countries not keen on fluoridation?
I have to confess to being something of a Euro-sceptic. The noble Baroness, Lady Gardner, dealt with that point very well indeed. Other countries are so different, not only culturally but in their diets and everything else, so I am not sure that the comparison is very useful.
It is now confirmed that this measure should have been introduced in a Bill and not by means of an amendment to another Bill. We have spent a lot of time on it, and we are going to spend a lot more time on it. I wish that the matter had been brought forward in a proper way by means of a Bill.
I return to the point about consultation, which has not been properly cleared up. The proposition seems to be that the people who carry out the consultation will be the very people who are in favour of one side of the argument. That simply cannot be right. It would be like the Labour Government being put in charge of the next election and being able to use taxpayers' money for their literature and campaign and denying it to all the other parties. Perhaps the Minister would like that—I would have liked it, once upon a time, before I was expelled from the party. But never mind about that.
The fact of the matter is that we need assurances before the Government introduce their proposal. Will the Minister tell us what consultations he will have with various people about the consultation process? That is my first question.
The measure will lead to the removal of individuals' rights to refuse compulsory medication. That is recognised in all democratic societies as a fundamental and inalienable right. The purpose of the amendment is said to be the improvement in the dental health of children—not even all children but particularly children of poor families. It is not to save children or others from life-threatening illnesses. Indeed, the outcome of better dental health in children can, as we have already heard, be achieved by other means. We have been told that a toothbrush and toothpaste would cost £10 per annum, as against 50 pence for fluoridation. But £10 per annum is only 19 pence per week—the cost of a Mars bar. If the child did not have the Mars bar, that would help the child to retain his teeth. So there are other means of bringing about the same result.
Why, then, should the whole population—children and adults—be forced to drink fluoridated water? There will be no alternative. One cannot do otherwise than drink fluoridated water. One has no option, as water is a life-supporting property, to which there is no alternative. Indeed, as we have heard, people could be ingesting a substance that could do them harm. Furthermore, it could bring about apathy in certain parts of the population about personal dental hygiene. People may say, "Oh well, we have fluoride in the water now, we needn't worry about looking after our teeth as the Government are doing it for us".
What about the damage to the environment? The average daily consumption per person is roughly 32 gallons, of which less than a gallon is ingested. By children, that is much less than a gallon. Thirty-one gallons goes to the land, the rivers and the sea and, as the noble Countess, Lady Mar, has pointed out, to lots of animals as well. That could do them all very grave harm. Have any studies been done to discover exactly what damage will be done to the environment?
We know that fluorides used in water are toxic. They are also classified as dangerous substances under the EU dangerous substances directive of 1976. However, there is no indication of that in pro-fluoridation literature. An article from the Guardian on 27th June headed, "Failure to test chemicals 'puts lives at risk'". There are 30,000 chemicals identified by the European Commission as not tested, and fluoride happens to be one of them. Those issues must be considered before the measure is brought into law.
What about human rights? There is no doubt that water fluoridation is a medical intervention by the state. It is not a water treatment process but a medical intervention. We do not know for certain what are the long-term adverse effects of administering an unregistered medicinal substance. Have the Government considered the implications of the articles in the European human rights charter, which do not permit the administration of a medicine or medical treatment? Have they considered our own Human Rights Act 1998, which implemented the European convention into British law? Have they considered all the legal implications? In my view, the legal and human rights implications are very serious and—if the Government are faced with litigation involving damage to health and/or the environment—could be highly costly to the taxpayers.
I do not want to carry on for too long although others have done so at very great length. The proponents have not spared this House of their opinions, but I shall spare them of many more of mine. I believe that compulsory medication should not be imposed even if a large majority should be in favour of that. In a democracy, minorities, too, have rights. In respect of compulsory mass medication, a minority of one should be sufficient to prevent it being implemented.
Finally, I say to noble Lords who support this measure: do not forget, this might be the thin end of the wedge. People might want to put other substances into the water. Noble Lords who are in favour of this mass medication might find those substances offensive to them and perhaps harmful to them. So we are in fact creating a precedent tonight that we may very well regret.
In 1985, based on the arguments, Parliament decided that, if proper processes were gone through at local level, the water supply could be fluoridated. The problem is that the mealy-mouthed water authorities and then the water companies refused the requests of health service authorities which had gone through a proper process and proper consultation. All this amendment seeks to do is ensure that, after the proper processes have been gone through, those water authorities and companies can no longer thwart the decision of those public health authorities.
I apologise for intervening. I followed what the noble Lord, Lord Hunt, said. However, I think he was being slightly unkind to the water companies. What is being proposed now is that the companies will be indemnified. Perhaps there would not have been such a delay if there had been such a proposal on the earlier occasion. I was not in Parliament in those days, so I was not part of that argument. However, I think that the noble Lord's slighting of the water companies was a little unjustified.
I am sorry to delay the Committee, but the fact is that some water authorities, and I think of Severn Trent in particular, were prepared to take the right decision. I am very sorry that other water authorities, particularly the one that covered the North West, did not take a similar position. The fact is that children in Manchester and the North West have suffered terrible oral health because of those authorities' failure to take the right decision.
The longer that noble Lords interrupt me the longer it is going to take. They know that I will not be intimidated.
Under the 1995 Act, it was not absolutely compulsory. Now it is going to be made compulsory. The water undertakers will not be able to refuse to do it under any circumstances if the local health authority insists on it after consultation. I only hope that the consultation will be proper.
Like my noble friend Lord Fowler, I have a strong sense of deja vu this evening. I apologise for extending the debate and I think that it is going to be a very late evening. I have been involved in debates on fluoridation regularly over the past 30 years in your Lordships' House. My debating opponents have changed but the arguments have not. My noble friend—if I may call him that—Lord Baldwin knows that I suffer a certain amount of inner conflict with my connections with complementary medicine. However, as a practising dental surgeon, I support the simple legislative process that would allow the addition of small amounts of fluoride to bring the water concentration to one part per million for 25 per cent to 35 per cent of the population, targeted at areas where tooth decay rates are unacceptably high. The proposed removal of the decision from water companies to local communities should make that simple public health issue much easier. However, the opponents of fluoridation have a knack of getting their way. I hope that this amendment will put an end to that.
Sir Donald Acheson's report, the Independent Enquiry into Inequalities in Health, acknowledged that although dental health had improved, there were still serious inequalities. This Government came to power with promises to reduce inequalities in health. Dentists looked to the Government to address the problems of high decay rates in deprived areas and to make NHS dentistry available to all patients who wanted it. Some 80 per cent of dental disease can be found in only 20 per cent of the population. That is the poorest 20 per cent.
Although I can understand the moral issue against the concept of forced medication, it is the adjustment of the level of a natural ionic content. Is it morally right to deprive children in some of our poorer communities a better quality of life by improving their dental health? Is it morally acceptable to allow children to suffer the pain and discomfort of decayed teeth and allow them to experience the trauma of tooth extraction, sometimes under general anaesthetic, when we know of a simple way of adjusting the concentration of a naturally occurring element that goes a long way to alleviating these problems?
We are not discussing the majority of children whom your Lordships may know. We are trying to help children who may not own a toothbrush, have no access to toothpaste and have inappropriate diets. I spent many years of my own dental career treating some of these children, and the memory of some of the difficult cases will stay with me all of life. It is virtually impossible to remove teeth from children as young as two, three, four or five with a local anaesthetic. Sedative techniques are not ideal for young children, so general anaesthetic is the only option.
As we have heard, each year thousands of children have general anaesthesia for the extraction of decayed teeth. All general anaesthetics are potentially dangerous. Although relatively rare, patients do die under general anaesthesia. The most recent figures that I have are that, in 1998, three children died under general anaesthetic having deciduous teeth removed. As my noble friend Lady Gardner reminded us, general anaesthesia is not allowed now in general dental practice, so those children are referred to hospital, specialist or community centres. In the days when general anaesthesia was used in general practice, I removed teeth from young children who had to be forcefully anaesthetised. It is not an experience that I would wish on dentist, surgeon or patient. It can leave a child with a long-standing fear of dentistry.
Apart from the avoidance of suffering among children and anxiety among their parents, any reduction in demand for paediatric general anaesthetics would free up a huge amount of scarce anaesthetic expertise and financial resource. I have heard nothing new this evening except the usual misconceptions. The time has come to create a democratic way of enabling communities, not water companies, to take the decision.
We have an on-balance decision to make tonight. I have been trying very hard to make up my mind whether it is an advantage that the majority of those who are going to vote tonight are not actually in the Chamber. However, as long as the Minister gives an assurance in his response that he will not adduce our voting practices as an adequate form of determining opinion on public consultation, I shall be content, at least on that particular matter.
There are just three or four points that I wish to pick up. A number of Members of the Committee have mentioned fluoride that occurs naturally in some places in water supplies. That is in the form of calcium fluoride; it is not hexafluorosilicic acid or disodium hexafluorosilicate. Those are the only two substances that are permitted to be added to water under this group of amendments. We should be clear that we are talking about different things. Calcium fluoride is a relatively innocuous substance. But that is neither here nor there.
The noble Earl, Lord Baldwin, did the Committee a considerable favour with his resume and summing up of Professor Sheldon's study which I have also come across. Other noble Lords also mentioned it. There is no point in my repeating the noble Earl's remarks except to say that the study raises serious questions.
There is always a problem with scientific evidence. I ran into that for the first time when the Science and Technology Select Committee examined medical uses of cannabis. Some 5,000 years' use of cannabis in the pharmacopoeia was not considered to be scientific evidence. There is no doubt that if you put fluoride into water there is some reduction—that is what we are talking about—in dental caries. It does not prevent dental caries and it does not cure them but there is some reduction in their occurrence.
We are not solely putting these substances into water for human benefit. The bulk of the water we use in our homes is used in baths, toilet cisterns, washing machines and so on. From there it goes down the drain into the sewage plant where all the nasties are cleaned out. However, the Minister did not respond to my question of whether it was possible to get the fluoride out of water in the sewage treatment process. If he could give me an assurance that that could be done, I would say no more and we could perhaps stop the debate. So far as I can see we are putting that fluoride into the general environment. We do not know the consequences of that. Evidence acquired over a limited period of time suggests that that is not a problem. However, that is all that we have. We may not have studied the matter for long enough.
My noble friend Lord Fowler and the noble Lord, Lord Hunt of Kings Heath, referred to the 1995 Act. It was said that that Act constituted the decision of Parliament and that it was correct. It may have been right then but in the light of subsequent developments and advances in knowledge is it still correct? The noble Lord, Lord Monson, said that the vast majority of other countries in Europe have ceased adding fluoride to water. The United States is ceasing to add fluoride to water, as is much of Canada.
At the very least we are rowing against the tide although someone suggested to me that perhaps Europe is not a good precedent for us to follow. That is neither here nor there. As I say, we have to take a decision on balance. It is not straightforward. Having heard what Professor Sheldon had to say, I come down on balance against the amendment.
Earlier this evening the noble Baroness, Lady Trumpington, called my noble friend Lord Livsey a typical Liberal. If being a typical Liberal involves recognising benefits—we have heard some very powerful arguments concerning benefits which I do not question—and asking for adequately funded public consultation, which I deeply regret the Government chose to oppose, I, for one, am pleased to be a typical Liberal Democrat. This is a difficult debate which will engender deep public interest. The Government have introduced the measure in a hurried manner and we have not had an adequate opportunity to debate it. I understand that in the short term the measure is a good thing. However, as the noble Lord, Lord Stoddart, said, the Government should have introduced the measure in a Bill. In such a Bill we could have asked for strategic health authorities to apply the measure for, say, five years.
One day this matter may be addressed through diet. Many noble Lords who support the measure admitted that in other countries—I believe that Switzerland and France were mentioned—fluoridation is not such an important issue as people's diets are not deficient in the relevant substance. It is awful that we cannot ensure that our children's diets are adequate in that regard.
In the light of the Government's intransigence with regard to my amendments, I am minded to vote against this amendment. I do so as I do not believe that there will be adequate public consultation on the issue and the way in which the Government introduced the measure was not satisfactory.
I have waited patiently to speak. I express my own view. These Benches have a free vote on the issue. I hope that applies to the other Benches. I stress that I express very much my own views.
I shall not rehearse the arguments for or against the measure as they have been explained fully. I shall not indulge in such repetition although I have a six-page speech which I shall obviously have to save for another day unless the Committee wishes me to start on it.
We know where we stand. I wish to make a few serious comments. We would not have had this debate had I not insisted that the Government could not simply bring this matter before the House on recommendation from another place. The fact that we have already spent four hours in discussing a few amendments reflects what others have said; namely, that the measure ought not to have been introduced in the way that it has. It is a bolt-on, an adjunct to the Bill. That is shabby and regrettable.
My anxieties concern four items, some of which have already been dealt with. I refer particularly to the Government's amendment. First, I refer to indemnity. I would have made a strong plea for that to be considered. However, the noble Lord, Lord Warner, indicated that the Government were willing to consider that matter.
Secondly, as regards the supply of fluoridated water to customers within the same supply area, I should be grateful if the Lord, Lord Warner, will explain how he envisages that process operating. For example, my area may not wish to have fluoridated water but the area where the noble Lord, Lord Hunt, lives may so wish. However, we may get our water from the same supply system. I do not think that the amendment addresses that issue. I should be grateful for some guidance on that matter. I have read the amendment carefully. Unless I have missed something, I cannot see how one can supply one area with fluoridated water but not another if they share the same supply. That is a practical problem.
I hope the noble Lord, Lord Warner, will explain how, if an area decides to cease having fluoridated water, the system will cope with that and whether the Government think that it is possible to achieve that situation. My noble friend Lady Gardner said that she did not wish those areas that already have fluoridated water even to have the option of voting.
I shall come to that. I apologise to my noble friend if I misunderstood her. It seems unfair that what is good for the goose is not good for the gander. I think that all of us in this House feel that there should be a fair deal for those people in deciding this issue.
Perhaps I may intervene. Is the noble Baroness suggesting that Birmingham, for instance, despite the fact that 40 years ago a proper process was gone through by the public authorities, should be forced into another consultation now on whether fluoridation should continue?
No, I was not suggesting that. But my noble friend stressed the fact—if I get it right this time—that she felt that a referendum should not be required. I think it was partly a matter of cost or because fluoridation is believed to be good for a particular area. That is why I raise the issue. But with places such as London, which will have several authorities within their supply system, the question is how the provision will be applied and dealt with. There may be a very easy answer. I should merely like clarification. That would be enormously helpful.
I turn to the process. Earlier, we had a vote, which the noble Baroness, Lady Miller, lost. I do not understand from the amendment exactly how the Government intend to seek and get the public view. The provision is vague. We are told that this matter can be set out in regulation. I do not know how many times I have stood at this Dispatch Box and objected to matters coming through in regulation which we cannot debate and cannot alter. I record my dismay again that here is another such occasion. Had this provision come through in a separate piece of legislation, we should not be in this position. We are in this position because the Government have tried to rush this matter and add it to this Bill. Therefore, I should be grateful if the noble Lord would explain matters more fully.
"We are enabling local communities to decide what they want to do on this matter".
She went on to say:
"I emphasise that no fluoridation scheme will take place unless there has been wide-ranging consultation in which both the proponents and opponents of fluoridation have been encouraged to participate and in which the majority of the population have indicated that they are in favour".—[Official Report, Commons, 1/7/03; col. 163.]
I therefore ask again what I asked earlier. Does that mean over 50 per cent of those who vote, or 50 per cent of all those who are eligible to vote? How do the Government envisage the practicalities being engaged? It worries me that if the result is based on the kind of turnout we have seen at general elections, it will be very slight. The Government need to give thought to the point.
When we first raised the issue, the noble Lord, Lord Whitty, on 22nd May in response to my letter—I am grateful for his response—said:
"We have to consider further suitable measures to publicise and consult in order to obtain, and how best to assess, a genuinely representative response from the local population".
I think all noble Lords would agree. What we cannot find out is how that is to be done. That is why I am pushing the Minister to go further.
Those who have spoken share the desire to reduce tooth decay in children—I should like to place that on record—whether through fluoridated water or through encouraging people to have better dental care. I would like to have seen a provision to encourage people to use toothpaste containing fluoride, even if the water is fluoridated, because the use of a toothbrush helps to stimulate good gums. We should not lose sight of that.
I have set out the difficulty that the Government have. I referred earlier to the survey undertaken by the Leicester Mercury. It approached our nine Members of Parliament. Four supported the Government's proposals, three were against, and two were undecided. I humbly suggest that they are reasonably well versed in this topic. But I fear that many people will not know the nuances but will merely see that there are two sides to the argument. Therefore, we need to make sure that the arguments for and against are put forward in a fair manner.
In conclusion, the fact that the Government have brought this provision through so quickly, even before some of their own inquiries on the implications of fluoridation for health are completed, is a mistake. I take issue, as I said, with the undefined way of seeking public opinion. I take issue with the Government that they were originally not willing to put this amendment before the Committee in a proper manner. I believe that we should have choice. We all agree on the desirability of reducing tooth decay. What divides us is the method of achieving that choice.
I hesitate to detain the Committee much longer on this subject, but I need to respond to one or two points. I shall deal with the subject of York later in my remarks.
The noble Countess, Lady Mar, drew attention to some concerns about fluorosis. I commend to her again the statements on this matter in the briefing from the Chief Medical Officer and the Chief Dental Officer. I urge other Members of the Committee who are concerned about dental decay to look at some of the statistics at the front of the briefing. It indicates, for example, that in the north of England in the school year 2001–02, 44 per cent of five year-old children had active tooth decay and each of those had on average three and a half decayed teeth. I shall not relay any more statistics.
It is no good wishing to stop tooth decay and ignoring the evidence from the Chief Dental Officer and the Chief Medical Officer in the conclusion to their briefing:
"From a public health perspective water fluoridation is the delivery method of choice to bring about population improvements in dental health".
That is the nub of the issue and that is what to some extent is behind the Bill.
The noble Lord, Lord Fowler, did better than I could in rehearsing the history of this subject. He was supported ably by, as was described earlier, some of the West Midlands mafia. I believe that the evidence in relation to Birmingham is very powerful. My noble friend Lord King told us about the experiences of Sandwell.
During the course of the debate, a number of questions were raised about the way that we treat water and the addition of chemicals to water. Perhaps I may pass on to the Committee the advice that I have been given. A number of chemicals used in water treatment can be toxic at high concentrations. All drinking water in England and Wales is normally disinfected by the controlled addition of low concentrations of chlorine—a highly toxic chemical.
The water industry is used to dealing with those water treatment processes safely to ensure that dosing is strictly controlled within the target concentrations. Two chemicals used in fluoride are themselves the subject of European standards which require strict purity criteria. There are additional controls on the use of fluoridation chemicals within the code of practice, which itself will be revised. That ensures that levels of impurity and trace elements from the mineral rock used during manufacture are very low. Fluoride is effectively removed by the coagulation process, which is normally part of the water treatment process on water abstracted from rivers.
Therefore, considerable safeguards are built into the way that we treat our water and the way that we use it. Fluoride is reduced during sewage treatment. I suggest that that limits any potential environmental impacts. I am also advised that in animals—noble Lords were concerned about this matter—there is no evidence of any effects from water with fluoride at concentration levels of up to 1.5 parts per million.
The noble Lord, Lord Monson, took us on a tour of Europe. I should like to take us on a tour of the world with regard to fluoridation. Throughout the world it is estimated that about 210 million people drink artificially fluoridated water and that a further 103 million drink water whose natural fluoride levels are high enough to provide a significant degree of protection against tooth decay. Countries with fluoridation schemes include the United States, Canada, Mexico, Argentina, Ireland, Spain, Australia, New Zealand, Hong Kong and Singapore. Many other countries have enacted the necessary legislation but have not yet introduced schemes. It is worth mentioning that the US is extending its fluoridation schemes. Therefore, we should not keep our attention only on what is happening in Europe.
The noble Baroness, Lady Byford, asked what would happen in areas within different strategic health authorities that may take a different view on the matter. I believe that the position is clear. The areas to be fluoridated will need to be identified at the beginning of the process. That will be dependent on the water treatment works that supply the area. Consultation will have to include all those who will be supplied with the fluoridated water. That could be part of a strategic health authority area or a combination of strategic health authorities. The water treatment processes occur in different parts of the country and, in many places, there would need to be a degree of consultation between different strategic health authorities.
Perhaps the noble Lord will give way. This is one of the problems that we are now facing. We are being asked to approve something on which, as he just said, consultation is still taking place. The Government do not really know what will happen. I may have misunderstood the situation, but we are faced with that problem tonight. That information should be before us prior to our being asked to support the amendment.
I am trying to say that water treatment plants do not fit neatly into the areas of strategic health authorities. Therefore, we must have a process of consultation between different strategic health authorities where there may be a wish to have fluoridation. That will have to take place in consultation with the water authorities, companies and undertakers, which will want to be able to explain to health authorities the areas covered by their treatment plants. With due respect to the noble Baroness, I do not believe that, at this late hour, the Committee is well equipped to have a debate about the precise allocation of water treatment plants in this country in relation to particular strategic health authorities.
A number of noble Lords, including the noble Baroness, Lady Byford, returned to the subject of the consultation process. Yet again, I shall try to be as clear as I can. We recognise the importance of the methods used in assessing public opinion. The word "referendum" never passed my lips. We shall hold wide discussions on this method of consultation. Noble Lords asked who we would consult. The consultees would include companies which conduct public opinion surveys, the Electoral Reform Society, the Local Government Association and professional bodies concerned with public health and dentistry, among others. Therefore, we have a very good idea of the groups—
We shall take away this issue and consider it. However, without being committed to particular forms of consultation, I am trying to explain to noble Lords that we have in mind to consult a very wide range of interests and bodies.
The noble Lord, Lord Stoddart, raised the subject of the European Convention on Human Rights. I am advised that in the only case under that convention concerning fluoridation—the Swiss case—the Office of the High Commissioner for Human Rights considered that it did not need to consider the issue of whether interference with the right to respect for private and family life arose because any such interference would in any event be justified.
I turn to the points that were raised in relation to the York study. I acknowledge the long and sustained interest of the noble Earl, Lord Baldwin, in fluoridation, and in particular the contribution that he made as a member of the advisory committee for the review conducted by the University of York. I did not mean to imply, and I do not believe that the Chief Medical Officer and the Chief Dental Officer meant to imply, that there were no reservations in that report. I certainly accept that the York team was critical of the quality of the research that it considered.
As the CMO and CDO's paper indicates, the department is taking steps to strengthen the evidence base. However, it is worth bearing in mind that in its conclusions at paragraph 12.4, the York report stated that with bone fracture and cancer studies the evidence is very balanced around the no effect mark. Very few of the possible adverse effects studied appeared to show a possible effect. York found no evidence of risk to overall health from fluoridation, a view that was confirmed by the Medical Research Council when we asked it to identify what further research needs to be undertaken. The department will continue with its research—
I wonder whether the noble Lord has read a little further on, where the York report goes to some length to say that because of the short length of the study some adverse effects may not have shown up in the long distance. I must again correct him on the no evidence point. It did not find no evidence. For the rest, I agree entirely with his analysis.
The quotation came directly from the report. I did not believe that the Committee would like the whole of the report read out.
We shall continue with our research programme, as I said, and monitor the outcome of the research conducted in other countries. That work is due for completion in the autumn, well before the Bill will have completed its passage through Parliament. We have made the regulations under which we want any new local consultations to be conducted.
We have had a very thorough debate about this issue. In a nutshell, the amendment 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 and I hope that the Committee will support the amendment.