REPORT OF THE
WATER FLUORIDATION PANEL
FLUORIDATION OF WATER IN SOUTHAMPTON AND SOUTHWEST HAMPSHIRE
1. South Central Strategic Health Authority had written to the County Council confirming its intentions to consult on proposals to fluoridate water in parts of Southampton and southwest Hampshire. Under regulations the Health Overview and Scrutiny Committee is specifically excluded from being a statutory consultee, however the Committee was able to investigate the issue in its own right and The Leader requested it to do so and provide recommendations for consideration by the full County Council in November 2008.
2. The Health Overview and Scrutiny established the Water Fluoridation Panel to scrutinise the proposals. The membership of the Panel being:
Mrs. A.M. McNair Scott (Chairman)
Mrs. P. Dickens
Mrs. M. Kerley (Co-opted member of the Health Overview and Scrutiny Committee)
Mrs. C. Leversha
Plus observers from each of Eastleigh Borough Council, New Forest District Council, Test Valley Borough Council, Southampton City Council and Hampshire Local Involvement Network, each with speaking rights but not voting rights.
3. The Panel's terms of reference were:
To consider the benefits and risks associated with the artificial fluoridation of water supplies to people living in Southwest Hampshire, recognising the intended benefits for target populations in Southampton City, and to reach a view on whether the proposal should be supported as a public health intervention.
This included consideration of:
· The effectiveness of water fluoridation in improving oral health
· The availability of alternative strategies for securing this objective
· The potential benefits and risks associated with the fluoridation of water, taking account of the available evidence
· The ethical issues raised by the proposal
· The legal and technical matters to be addressed
· The views of relevant experts and key stakeholders.
· The content and conduct of the consultation exercise and the way in which the feedback received is weighted and presented to the South Central Strategic Health Authority Board, taking full account of Cabinet Office Guidance.
No comments from the general public were invited as they were able to make their own views known directly to the South Central Strategic Health Authority for its consideration.
4. At meetings in public on 25 September and 6 October 2008 the Panel received evidence from:
· Southampton City Primary Care Trust
· Nuffield Council on Bioethics
· Hampshire Against Fluoridation
· British Fluoridation Society
· Professor Sir Iain Chalmers (Editor of James Lind Library and co-author of the British Medical Journal article "Adding Fluoride to Water Supplies")
· National Pure Water Association
· UK Councils Against Fluoridation
· Portsmouth University Community Dentistry Project
· South Central Strategic Health Authority
· Southern Water Authority
· British Dental Association
· Hampshire Primary Care Trust
· British Association for the Study of Community Dentistry
· Hampshire Local Dental Committee
5. The Panel subsequently met to consider all of the evidence received, including written evidence, and prepared a report and recommendations. The report of the Panel is attached.
6. The conclusions of the Panel are:
The proposals to add fluoride to drinking water for parts of the population of Southampton City and south west Hampshire raised a number of complex issues. The Review Panel considered 7 distinctive but related themes in coming to its conclusions. These are set out below by theme.
Improving oral health:
_ Overall fluoride does have a beneficial impact on the prevalence of caries and improves oral health. In particular there is wide ranging evidence that the topical (surface) application of fluoride is beneficial.
_ The Review Panel is not however of the view that the case put forward in the South Central Strategic Health Authority consultation document is convincing in its argument that adding fluoride to drinking water is the only way to improve the oral health of 7 of the 11 deprived communities in Southampton City. In particular the Review Panel is concerned that:
- There is little evidence of suitable quality to support the assertion that this action will reduce health inequalities.
- Alternatives exist that are less intrusive and coercive.
- The total exposure to fluoride in the population has not been evaluated and taken into account. The importance of this point has been emphasised by all the authoritative reference documents identified by the Review Panel as well as the World Health Organisation..
- The introduction of fluoride to drinking water will result in some children within the population that have otherwise healthy teeth experiencing fluorosis. The extent to which this would be severe enough to be of aesthetic concern is disputed in the evidence, but a conservative (1 in 22) estimate based on the under nine population in the areas covered by the 2 schemes (source: Atkins) suggests that a total of 846 children in the area, of which 171 would be from south west Hampshire, could be affected by fluorosis of aesthetic concern. Taking a figure of 1 in 8 , which is cited by the York Review, the number of children affected in this way would increase significantly.
_ The consultation document does not give a complete picture of the oral health of the population affected, figures for 8, 12 and 15 year old children were not included.
_ The balance of benefit and risk has not been presented in accordance with the findings of authoritative reports such as the York Review and Medical Research Council, nor has this been properly explained to local people
_ Other less coercive interventions are available to achieve the same goals
_ The conflicting principles involved meant that the Review Panel was unable to come to a consensus on the need for consent
_ The availability of other interventions and the inconclusive evidence relating to the impact of fluoridation on individual health requires that a precautionary approach be adopted
Impact on Health:
_ Adding fluoride to drinking water has the potential to result in an increase in moderate to severe fluorosis in the communities affected.
_ There may be harms other than fluorosis as a result of adding fluoride to drinking water.
_ The plausibility of other serious health impacts from the fluoridation of water reinforces the view of the Review Panel that a precautionary approach is needed until such time as additional research has been done. It is of serious concern that, despite this point being made repeatedly in the literature, credible research is still not available.
Alternatives to adding fluoride to water:
_ Effective alternatives to adding fluoride to water do exist, with the potential to target those affected rather than the population as a whole.
_ Particular opportunities exist for the creative use of skill mix to provide targeted support to vulnerable groups and using existing skills, such as those of health visitors more fully.
Exposure to Fluoride:
_ Evidence has not been provided to demonstrate that adding fluoride to water at 1 part per million (ppm) equates to individuals receiving an optimal therapeutic dose. Current daily intake of fluoride from other sources may already exceed the equivalent of 1ppm in water.
_ The recent decision of the Republic of Ireland to reduce the longstanding accepted dose for adding fluoride to water from
1 ppm to 0.7ppm brings into question the level of dosage for England as set out in the current legislation.
_ Individual exposure will be affected by the addition of fluoride to drinking water at 1ppm as well as other sources.
_ The conflicting information about using fluoridated water to reconstitute infant formula reinforces previous conclusions about the need to adopt a precautionary approach.
Nature of Fluoride:
_ There is not sufficient evidence to show how individuals vary in the way in which they retain and excrete fluoride, or the impact that hard or soft water may have on this.
_ There is not sufficient evidence to show that artificial fluoride acts in the same way as natural fluoride.
Legal and Technical Issues:
_ The technical appraisals show that the options for introducing fluoride to the water supplies of the full target population are neither viable nor effective.
_ The projected costs are not sufficiently robust.
_ The conflicting evidence received makes it difficult to determine if there are additional legal issues that need to be taken into account.
Overall it is not clear what impact the addition of fluoride to the water will have on people living in Hampshire who will be affected by the schemes proposed. This population does not have the same dental health challenges as reported in Southampton City. There may be a benefit to Hampshire children living in the area affected but there is also a significant possibility that children with otherwise healthy teeth could suffer from a degree of fluorosis, which may be of aesthetic concern and may be an indication of fluoride toxicity. Additionally there may be other health effects on the population as a result of adding fluoride to water at this level.
The proposals only cover 7 of 11 deprived areas identified by Southampton City Primary Care Trust in its population. If the evidence received is correct and one of the two schemes is not viable or cost effective this would reduce the deprived areas being covered to 6 out of 11. Other options exist for targeting the most vulnerable populations to improve the oral health of children and experience elsewhere has shown these to be effective.
As clearly stated in the following report the Review Panel is convinced by the sincerity, integrity and passion of all the stakeholders presenting evidence for consideration. The goal of eradicating poor oral health, particularly for children who may suffer from significant pain and distress, is laudable. The Review Panel would also agree that the most vulnerable in our society should be protected and understands the notion that, in order to achieve the greatest good for some the preferences of other individuals may be set to one side. However where the evidence is unclear or equivocal about the impact of an action on individuals or communities, then those individuals and communities should be able to contribute to the discussion about the way forward in an informed and participative manner. The Review Panel has already made clear its concerns that this latter point has not been addressed in the consultation by the South central Strategic Health Authority. Equally it is apparent that the experience of the Review Panel in considering this matter replicates many of the concerns raised by Nuffield and rehearses arguments that have taken place since the first fluoridation schemes were introduced over 60 years ago. To quote the comments of the Chairman of the United States National Academy of Sciences committee reported in a recent article in the journal Scientific American `in the face of ignorance controversy is rampant'.
Most significantly the Review Panel has been persuaded not to support the proposal by the lack of robust and reliable scientific evidence produced to support this proposal. It is clear that scientists and health professionals recognise that there are `unknowns' with regard to the need to understand the effect of fluoride on the body (not just teeth). This work has simply not taken place. in the absence of scientific evidence of sufficient quality the Review Panel based its evaluation on the findings of the York Review informed by the work of the Nuffield Council on Bioethics.
7. The Review Panel recommends that:
The South Central Strategic Health Authority be advised of The County Council's comments on proposals for the fluoridation of drinking water in Southampton and Southwest Hampshire as follows:
In the light of the issues reviewed and the evidence received the Review Panel considers that this important debate needs to be held in a more mature and participative way than has been the case to date. The suggestion from Sir Iain Chalmers, that rather than simply asking if fluoride should be added to water supplies or not, communities should be engaged in contributing to research that is based on a more integrated approach to resolving problems of this nature is one that the Review Panel would wish see endorsed and commended to the South Central Strategic Health Authority. It is therefore the view of the Review Panel that the following recommendations are made to the South Central Strategic Health Authority on behalf of Hampshire County Council:
a. The South Central Strategic Health Authority takes the lead, working with local stakeholders, communities and principal national researchers in a way that conforms to the stewardship model advocated by the Nuffield Council, to understand better the options open to improving poor oral health in those affected and takes forward agreed programmes for achieving this objective. Initial approaches to key national commentators on this issue indicate a strong interest in, and willingness to contribute to, research of this nature.
b. Hampshire County Council agrees to actively engage with and support this work.
c. Taking account of the plausibility of harm a precautionary approach to the addition of fluoride to water be adopted until such time that clear evidence of benefit and harm has been established.
d. The alternatives to adding fluoride to water supplies to improve oral health that exist are fully explored with a view to targeting the children affected rather than the population as a whole.
e. That further work be taken forward by the South Central Strategic Health Authority and interested Primary Care Trusts to establish the total daily exposure of populations to fluoride and understand the threshold at which this ceases to be therapeutic. This information should be accessible to all local people.
f. That the South Central Strategic Health Authority and interested Primary Care Trusts undertake further work to provide reliable information about the prevalence and severity of fluorosis in populations exposed to fluoride.
g. That the South Central Strategic Health Authority actively and effectively promotes the publication of clear guidance about the use of fluoridated water to make up infant formula.
h. Taking account of the recent decision in the Republic of Ireland to reduce fluoride levels and the evidence base underpinning this the South Central Strategic Health Authority lobbies the Department of Health to reconsider the level of 1 ppm set out in the legislation to ensure that this is robustly evidenced, and if feasible reduced.
i. As a consequence of the evidence received by the Review Panel the projected cost and technical feasibility of the proposal is reviewed by the South Central Strategic Health Authority.
j. Until such time as the further work outlined above has taken place the County Council does not support any proposal for adding fluoride to the water of people living and working in Hampshire.
k. That the Review Panel continues to evaluate the content and conduct of the consultation process, providing feedback to the South Central Strategic Health Authority as appropriate.
l. That the Review Panel assesses the evaluation of the responses to consultation, and the weighting given to feedback from the public and local authorities to ensure that the views of the population affected are taken into account by the South Central Strategic Health Authority Board.
m. That the Review Panel confirms whether or not it is satisfied with the balance of scientific and ethical issues considered by the South Central Strategic Health Authority Board when coming to a decision and reports back to full Council on this matter in order to allow Hampshire County Council to consider the scope for any further action required in the interests of the population of Hampshire that would be affected by the proposal.
ANNA McNAIR SCOTT