Dear Mr Easton
SHA consultation: Fluoridation of Water in Southampton and South West Hampshire.
I am writing with some additional questions raised by our Review Group and to provide some feedback on the consultation document. We are deeply concerned about the process that the SHA is intending to follow with regard to reaching a decision. The way in which Southampton City PCT is actively promoting its preferences means that local people are getting selective information on this matter which is being vigorously promulgated.
You will note from our comments on the SHA consultation document that we are not of the opinion that the information provided has been presented in a balanced manner. No options have been provided and the emphasis on the public providing `peer reviewed evidence' suggests that the views of the public will be superseded by the views of health professionals. Members noted that only 5000 copies of the consultation document have been circulated and are of the view that the questions are not open, leading people towards a preferred outcome. Taking these points into account we are not convinced that the telephone poll suggested will provide a useful source of informed feedback.
It is deeply disappointing that this process has been undermined by the same shortcomings described by the Nuffield Council on Bioethics in their discussion about the fluoridation of drinking water. We would therefore be keen to explore the feasibility of further work across the communities affected to assess the scope for a more informed discussion about oral health and the potential for a more rigorous approach to reducing the incidence of dental decay in our population. Scotland has already shown that people are able to contribute constructively to this debate and that significant improvements in oral health can be achieved.
Set out below are some specific questions for consideration by the SHA. It would be helpful if we could have a response to these by 28 October 2008, when our Review Group will next meet. Our comments on the consultation document are appended at Annexe A.
_ Our understanding is that fluoride works best as a topical agent. What is the `optimal' level of fluoride that needs to be ingested to provide a therapeutic effect to teeth. When and how was this determined and what clinical or other trials have taken place.
_ At what threshold (on a daily dose basis) does ingested fluoride cease to be beneficial and have the potential to cause health problems.
_ Has there been any research of the same quality since the York Review that would mean that its findings needed to be revisited.
_ York suggests the level of fluorosis of aesthetic concern to be 12.5% of the population, the MRC puts this figure at 3-4% and SCPCT states that severe fluorosis does not occur in UK children. Which is correct.
_ How is the incidence and type of fluorosis measured in the UK.
_ Is 1 ppm fluoride in water equally effective on all tooth surfaces. Please provide evidence.
_ Is 1pmm fluoride in water effective in reducing periodontal disease in children and adults. Please provide evidence.
_ What is the level of periodontal disease in the population being targeted. Please provide evidence.
_ A number of reviews, including the York Review, and the MRC and WHO have stressed the importance of understanding total exposure to fluoride. What has been done to assess this in Southampton and how has this influenced the suggested figure of 1ppm.
_ What demographic factors influence trends in poor oral health e.g. ethnicity, immigration or other changes in the population and what account has been taken of these factors in this proposal.
_ Why are alternative options to adding fluoride to drinking water, or adding fluoride to water at different levels not included in the consultation document. This could include option for people to indicate that they did not want any change to the status quo.
_ How is the SHA enabling alternative views on the proposals to be shared with people attending the `drop' in sessions.
_ What is the basis for insisting that responses from the public should be based on peer reviewed evidence - this means only the educated few will be able to make a case.
_ What work is taking place with people in the target areas to ensure that the proposed way forward is acceptable to them and build and understanding of the issues that lead to poor oral health in this population.
_ Is the SHA willing to consider alternative options. How could these be included in the considerations of the Board.
_ How is the Board going to weight the different responses received- including those generated as a result of SCPCT's publicity campaign.
Please do contact me if you have any queries about the information was have requested.
Anna McNair Scott
Chairman, Health Overview and Scrutiny Committee
Comments on the Consultation Document Annexe A
4.6 & 4.7
This is welcome but the evidence and research opinion is polarised. We have grave concerns that greater emphasis will be placed on the views of health professionals who are already committed to introducing fluoride to drinking water. Indeed the way in which the document goes on to use selective evidence is a cause of significant concern
The estimates refer to caries saved, not teeth saved- this is misleading.
We would have welcomed the opportunity to have a proposal put forward that set out all the facts. The criticisms expressed in the Nuffield Review would apply equally to this consultation document, particularly with regard to the selective use of the information available and the relative strength/weakness of the evidence.
We would intuitively agree with the comments relating to the impact of poor dental health on individuals. It would be helpful to see the evidence supporting this. Equally the same premise should apply- as demonstrated by the Scottish Consumer Council- to fluorosis that is of aesthetic concern
It would be helpful to have put the figures in some sort of context in terms of overall improvements in the oral health of adults and children in recent years and the percentages of children that are suffering from severe decay. Our understanding is that the average dmft is masking the fact that a smaller number of children have more severe decay.
It would be helpful to understand how the figure of 1ppm was arrived agreed. Whilst this is a level recommended by WHO, there is also a need to take account of total fluoride exposure in a population - has this work been undertaken. Equally what account has been taken of the decision of Ireland to reduce the dose from 1ppm to 0.7ppm. Our understanding is that the range of fluoride for beneficial effect was initially set in the USA at 0.7 to 1.2 ppm.
We would concur with the view that robust scientific evidence should be taken into account. Should the SHA please confirm if the findings of the `York Review' have been superseded by subsequent research of equally high quality and the way in which the Board will be apprised of the range of views that exist.
We could find no reference to environmental issues in the document and would be grateful if these could be made available.
This relates only to the dental health of 5 year old children in Southampton, not those in south west Hampshire who have different dental challenges. We have requested but not received any oral health strategy for SCPCT (as exists for Hampshire PCT) and have no idea of the total expenditure on improving oral health or the impact that action to date has had on improving children's dental health. The fact that six dentists are able to accept new NHS patients does not mean that these are easily accessed by the target population. We have received no evidence of work being done with the target population to understand why they are not accessing NHS dental services. Again work of this nature has been done in Scotland, providing opportunities for removing barriers to access.
The figures provided do not reflect the fact that only 7 of the 11 high priority area would be included in the scheme- including some of the most deprived areas. We still do not know how many children in these areas will be covered by the proposal.
The costs are assuming an efficacy rate of 25%, far higher than that suggested by the York review. The cost effectiveness of the scheme reduces considerably if this figure is less than anticipated, for example efficacy may be reduced by other sources of fluoride in the population. The aggregate dmft rates are based on post codes with no way of ascertaining the total number of individuals with at most risk. No account is taken of the need to treat fluorosis that occurs as a result of adding fluoride to water.
The reference to optimal dose is misleading. The level of 1 ppm was set at a time when populations were not exposed to other sources or fluoride, as in toothpaste etc. Account of total exposure should inform the dosage, not the level included in water
There seems to be bias in the presentation of the information. Decay rates have declined world wide - regardless of the addition of fluoride to water. Additionally no indication is given of the countries that have pursued other options to fluoridating water or ceased to do so yet still show significant reductions in the incidence of tooth decay. No information is given on any of the alternatives to adding fluoride to water which have been shown to have a beneficial effect.
The comment in this paragraph about the importance of good quality reviews is heartily endorsed by our Review Group; however the commentary then goes on the make claims based on selective use of sources.
We are also concerned that the document makes reference to the York Review finding `no evidence of harm'- our understanding is that York was unable to find evidence of suitable quality to come to a view either way. This is a different point.
Again we need to take issue about the way in which the findings of York Review are presented. Our understanding is that York found the evidence overall to be weak with a range of possible benefits/disbenefits. No specific benefits have been demonstrated. We are also concerned at the comments on inequalities attributed to the York Review, which, in a subsequent statement, said that the findings on inequalities were `weak, contradictory and unreliable'. We would appreciate confirmation on the evidence relating to adults as, again relying on York, our understanding is that the available evidence was not of sufficient quality to come to a view.
We were confused about the way in which the prevalence and severity of fluorosis is presented. York suggests that 48% of the child population will have some degree of fluorosis and 12.5% will develop fluorosis of aesthetic concern. The MRC report suggested different levels but this research was not as rigorous as that of the York Review. Our reading of the Australian Review suggests that they found evidence that was broadly consistent with York. The pictures presented could therefore be interpreted as being misleading as they do not show what fluorosis of aesthetic concern might look like.
We are concerned that this section quotes research that either was not sufficiently robust to be considered by the York Review, or was considered to be of low quality. We are of the view that as currently presented the document gives a potentially false reassurance to the public.
Again we strongly welcome the references to the Nuffield Council on Bioethics. Their work in this area is key. Nevertheless we are of the view that their views on this matter are partially presented. The chapter on fluoridation draws out a number of arguments for and against adding fluoride to water and are clear that there are potential harms as well as possible benefits. They are also critical of the selective use of information by those wishing to drive through a decision to fluoridate water as well as the need for people to have the information they need to make an informed choice. They point out that `the evidence of the benefits and harms is weak overall, particularly in the context of historically low levels of caries in the population'. The three areas to be covered include clarity about health need, the degree of potential benefit and harm and the possible alternatives that are less intrusive. This balance is not reflected in this section, or consistently throughout the consultation document.