The consultation over putting fluoride in water supplies on the south coast is proving a ‘totemic argument between state and individual’. Other areas will be watching the outcome closely, reports Rebecca Evans
Next month, the board of NHS South Central will decide whether to fluoridate the water in parts of Southampton and south west Hampshire.
The decision will be significant, not just for the 195,000 people it will affect directly, but because the whole process of consultation, decision making and any subsequent fallout is being watched keenly by other strategic health authorities and primary care trusts that might want to follow suit.
Fluoridation is a contentious issue. NHS South Central is the first region to consult on water fluoridation since the legislation changed in 2005.
At that point, the government made it clear that it supported fluoridation to improve dental health where the local population was consulted and left the decision up to strategic health authorities.
Only a small minority of people in the UK - around five million - live in places with artificially fluoridated water, mostly in the West Midlands and Tyneside. Many of these areas have drunk fluoridated water for decades.
But introducing it in a new area is a different matter, bringing forth passionate and strongly held views for and against. These are not just about the dental health benefits or cost-efficiency, but also debates over public health interventions versus personal choice or, as NHS South Central chief executive Jim Easton puts it, “a totemic argument between the state and the individual”.
Unsurprisingly, this makes the consultation difficult and fraught. It also makes the process extremely important.
As the first region to attempt to introduce fluoridation since the law changed, it must be fair, transparent and follow the rules to the letter, and be seen to be. If the SHA does decide to introduce fluoridation, neither it, nor the government, would want to see it face a judicial review.
Chief dental officer for England Barry Cockcroft says: “It’s very important with this first one that it’s properly done; in many ways it tests the legislation that we have got it right.”
The SHA has put a lot of effort into ensuring it hears everyone’s opinion (see box, below). The issue attracts national and even international lobbying groups. These should have their say, Mr Easton says, but must be balanced with the often “quieter voices” of local groups.
There is also the question of how to tackle what he calls “the battle for truth in an information age” - that is, people forming views based on information they have largely found on the internet.
Mr Cockcroft, one of the pro-fluoridation panellists at all three of South Central’s Question Time-style public debates (see box below), says this is what he found most challenging. “The most difficult arguments to cope with are the ones that sound like they are scientific but are not, but people who are not scientifically based themselves are very easily influenced by that kind of thing.”
Mr Cockcroft says it is for these kinds of reasons that the legislation says the SHA must assess the cogency of the competing arguments. To enable it to do this, it went out to tender for an independent scientific adviser who will weigh up the evidence and advise the board.
Southampton City PCT is free to openly commend the proposal to fluoridate the water. It is the PCT that requested the consultation based on its concern that dental health in the area is among the worst in the country and its belief that raising the level of fluoride in the water supply would significantly improve the dental health of local people, particularly children.
Nothing to smile about
PCT director of public health Andrew Mortimore says the PCT reviewed the area’s oral health needs and found that dental health had not improved in five years - in fact, the figures were worse in 2006 than they had been in 2002. More than four in 10 children had tooth decay by the time they started school.
Dr Mortimore says the problem tends to be worst in areas with the greatest social disadvantage.
“We spent a lot of time, a lot of money on schemes, got a lot of very good people working on oral health promotion, dietary improvements, dental hygiene, supporting parents and families, but at the end of the day it was not making the difference. We came to the conclusion we needed to re-look at water fluoridation and whether it could be introduced.”
He compares Southampton’s situation enviously with the West Midlands, where the water has been fluoridated for around 40 years and with the best dental health in the country - certainly much better than the socioeconomic demographics would suggest.
“We understand that this is an issue where you cannot get a yes from everyone and choice is an important issue, but so is the choice to have fluoridated water. It is the most vulnerable in our communities who can’t make the decision for themselves, particularly the children.”
SHA vs PCT
Southampton city council has come out in favour of the fluoridation proposals - but Hampshire county council, which covers some smaller areas that would also be affected, is against. Anna McNair Scott, chair of the council’s health overview and scrutiny committee, says fluoridation seems to her to address a symptom of health inequalities - poor dental health - rather than its causes, such as bad diet, which will still lead to other health problems and inequalities.
What the general public will make of the proposal remains to be seen. Dr Mortimore says the opinion survey conducted before the consultation began would suggest there is a good measure of public support. “I don’t think there’s anything else that public consultation on a health issue is quite like this in terms of the firm views and passion it attracts in those who are opposed to something that the NHS is consulting on that is for the benefit of a population.”
It is also difficult to convey to the lay person that the PCT and the SHA have different roles, he says. The PCT is the key proponent, while the SHA is the decision maker and the organisation responsible for the consultation. “We can’t be seen to be joined up in ways that feel very different from most other things we do as an NHS,” he says.
The PCT’s responsibility for tackling health inequalities does not, on this issue, always resonate with the public. At the debate, several members of the public argue that fluoridation should not be imposed on everyone to improve the dental health of a feckless minority.
The suggestion by the independent chair of the panel, Radio 4 broadcaster Peter White, that part of the objective of a public health system is “to reach people who cannot be reached by other methods” seems, among that particular audience at least, to fall on deaf ears.
NHS South Central deputy director of public health James Mapstone believes views on the greater good have changed.
“What [the drop-in events] made clear to me is how much individual choice is really precious to some people now and I do think that’s probably a shift from where we were 20 years ago, even 10 years ago.
“They used to take more of a ‘I will do this for society as a whole’ [position] and I’m starting to feel that there’s a change and public health has to respond to that.”
But Mr Easton says he is “really pleased about the level of discussion and debate, even though some of it is vigorous and difficult”.
“This is public health in the raw, being debated and discussed in local communities. It’s what we are on the pitch to do.”
The SHA board will make its decision, in public, on 26 February.
In the pipeline
New legislation gives SHAs the final decision on water fluoridation following public consultation.
Southampton City PCT asks former Hampshire and Isle of Wight SHA to investigate the feasibility and cost of fluoridating the water supply.
SHA receives the economic analysis it has commissioned.
SHA receives the feasibility study it has commissioned.
A pre-consultation exercise is carried out to assess awareness and design the consultation process.
SHA board approves request to carry out a formal consultation.
SHA runs public consultation.
SHA board makes decision.
For and against
Public views at NHS South Central’s debate on 3 December 2008
“The obvious route [is] targeting the areas in the schools and bringing these parents to court over it.”
“Taking parents to court if their children had bad teeth - what do you think that would cost and is there any justice in that?”
“Birmingham has one of the highest infant mortality rates in the country and I’m wondering whether that could be linked with fluoride in the water.”
“It’s entirely due to one ethnic group and if you took that group out of the population it would look very much like the England average so unless someone is trying to argue that fluoride changes ethnicity it doesn’t actually help very much.”
“If we allow fluoridation to go ahead we could eventually reach a situation where silly old England is the only country in the world that still puts rat poison in its drinking water.”
“The rest of the world is growing, where feasible, fluoridation. Other countries don’t have the same water supply that we have, people don’t know where the water’s going and that’s obviously difficult to control.”