Agenda item

Presentation of the Director of Public Health, Durham County Council.

The Board received a briefing note in relation to North East Water Fluoridation from NHS England (for copy see file of minutes).  The Director of Public Health noted she would give a presentation to the Board on Oral Health Promotion and Community Water Fluoridation.  She explained a member of the public was also in attendance to ask a question to which she would respond, the Chair having used his discretion to allow questions.

The Director of Public Health explained that in the past, prior to 2022, Local Authorities had had statutory responsibility and decision-making responsibilities for any new or varied water fluoridation schemes.  She noted the responsibility had transferred to the Secretary of State for Health and Social Care in central Government.  It was added that the Leaders of the seven Local Authorities in the North East had wrote to Government in terms of going ahead with water fluoridation.  The Director of Public Health noted that the Adults, Wellbeing and Health Overview and Scrutiny Committee had recently met and supported water fluoridation, with that response to be forwarded as part of ongoing Government consultation.

The Board noted that Local Authorities were responsible for the promotion of oral health, and in 2023 the Oral Health Promotion Strategy for County Durham was updated with water fluoridation being identified as an effective way of reducing inequalities in dental health.  The Director of Public Health noted that the aims of the strategy were to: improve oral health of everyone living in County Durham; reduce oral health inequalities; create supportive environments, working with communities and partners to promote oral health; and contribute to good oral health across the life course.

The Director of Public Health referred to the evidence base for community water fluoridation, noting that it was effective, safe, reduced inequalities, cost effective and sustainable.  She noted oral health was an integral part of overall good health and wellbeing and that the impact of severe tooth decay had wide implications for children and families: pain, hospital admissions, and missed days from school.  

She added that tooth decay was the most common oral disease affecting children and young people with lifelong impacts and although largely preventable, a significant proportion of our residents still experienced poor oral health.

The Director of Public Health explained that water fluoridation was associated with less dental caries and an increase in the number of individuals with no caries.  She added that there was also an increase in the number of individuals with dental caries in areas where water fluoridation schemes had been discontinued.  She noted that ensuring drinking water contained the recommended level of fluoride was an effective way to prevent tooth decay and water fluoridation at levels within the UK regulatory limit of less than 1.5mg/l was effective and safe, and without any convincing evidence of adverse health outcomes.  She explained that fluorosis was a possible dental side effect of water fluoridation and that in mild cases it appeared as white flecks on teeth, however, the risks of fluorosis need to be balanced against the health risks of severe dental decay.

The Director of Public Health noted several common myths associated with water fluoridation, including that fluoride was a poison or pesticide.  She explained that fluoride was naturally present in water and in some areas of the UK it was naturally at levels similar to, or even slightly higher than, those seen in fluoridation schemes.  She noted that fluoride sources originate with fluoride-bearing rocks which were then processed to produce a variety of materials and it was added that fluoride does not change the taste of drinking water.  She noted another myth was that fluoridation was a form of mass medication, however, she noted that a medication was typically used to relieve symptoms and fluoride was a mineral, not a medication.  She added it was proven by decades of research to prevent tooth decay and that fluoridation worked in addition to fluoride in toothpaste.  She noted it was a public health measure endorsed by the four UK Chief Medical Officers.

The Director of Public Health noted another question sometimes raised was why some non-fluoridated areas had better children's dental health than some fluoridated areas.  She noted that while fluoridation was effective, the prevalence of tooth decay depends on a wide range of factors including deprivation, dietary habits and regular tooth brushing with a fluoride toothpaste.  In terms of any risk to pregnancy from fluoridated water, she noted that there was no evidence that fluoridated water at controlled levels had a negative impact on fertility, conception, pregnancy, perinatal health, childbirth or mother and baby wellbeing.  She noted that there were benefits to developing children, which was a major reason for implementing fluoridation, with fluoridated water being the preferred method of getting the benefits of fluoride in the diet to other alternatives, such as supplements or toothpaste.

The Director of Public Health noted that the North East had a long history of fluoridation, both natural and artificial.  She added that areas of the North East that benefit from natural fluoridation were Hartlepool, parts of east Durham and parts of Sunderland, however, only Hartlepool and parts of east Durham had naturally fluoridated water at or near the optimum level for dental health.  She noted that Northumbrian Water had supplied artificially fluoridated water to the North East from the late 1960s including: County Durham, Chester le Street, Consett, and Stanley; Northumberland, Alnwick, Hexham, Cramlington; North Tyneside; Newcastle; and Gateshead.

The Board noted a graph showing levels of dental decay in Middlesbrough, a non-fluoridated area comparted to those in Hartlepool, a naturally fluoridated area, with Hartlepool having reduced levels of decay.  The Director of Public Health noted that in County Durham, 26 percent of five-year-old children living in non-fluoridated areas had decay experience, that being two percent higher than those living in fluoridated areas, at 24 percent, and 3.6 percent higher than those living in naturally fluoridated areas, at 22.4 percent.  She noted that, in County Durham, the prevalence of experience of dental decay was 21.5 percent in 5-year-olds living in the least deprived areas, compared with 31.7 percent of those living in the most deprived areas.  The Director of Public Health referred the Board to data and graphs setting out data from 2020/21 to 2022/23 which showed County Durham’s hospital admission rate for tooth decay requiring tooth removal for 0 to 5 years old was 398.5 per 100,000, equating to 120 children per year.  She noted those children were receiving general anaesthetic, which had inherent risks, for what was a preventable disease.  She referred members to information as regards the cost effectiveness of water fluoridation schemes, highlighting estimated savings in relation to NHS treatment which was preventable as a result of water fluoridation schemes.

The Director of Public Health noted that the Government’s policy paper ‘Faster, simpler and fairer: our plan to recover and reform NHS dentistry’ set out a focus on prevention of tooth decay, including the long-term ambition to systematically bring water fluoridation to more of the country, with a particular focus on the most deprived areas, which stood to benefit most.  She noted there was a legal duty on the Secretary of State to undertake a formal public consultation before entering into new fluoridation arrangements or varying existing agreements to community water fluoridation schemes across the North East of England.  She explained as regards the consultation process, noting it ran for 12 weeks, 25 March 2024 to 17 June 2024, with links included within the agenda papers and presentation to the Government’s webpage.

The Director of Public Health highlighted the support for fluoridation schemes with national support including from: the four Chief Medical Officers of the UK; the Chief Dental Officer from NHS England; the British Dental Association, the British Medical Association; the British Association for the study of Community Dentistry; the British Fluoridation Society; the Royal College of Paediatrics and Child Health; and the British Society of Paediatric Dentistry.  She added that regional and local support came from the dental profession, medical colleagues, the Integrated Care Board (ICB), with all 12 Local Authorities in the North East having expressed their support for the Government’s proposal to extend fluoridation.  She noted that Health and Wellbeing Boards and Health Scrutiny Committees had recognised the impact water fluoridation could have to improve oral health and wellbeing.

She reiterated that the North East North Cumbria ICB supported the extension of water fluoridation across the North East and noted the Association of Directors Public Health North East (ADPHNE) and the Regional Dental Committee all support water fluoridation.

The Director of Public Health noted a quote from Professor Chris Vernazza, Head of School of Dental Sciences, Newcastle University, Professor of Oral Health Services and Honorary Consultant in Paediatric Dentistry:

“In my clinical work, I see the devastating impact of dental decay on children and their families and every time I remove multiple teeth from a child under general anaesthetic, I am deeply saddened. There is good evidence for the benefits and safety of water fluoridation and the economic arguments stack up too. I fully support implementation of fluoridation in our region as a key part of the package required to prevent this widespread disease”.  

The Director of Public Health concluded by noting that the Local Dentistry Committee expressed their full support to extend water fluoridation, noting the benefits as a public health intervention.  She asked Mr M Watson, member of the public to ask his question.

Mr M Watson noted tooth decay data relating to five-year-olds collected in Oral Health Surveys (OHS) for 2021-22 only had a response rate of 3.8 percent, and therefore there was concern in terms of the low rate of response over the last 14 years in respect of this data.  He asked, with such scant historical data, how would it be determined if water fluoridation was a success in the future.

The Director of Public Health noted that the monitoring was carried out by Government, with the Council receiving reports regularly, with three having been received to date.  She explained these reports were prepared by the Water Fluoridation and Health Monitoring Working Group, on behalf of the Secretary of State for Health and Social Care, in intervals of no greater than four years, the last being received in 2022. 

She noted the report detailed hospital data and information for 0- to 19-year-olds, and information was reviewed locally and monitored in terms of trends to help target interventions and responses.  She added that information relating to monitoring was shared and fed back to Government.  She noted she did not agree that there was scant historic data, adding that historic and contemporaneous data was both qualitative and quantitative, and in line with national standards.

The Director of Public Health noted a number of questions from members of the public from County Durham and some other areas which had fallen under a number of themes, and responses would be sent to those individuals.  She explained several questions related to concerns in adding hexafluorosilicic acid to water supplies.  She explained that the 1985 Fluoridation Act specifically identified the use of hexafluorosilicic acid as a chemical permitted for use in community water fluoridation schemes and therefore the Government were exercising the power under the Act, reiterating that hexafluorosilicic acid was stated specifically within the Act for use in water supplies.  She added there was very strict monitoring regimes by water authorities.

The Director of Public Health noted that some questions had related to the public consultation and how the public were being made aware.  She noted that Local Authorities would respond to the Secretary of State for Health and Social Care, adding that Local Authorities and the Health and Wellbeing Boards were consultees that would respond to the Department for Health and Social Care.  She noted the Government responsibility to inform the public, however, noted that the meetings of the Adults, Wellbeing and Health Overview and Scrutiny Committee and Health and Wellbeing Board were open to the public.

Councillor R Bell noted Cabinet had taken a view that the Adults, Wellbeing and Health Overview and Scrutiny Committee and Health and Wellbeing Board should respond to the consultation.  He noted he felt that water fluoridation should be a last resort, once other interventions such as suppling toothpaste and direct advice on teeth cleaning were exhausted.  He noted that many young people would rarely ask for a drink of water, many drinking sugary carbonated drinks.  He added many others consumed tea and coffee as their main drinks.  He asked as regards any correlation in terms of consumption of fluoride and evidence of issues in the older population, such as osteoporosis.  David Landes, Consultant in Dental Public Health, NHS England explained there had been a number of studies which showed reduction in decay in fluoridated areas, and associated decreases in dental disease.  He noted there had been a number of studies with older people and there had been no evidence of increased hip fractures.  He noted studies in Hartlepool, which had similar fluoride levels since around 1840 and no impact or difference was seen compared to other lower fluoride level areas. 

The Consultant in Dental Public Health explained that oral health had significantly improved over the last 30-40 years with the increase in use of toothpaste and fluoridation, adding that fewer older people were wearing dentures.     

Resolved:

(a)         That the update report and presentation be noted;

(b)     That a response on behalf of the Health and Wellbeing Board to the consultation be drafted and submitted accordingly.