NORTHERN IRELAND FORUM

FOR

POLITICAL DIALOGUE

_____________________

INVESTIGATION INTO THE

PROPOSED FLUORIDATION OF

WATER SUPPLIES IN

NORTHERN IRELAND

(Interim Report)

by

STANDING COMMITTEE C

HEALTH ISSUES

8 November 1996

ACKNOWLEDGEMENT

The Committee wishes to express its thanks and gratitude to all of the people who contributed in any way to its investigation into this complex and difficult subject.

We recognise that sacrifices were made in terms of time and effort and in some cases substantial costs were incurred by those who assisted with the work of this investigation.

The Committee is much indebted to all concerned.

CONTENTS

1. BACKGROUND 1

2. CONTEXT 1

3. HISTORY 2

4. MODE OF INQUIRY 3

5. ANALYSIS 4

6. FINDINGS 4

7. RECOMMENDATIONS AND REASONING 7

8. SUMMARY OF KEY RECOMMENDATIONS 11

APPENDICES

Appendix A Letter from Committee to Minister of 27.9.96

Appendix B Letter from Committee to Minister of 11.10.96

Appendix C Letter from Minister's Office to Committee

Appendix D Details of those who gave Oral Evidence

Appendix E Details of those who gave Written Evidence

Appendix F Committee Membership

Appendix G Committee Remit

1. BACKGROUND

1.1 Following representations made to it, the Health Committee of the Northern Ireland Forum for Political Dialogue decided to look into the issue of fluoridation of the public water supply - this being an issue of public concern which fell within its remit (see Appendix G).

1.2 All of the representations were from groups and persons opposed to fluoridation. No-one in favour of fluoridation had approached the Committee, either in response to its press notices or through contact with members, and there was some concern that that particular side of the argument should also be heard.

1.3 As a result of this individual members of the Committee were empowered to make contact with a number of the principal advocates of fluoridation in the Province. These then formally sought a hearing before the Committee.

1.4 Because of the time pressures on the Committee, transcripts of the oral cases presented by the witnesses before the Committee, do not accompany this report.

2. CONTEXT

2.1 This Report was prepared in great haste in order to meet a deadline for a decision on fluoridation of the public water supply in Northern Ireland by the Minister, Mr Malcolm Moss. Of necessity, it must be regarded as an interim report.

2.2 The Committee had written to the Minister on 27 September 1996 and on 11 October 1996. A response was sent from the Minister's office on 23 October 1996 indicating his timescale for decision. The original deadline was later relaxed when it became clear that the Forum could not possibly have responded to the timescale indicated. The correspondence is appended.

2.3 The Committee is concerned at, and wonders as to the need for, the apparent haste of the Minister to decide on the matter and trusts that this is not indicative of a decision having already been made.

2.4 Because of the time limitations placed upon the efforts of the Committee it was seriously limited in what it could hope to achieve. There was a need to produce within the given timeframe a document that would attract the endorsement of the Forum and thus enable the Minister to make an informed decision. Nevertheless notwithstanding this constraint the Committee is confident of its conclusions and recommendations.

3. HISTORY

3.1 The proposed fluoridation of public water supplies has been an emotive subject over many years and is an issue that is far from being confined to Northern Ireland or the United Kingdom.

3.2 Parts of the United Kingdom public water supply are fluoridated and indeed this is the case in Northern Ireland where water supplied to Tandragee and parts of Holywood is subject to fluoridation. This has been the case for decades. The water supply for the rest of the Province is not fluoridated but provision exists under the Water (Fluoridation) (Northern Ireland) Order 1987 to change this situation.

3.3 The Order empowers the Department of the Environment for Northern Ireland, on the application of a Health and Social Services Board, to fluoridate the water supplied within the area, or a part of the area, of that Board.

3.4 Before making such an application the Board is required to publish details of its proposals, to consult District Councils within the affected area, and obtain the approval of the Department of Health and Social Services.

3.5 In 1992 after a consultation period the Boards decided to fluoridate water supplies in their areas. Progress was stymied however because the areas supplied by the reservoirs at Dunore Point and the Silent Valley altered and it was felt that under the provisions of the Order the Boards were once again obliged to enter into a further period of consultation.

3.6 The Boards prepared a joint consultative document and the consultation process was launched in 1996 through press advertisements. The closing date for responses was 12 April 1996.

3.7 Public representatives and District Councils were also asked to submit their views and the Health and Social Services Councils were consulted.

3.8 The Boards have completed their period of consultation and have now applied to the Minister, Mr Malcolm Moss, in his capacity as Minister with responsibility for the Department of Health and Social Services (DHSS), for permission to approach the Department of the Environment to arrange fluoridation of the water supply. The arrangement is that DHSS will fund fluoridation over the next ten years at the rate of two schemes per year. The reservoirs at Dunore Point and Silent Valley are however the largest; between them they provide water for around half the province's population.

4. MODE OF INQUIRY

4.1 Two days of the Committee's time were set aside to hear those wishing to speak on fluoridation. This was based on the representations made by the parties to the debate and also took into account the possible time limitation that an imminent Ministerial decision would place upon the Committee.

4.2 Because the unprompted responses were from those opposed to fluoridation those who wished to speak on that subject were heard first (on 17 October). This allowed notice of hearings to be given to the later respondents (the pro-fluoridation group).

4.3 There were some objections to this sequencing from the group opposing fluoridation on the grounds that those proposing change, ie a move to fluoridation, should, in their view, according to generally applied principles, be required to put their case first. It was also the case that those opposed to them were afforded the opportunity to hear them put their case from the public gallery before preparing and putting their own. The Committee however felt that this would not prejudice a fair hearing bearing in mind that all parties could present additional written evidence of rebuttal at any stage.

4.4 Oral evidence was supported by substantial documentary evidence from both sides in any event and this included documentation sent in after the hearings referring to points made by opponents at oral sessions.

4.5 Details of those who presented evidence are appended. It will be noted that the proponents of fluoridation were mainly members of the dental profession (this is also true of the written evidence) while their opponents were a more mixed group of people of a similar standing in the community.

5. ANALYSIS

5.1 Evidence offered in support of the cases ranged from the anecdotal to academically researched material. The Committee has analysed this under a number of headings in an attempt to crystallise the main findings that can sensibly be drawn from the complex body of evidence given. Arguably there might be other headings or different headings, but it is our view that the main burden of the argument breaks down under the categories of dental, medical, environmental and political. The principal issues identified in the last of these are the democratic and legal processes.

6. FINDINGS

6.1 The Committee has drawn the following conclusions from the information made available to it during the course of its investigation.

Dental

6.2 The evidence given to the Committee, both oral and written, supporting the fluoridation of the public water supply on the basis of dental health benefits that might reasonably accrue, was strong and clearly presented in a systematic and well-rehearsed way.

6.3 There can be no doubt that the chief supposed benefits to the community of fluoridation would come under this heading. The advocates of fluoridation would identify advantage in terms of an improvement in dental health and well-being in the community and the concomitant cost savings of a reduced requirement for dental care.

6.4 Arguments deployed against fluoridation challenge its effectiveness in the dental area and maintain that it can be deleterious to the dental health of the population.

6.5 The Committee as a whole is in no position to make an assessment of the relative strengths of the opposing arguments in this area. Suffice to say that it seemed clear to us that the dental establishment is foremost amongst the pro-fluoridation lobby and it would seem that a majority of dental practitioners support it.

Medical

6.6 Medical evidence was produced on both sides with each group fielding

medically-qualified advocates. Some of the opposing argument was of a highly technical nature. Once again, the Committee could not, in the time available to it and with its limited resources, come to any definitive conclusion on the question of the effects of fluoride on the general health of the population. Some of the statements made by those opposed to fluoridation, should they prove to have a factual basis, would give the Committee considerable cause for concern.

6.7 There may be, as is often the case, a degree of truth in each of the respective positions but until the balance of this is clear to (a) those whom the proposition to fluoridate will affect, and (b) to decision-makers, it would plainly be imprudent to proceed further. Different members of the Committee, as the oral transcripts will show, were unhappy with the evidence given by both sides in this area.

Environment

6.8 The affects of fluoridation on the environment were discussed in some depth by both sides and particularly by those opposed to the proposition. The stances taken by the two groups were far apart and little or no common ground could be identified by the Committee. The Committee is not able to take a position on the matter and doubts the wisdom of anyone else attempting to do so on the basis of the evidence given to us to date or of any analysis attempted to date.

Political

6.9 The Committee is cognisant of the requirements of Article 6 of The Water (Fluoridation) (Northern Ireland) Order 1987 which places upon the Boards a requirement to consult (as part of a series of steps it must take) before it can fluoridate a water supply. Consultation under this provision was carried out by the various Boards using a jointly agreed advertisement. The joint approach ceased at this point and the Boards then consulted, in keeping with the provision, in their own areas. Most of the participants in the consultative process appear to have been medical and dental professionals.

6.10 So far as the Committee can ascertain there was little involvement of the public at large and yet this is a matter that is so universal in its implications that it potentially affects the whole general population. It should be remembered that the Boards are not democratically elected bodies and that the most powerful influences within them are probably the health-care professionals.

6.11 The Committee also notes that virtually all District Councils are opposed to fluoridation. The Council ward is the smallest political unit returning an elected representative within our political system. If elected representatives at this level are opposed to fluoridation then it would seem sensible to assume that the scale of underlying misgiving about fluoridation amongst the general public is large. Indeed if the democratic process is to be accepted as a representative yardstick at all - and in

the absence of anything else it has to be - the scale of opposition is likely to be infinitely larger, in purely numerical terms, than the numbers currently supporting the stance taken by the Boards.

6.12 The Committee also notes that the Health and Social Services Councils are opposed to fluoridation.

6.13 All of this raises in the minds of the Committee the inescapable question of the effectiveness of the Boards' various consultative processes. Where for instance is there evidence of public participation sufficient to justify anyone taking decisions in its name? Without this the process can only be regarded with great suspicion and indeed some might view it in stronger terms.

7. RECOMMENDATIONS AND REASONING

7.1 The quantum of written evidence provided by both sides in the short timeframe of the Committee's enquiries was truly massive. This is to some extent a reflection of evidence already produced for discussion in other fora at earlier dates. It is also a subject that has generated, and continues to generate, debate world-wide and we must not lose sight of this.

7.2 The continuing high level of debate points to the fact that we are not dealing here with a simple clear-cut issue. The subject is emotive and opinions are strongly, and in our view very genuinely, held.

7.3 The Committee was most impressed by the standard of presentations and the determined effort put in by the two opposing groups.

7.4 Our task as representatives of the people is to do what we consider to be best for those we represent. It seems to the Committee that this boils down to acting positively where there is a reasonable degree of certitude and refraining from rash actions where there is an absence of this.

7.5 The proposition was put to the Committee that it should exercise "leadership" by supporting the advocates of fluoridation and persuading those who have doubts. This argument in the Committee's view seems to be a means of circumventing adequate consultation and the democratic process and cannot be subscribed to.

7.6 Another argument has been advanced that society needs to be guided by those within it who are expert in a given field. But who is to decide who the experts are when both sides of the argument claim an expertise? It in any case seems to us that this is an argument propounded by some experts who are convinced that they know best. They may make their proposals for the best of motives but once again ignore the basic

requirements of democracy where in the end, when it comes to the decision, everyone must be accorded the same standing.

7.7 It raises also a moral question: Is it right ethically to ignore the will of the people most affected by handing them over to the tender mercies of the experts? We do not think so.

7.8 The fluoridation debate as it has turned out is as much an exercise in democracy, or at least it ought to be, as it is about scientific argument. It is reasonable and necessary that the experts argue so that knowledge might progress; but please let it be the people who decide. This is nothing more than a very fundamental requirement of democracy in action and it is the only sensible way to proceed.

7.9 It does not, in the public perception, make sense or inspire confidence in their even-handedness, or at least in their expertise in consultation, for the Boards to in the first instance conduct a "consultation" and then to become the main advocate of one side of that process. The Boards as appointed bodies are seen as part of an administrative superstructure and they do not, and cannot possibly, represent the Northern Ireland public in this matter.

7.10 The Committee notes that Boards themselves had voted in favour of proposals to fluoridate before they began their present consultation phase. This consultation phase was necessary because of changes to the areas supplied by the two large reservoirs. In view of the Boards' earlier decision the Committee fails to see how they could proceed to a consultation phase and purport to maintain an open mind on an issue that had, effectively, already been decided by them.

7.11 The consultation process must not be seen as a "going through the motions": heed must be taken of public concerns and decisions must accurately reflect these.

7.12 The Committee noted that those opposed to fluoridation claimed to be at a disadvantage because those proposing fluoridation (mainly the Boards) were fully funded in their effort indirectly by the Government itself while they (those against) had to resource themselves. Future consultation should, in our view, be designed so far as is possible so that no group can claim such disadvantage. Credibility and assurance that there are no possible conflicts of role or interest in such a process is

most important.

7.13 On the basis of the foregoing we conclude that any decision to proceed with fluoridation at this time would be a wholly irresponsible and premature decision that would fly in the face of public sentiment.

7.14 The Committee cannot therefore recommend the planned fluoridation of the water supply. Of the four areas discussed in paragraph 6 above, it was the political concerns which united the Committee against the fluoridation proposals.

7.15 The Board's proposals in the face of near unanimous local authority opposition most clearly demonstrates the flaws in the consultative process. The Committee reiterates that to ignore the wishes of the democratic representatives of the proposed recipients of fluoridated water is at best high arrogance and at worst abusive.

7.16 A proper and credible widescale independently conducted consultative process should have taken place. Broad agreement with the Province's elected representatives on how this might have been achieved would have been the logical starting point.

7.17 The Committee does not wish to speculate on what conclusion a better prescribed, more rigorous and more acceptable process of public consultation would have reached. However, such an approach would have been the only equitable way to determine the merits or demerits of fluoridation.

7.18 In the absence of a Province-wide body with an administrative role, where public bodies undertake a consultative process the views of local authorities must be given proper weight. Indeed the views of the local authorities must be a major determining factor in any such process.

7.19 Legislative changes should be made in order to facilitate this. The mistakes exposed by the "consultation" over fluoridation must not be repeated. The "nanny state" is not a healthy role model for any future form of accountable democracy in Northern Ireland.

7.20 The Committee recognises the high levels of dental disease, particularly amongst children in Northern Ireland.

7.21 It acknowledges the commitment and expertise of those involved in preventing and treating dental disease.

7.22 The Committee recommends widespread support for further efforts to promote dental health, including dental hygiene, encouragement for dental attendance, health education, and the involvement of the public in planning and developing dental services.

117.23 Finally the Committee or its representatives is willing to meet the Minister at any time to discuss these issues.

8. SUMMARY OF KEY RECOMMENDATIONS

8.1 A decision on fluoridation of the public water supply should be deferred until the other Recommendations are implemented (7.4, 7.6, 7.7, 7.8, 7.13, 7.14).

8.2 The views of local authorities must be given proper weight and these should be a major determinant of the decision in fluoridation (7.17 & 7.18).

8.3 Legislative change should be made where necessary to facilitate the foregoing (7.19).

8.4 The Committee recommends widespread support for further efforts to promote dental health (7.22).

8.5 The Minister is invited to discuss the report with the Committee or its

representatives (7.23).

APPENDICES

APPENDIX D

STANDING COMMITTEE 'C'

HEALTH ISSUES

Details of those who attended and gave oral presentations:-

DATE | NAME | PROFESSION (where known)

17.10.96

(Anti-Fluoridation)

Rev O Collins | Minister of Religion

Mrs O Collins | Pharmacist

Miss M Hanna

Dr D Holmes | Lecturer

(Representing the Environmental Alliance)

Mr Boyd

Mrs M Harbinson

(Representing NPWA)

Dr P Mansfield | Medical Doctor

(Representing Upper Bann Pure Water Association)

Ms V Best

24.10.96

(Pro-Fluoridation)

Mr W Maxwell | Dentist

(Representing the EH&SSB)

Mr T Frawley | General Manager

Dr B McConnell | Medical Doctor

Miss J McGaffin | Dentist

(Representing the WH&SSB)

Mr N Campbell | Dentist

(Belfast City Hospital)

APPENDIX E

STANDING COMMITTEE 'C'

HEALTH ISSUES

Details of those who presented Written Evidence:-

In Support of Fluoridation:

Dr Longmore BDA'; 'Working for Dentists'

M A Lennon University of Liverpool; Professor of Preventive Dentistry

Mr W Maxwell Eastern Health & Social Services Board

Mr T Frawley Western Health & Social Services Board

Mr N Campbell Dentist - Belfast City Hospital

Against Fluoridation:

T Moore National Pure Water Association (NPWA)

Mrs M Harbinson " " " "

Mrs J Jones " " " "

Dr D Holmes College Lecturer

Rev O Collins Church of Ireland Clergyman

Mrs O Collins Graduate Pharmacist

Miss M Hanna

Miss C A Weatherup

Mrs R Allen Southern Health & Social Services Council

Mr M Rotherham Environmental Alliance

Ms H Orr " "

Mr Dunlop

Miss V Best

Mrs P Kennedy

APPENDIX F

STANDING COMMITTEE 'C'

HEALTH ISSUES

Committee Members who attended the Evidence Session on Fluoridation:-

Lord Alderdice Alliance

Mrs M Beattie DUP

Mr C Calvert DUP

Mr G Campbell DUP

Dr A Evans Labour

Mr S Gardiner UUP

Mr P King UUP

Mr F McCoubrey UDP

Mrs J Parkes DUP

Mr T Robinson UUP

Mr H Smyth PUP

Mrs M Steele UUP

Dr J Wilde Women's Coalition

Mr C Wilson UKUP

Mr R Empey* UUP

Mrs V Kinghan* UKUP

Mrs M Marshall* Alliance

Ms G Rice* Alliance

Rev E Smyth* DUP

*Not regular members of the Health Committee during period of investigation.

APPENDIX G

REMIT: The Forum has set up a number of Committees. The Committee to deal with HEALTH ISSUES is among these.

DESIGNATION: STANDING COMMITTEE C

TERMS OF REFERENCE: To examine the health needs of the community in

Northern Ireland with particular reference to health care administration; acute hospital services, community care services and access by the rural

community and report to the Forum by 31 March 1997.

• Investigation into the Proposed Fluoridation of Water Supplies in Northern Ireland (Interim Report) (introduced on 1996-11-07 00:00:00 - CREATE - e799631) [This document] [view current proposal at this moment]
  • None (introduced on 1996-11-07 00:00:00 - REPORT_PROPOSAL - e799634) [view current proposal at this moment]