Health and Care Bill

Earl Howe Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 31st January 2022 Lords Chamber

I hope that the Minister will be able to accept what I regard as sensible amendments to move us toward a strategy to deal with the treatment and prevention of oral ill-health.

[Earl Howe (Con)]

My Lords, I am very grateful for the contributions to this debate from noble Lords, bringing us to a set of issues which many of us have been grappling with for a number of years.

I turn first to Amendment 224, and the access issue. The point I must stress before any other is that this Government are committed to improving access to dental services across England. With that aim, we are working closely with NHS England to increase dental capacity as rapidly as possible. Since the start of the year, the threshold for dental activity in NHS practices has again increased and is set at 85% of pre-pandemic activity, allowing more patients to be seen. Building on this, NHS England recently announced an extra £50 million to urgently provide hundreds of thousands of additional appointments.

Beyond recovery from the pandemic, we recognise the need to reform the NHS dental contract to increase access. NHS England is leading on dental system reform and working closely with key stakeholders to deliver this. I think it was the noble Baroness, Lady Merron, who asked about dental morale. Much of any dip in morale has to do with what is seen as a delay in introducing the new dental contract, which has been promised for a number of years. There are all sorts of very valuable reasons for that delay, which the profession is being consulted on, but I understand that dentists are keen to see a new structure of remuneration.

That is a summary of the current backdrop. Noble Lords should be in no doubt of the Government’s continuing commitment to improving the provision of NHS dentistry across the country. What we are doing demonstrates that commitment, and for that reason we do not feel that a requirement to publish a statement on this work is necessary.

This brings me to the amendments on water fluoridation. This Government want to see more of the population benefit from fluoridation, which we know reduces oral health inequalities and the burden on NHS services. I will first address Amendments 259B and 259D, tabled by my noble friend Lord Reay, which take us in a different direction. I realise that he feels strongly about the issue, but in relation to Amendment 259B, the clear advice that I have received is that there is no evidence of harms to the environment from water fluoridation schemes. There are existing safeguards in place to protect the environment and public health.

As part of their overall responsibilities, water companies are already required to comply with relevant environmental legislation. The Town and Country Planning (Environmental Impact Assessment) Regulations 2017 and other legislation set out the thresholds and criteria for which an environmental impact assessment is already required. The installation of water fluoridation plants in some areas may already fall within this scope. The Environment Act 2021 will, when brought into force, place a duty on the Government to have due regard to the policy statement on environmental principles in our policy-making. New and revised policies will need to take into account their impact on the environment. The Environment Agency also monitors the ecological health of our rivers at a large number of sites. If there had been or were to be a failure in the safeguards, the agency could detect this through its routine monitoring programme.

Turning to Amendment 259D, I emphasise to my noble friend that the scientific evidence around fluoridation is kept under constant review. Several authoritative scientific reviews have looked at the general health effects. The common finding of such reviews is that there is no convincing scientific evidence that fluoride in drinking water at levels used in fluoridation schemes is a cause of adverse health effects. This view is shared by the UK Chief Medical Officers, who issued a joint statement last September supporting water fluoridation as a safe and effective public health intervention to improve oral health.

I listened carefully to my noble friend, but the Government are committed to keeping the evidence under review, and it would be inappropriate to carry out evidence reviews focusing on studies from a specific time period and a specific part of the world, as he suggested. Keeping the evidence under review is what we will do but the Secretary of State is also required to monitor the effects on the health of the population living in areas with water fluoridation schemes and then publish a report no less than every four years. The next report is due in March of this year.

My noble friend suggested that the water fluoridation elements of the Bill have somehow been slipped in without adequate time for debate. In fact, the White Paper setting out proposals for the Health and Care Bill, published in February 2021, highlighted the current difficulties faced by local authorities and set out our intention to use the Health and Care Bill to give the Secretary of State the power to directly introduce, vary or terminate water fluoridation schemes. So the water fluoridation elements of the Bill have been there from the outset and open to debate.

Both my noble friend and the noble Lord, Lord Storey, referred to the Childsmile initiative in Scotland and asked why we cannot have a scheme in England. In fact, daily supervised toothbrushing programmes in England can already be entered into by local authorities or the NHS. There are already some schemes around the country; I visited one myself when I was dentistry Minister. Public Health England has published guidance in this area to help local authorities who are interested in schemes. Against that background, I hope that my noble friend will feel at least a little reassured, and sufficiently so to refrain from moving his amendments when they are reached.

On Amendments 260 and 262, the public voice on further fluoridation remains important and we are committed to ensuring that the population continues to have its say on any future water fluoridation schemes. We are bringing forward plans for an initial expansion of water fluoridation schemes over the next three years. We will consult the public on these plans later this year, subject to the successful passage of the Bill and funding being confirmed. The outcome of that consultation will inform regulations to be drafted later this year. These regulations will be subject to the affirmative procedure.

Underpinning any scheme expansion is the need to undertake feasibility studies and to secure funding, as well as public consultation against which we do not have certainty and cannot pre-empt the outcome. As such, we cannot at this stage set out a programme of expansion; because of that, any programme drafted in advance of the completion of these steps would be so heavily caveated and subject to change that its utility would be substantially undermined. I am of course very happy, as is my noble friend Lord Kamall, to update the House as expansion plans are developed and agreed. However, we do not believe that this needs to be specified on the face of the Bill.

Amendment 261 relates to cost-sharing for new schemes. There are no current proposals for cost-sharing. However, given the cycle of legislation and the infrequency with which these opportunities present themselves, we have taken the decision to include such measures now to provide flexibility for this in future. I can assure the House that, should we bring forward any plans to cost-share in the future, we would seek to fully engage with relevant groups at the earliest opportunity. Any plans to cost-share with public sector bodies would also be subject to regulations on which there is a requirement to consult.

I would say to the noble Baroness, Lady Walmsley, that funding for both new and current health improvement initiatives is within the overall capital budget allocated to the department over the next three years. We will be undertaking a business planning exercise before this funding is made available from April 2022, and we will confirm this is due course.

The noble Baroness asked about the effect on water bills. There will be a cost associated with water fluoridation schemes that will need to be met either through taxation or other means. However, we know that in the end this is a cost-saving measure; the money spent to implement these schemes will save the nation money in the longer term and will benefit health. As I said, currently there are no plans to cost-share with water companies or indeed any other public sector bodies. However, given the opportunity presented by the Bill, we are enacting the relevant provisions.

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[Baroness Bennett of Manor Castle (GP)]

I raised the issue of the lack of public trust in tap water and the fact that that is a public health issue and could be magnified. Could the Minister comment on that and suggest what the Government are planning to do about it?

[Earl Howe (Con)]

I apologise to the noble Baroness, because she was making a significant point. I am not sure that I share her perception that those who buy bottled water in supermarkets necessarily do so as a reflection of their lack of trust in tap water; a lot of it has to do with some myths around the benefits of bottled water. However, be that as it may, I will take advice and write to the noble Baroness. I am not sufficiently sighted on the issue she raised and the evidence behind it, so it is probably appropriate if I look into it and write to her.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this has been a very interesting debate. On dental access, a number of noble Lords—my noble friend, the noble Baroness, Lady Bennett, the noble Lord, Lord Storey, and the noble Baroness, Lady Walmsley, among others—commented on the great difficulty that many people have at the moment in getting access to an NHS dentist. The noble Lord, Lord Storey, focused in particular on children, which is my particular concern. More energy needs to be put into developing a dental strategy. On thoughts of contracts, anyone who has been a dental Minister will know that the problem with contracts is that dentists always overperform, and the Treasury then claws back in future years, leading to unhappiness and misery in the profession. The fact that the pilot schemes, on which I think work is being based for a future contract, have now stopped, or are going to be stopped, is a great pity, and it does not show positive intent.

On fluoridation, I was delighted that the noble Lord, Lord Young, intervened. A couple of debates ago I was watching on the screen, and he chided me for what I thought was a perfectly formed piece of legislation at the time, many years ago. He talked about his experience as a Minister 42 years ago. I think it was because of his work that I, 37 years ago, as secretary of the Edgware/Hendon Community Health Council, organised public meetings in part of the Borough of Barnet on fluoridation, prior, we hoped, to the then area health authority implementing a fluoridation scheme. Although the public meetings came out strongly in favour of fluoridation, of course nothing happened. I am afraid that the experience in Barnet and Edgware and Hendon was repeated up and down the country, which is why I applaud the Government for doing what they are doing now.

The noble Baroness, Lady Northover, spoke very eloquently about the evidence from deprived areas. Sandwell, next door to Birmingham, is high up in most indicators of poor health, except in dentistry. That is because, unlike Liverpool, Birmingham City Council took the decision in the 1960s to fluoridate the water supply and Sandwell got the benefit. The result is that, in general, oral health in the West Midlands is very good indeed.

I listened with great interest to the noble Lord, Lord Reay. He mentioned the Jauncey judgment, which unfortunately I remember. I remind him that, although Lord Jauncey ruled that Strathclyde Regional Council was exceeding its powers in seeking to fluoridate the water system, he accepted that the amount of fluoride it wanted to put into the system would have no significant adverse effect on health, that fluoridation had been shown to be harmless and that it would be effective. When we quote Lord Jauncey, we need to quote the whole judgment, rather than just whether Strathclyde was found to have the power to put fluoride in the water.

I will not repeat what the noble Earl, Lord Howe, said. In only September, the Chief Medical Officers spoke in their judgment about the effectiveness and safety of fluoride. I was very glad to hear the point the noble Earl made about expansion; I am very glad that it is on the Government’s mind. I look forward to the consultation, which I take will be a national one, if there is going to be an expansion; that is very good news indeed.

On cost sharing, I register that this Bill is full of little clauses which give Ministers powers to do something in the future, when they know what they want to do. I mention procurement regulations in Clause 70 at the same time; I think that is going a bit too far. Having said that, I beg leave to withdraw my amendment.