Open consultation

Community water fluoridation expansion in the north east of England

Updated 24 April 2024

Applies to England

Introduction

The Health and Care Act 2022 provides powers for the Secretary of State to introduce, vary and terminate community water fluoridation schemes.

Faster, simpler and fairer: our plan to recover and reform NHS dentistry sets out a focus on prevention of tooth decay. This includes the long-term ambition to systematically bring water fluoridation to more of the country, with a particular focus on the most deprived areas, which stand to benefit most.

Before using these powers, public consultation is required on the proposal.

We are consulting on a proposal to request the relevant water company, Northumbrian Water Limited (NWL), to enter into new fluoridation arrangements, and to vary existing agreements, in order to expand community water fluoridation schemes across the north east of England. This is because of the significant and long-standing inequalities in the region and is part of the government’s plan to improve dental health.

Our proposal

Around 1 in 10 people in England currently have fluoride added to their drinking water supplies. We are proposing to expand community water fluoridation further in the north east. Following this consultation, subject to a decision by the Secretary of State, the government would enter into agreements with NWL to increase the level of fluoride to the water supply in specified areas. The Secretary of State is also responsible for reimbursing water companies for costs associated with water fluoridation schemes with no impact on customer bills.

This proposal builds on earlier work supported by local authorities and partners in the north east to publicly consult on expanding community water fluoridation.

The World Health Organization (WHO) recommends a maximum level of 1.5 milligrams of fluoride per litre of water (mg/L). There is strong scientific evidence that water fluoridation schemes can help reduce tooth decay and is a safe and effective intervention.

The government can require water companies to increase the naturally occurring concentration of fluoride in water supplies to 1.0 mg/L. This is well within WHO’s recommended maximum level known to reduce tooth decay. Similar schemes operate around the world covering an estimated 400 million people, including in the USA, Canada and Ireland. Around 6 million people in England already have extra fluoride added to their water supply, while some supplies provide a similar level of fluoride naturally.

We have asked NWL to investigate whether it would be operable and efficient to supply fluoridated water throughout the rest of the north east of England. This could largely be achieved by introducing the necessary equipment at existing water treatment works.

Expanding community water fluoridation in the north east will generate a net social benefit of £315 million to:

• reduce tooth decay in children and adults
• reduce the disparities in dental health, particularly for children
• reduce the need for dental services and costs to the NHS, such as children going to hospital for tooth extractions due to decay and managing the burden of pain and infection

Geographical scope of the proposal

Existing areas

Many places in the north east of England are already covered by existing agreements to increase fluoride levels, dating back to the late 1960s and around half the population of the area. These existing areas include:

• parts of County Durham
• Gateshead
• Newcastle upon Tyne
• North Shields
• Wallsend
• Whitley Bay

Proposed expansion areas

Our proposal would extend this further so that the following local authorities would all have fluoridated water at a level that reduces tooth decay:

• Darlington
• Durham
• Gateshead
• Hartlepool
• Middlesbrough
• Newcastle
• Northumberland
• North Tyneside
• Redcar and Cleveland
• South Tyneside
• Stockton
• Sunderland

Because of the way water is provided, there would also be some supply to neighbouring parts of Westmorland and Furness Council and North Yorkshire Council areas.

Excluded areas

Feasibility work has identified that there are some isolated rural areas where it would be impractical due to their location to supply fluoridated water in a cost-effective way.

Areas in and around Hartlepool are also largely supplied by Anglian Water where water naturally contains fluoride at a level that is beneficial to dental health. Those areas are also therefore not part of the proposal to expand the community water fluoridation scheme.

Map

The entire area covered by this expansion proposal can be seen in the map below, which sets out where existing agreements are in place, the areas where water is naturally fluoridated to the necessary levels and those areas that would be excluded.

You can check whether you are affected by the proposal by entering your details at this postcode checker. The postcode checker has been updated to add some postcodes related to the Alston area that were previously omitted.

Oral health needs in England and the region

While oral health has improved greatly in recent years, tooth decay remains a significant, yet largely preventable, public health problem in England. It is caused by consuming sugary food and drinks and poor dental hygiene. It affects people at all stages of life and is the most common oral disease in children. Tooth decay is also a progressive disease which, if left untreated, can cause severe pain and infection leading to difficulties eating, sleeping and socialising. Evidence (see the health monitoring report for England 2022) shows water fluoridation is one effective way to help prevent tooth decay.

In the school year 2021 to 2022, almost a quarter (24%) of 5 year olds in England had experienced tooth decay. Those in the most deprived 20% of areas of the country were 2.5 times as likely to have experience of tooth decay as those in the least deprived 20% of areas. In the same year, some groups were more affected by tooth decay. The oral health survey of 5 year old children 2022 showed 38% of children in the Asian or Asian British ethnic group were affected by tooth decay. School children in year 6 living in the north east were more likely to have tooth decay (16%) compared with children living in the south west who were less likely (12%).

Tooth decay can disrupt children’s learning and development as pain and infections from decayed teeth can result in school absences. In 2019, data showed 6% of children aged under 16 in England had time off nursery or school in the previous 6 months because of problems with their teeth, mouth or gums.

Tooth decay is still the most common reason for hospital admission in children aged between 6 and 9 years. Tooth extractions in hospital can also impact schooling and educational attainment, as well as being a distressing experience for children and their families.

The adult dental health survey 2009 showed that 30% of adults in England had decayed teeth with 34% of adults in the north east affected.

Tooth decay also has a considerable impact on the NHS. The costs to the NHS of hospital admissions for tooth extraction in children aged 0 to 19 years have been estimated based on the latest NHS national cost collection data. The costs were £64.3 million for all tooth extractions and £40.7 million for tooth decay related extractions in the financial year 2022 to 2023.

There are large inequalities in oral health across the north east of England. Every child who has teeth is at risk of tooth decay, but the risk increases for those living in more deprived areas.

Local and regional needs assessments have also identified lack of access to water with adequate levels of fluoride as an important gap for improving oral health.

Evidence

Health

The 4 UK Chief Medical Officers have concluded that on balance there is strong scientific evidence that water fluoridation is an effective public health intervention for reducing the prevalence of tooth decay and improving dental health equality across the UK. It should be seen as a complementary strategy, not a substitute for other effective methods of increasing fluoride such as fluoride toothpaste. Good practices such as regular dental check-ups and limiting sugar are important, but water fluoridation does have a positive effect even when those practices are absent.

There have been multiple systematic reviews of water fluoridation schemes from around the world. The common finding of these reviews is that water fluoridation is a safe and effective public health intervention for reducing the prevalence of tooth decay. There is evidence that levels of tooth decay are lower in fluoridated areas compared to areas without water fluoridation schemes. Systematic reviews which have looked at the general health effects of fluoridation have found no credible evidence that water fluoridation is harmful to health at permitted levels.

There is a legal obligation to monitor health impacts of water fluoridation schemes every 4 years. The health monitoring report for England 2022 looked at the prevalence and severity of dental caries in 3 to 5 year old children and hospital admissions for removing teeth due to decay in children and young people.

This latest report found that 5 year olds in areas with a fluoridation scheme in place were less likely to experience dental caries than in areas without a scheme. It also found that children and young people in areas with a fluoridation scheme in place were less likely to be admitted to hospital to have teeth removed due to tooth decay than in areas without a scheme. These effects were seen at all levels of deprivation, but children and young people living in the most deprived areas benefitted the most. The findings of health monitoring reports are consistent with the view that water fluoridation is an effective and safe public health measure to reduce the prevalence and severity of tooth decay and reduce dental health inequalities. The next monitoring report will be produced in 2026.

There are well-established adverse associations between levels of fluoride in water and the prevalence of dental mottling, referred to as dental fluorosis. Severe fluorosis can cause brown staining and pitting of teeth but is generally seen in those countries with very high naturally occurring levels of fluoride in groundwater. These levels of fluoride are above those used in water fluoridation schemes and this proposal. There is a small risk of dental fluorosis from levels of fluoride used in schemes, but this is not the same in all areas. It can also affect people in non-fluoridated areas.

The government considers that the overall weight of evidence and authoritative reviews of a large body of relevant and suitable studies indicates that fluoride, at the levels permitted in drinking water, presents no risks to health. This includes: 

• Health effects of water fluoridation (Australian National Health and Medical Research Council, 2017)
• Fluoridation: an update on evidence (Royal Society of New Zealand, 2021)
• Impact of community water fluoridation on systemic health excluding oral health. An evidence review (Irish Health Research Board, 2022)

Contemporary studies in the UK have also increased the evidence base on community water fluoridation for:

• children (see Evaluation of water fluoridation scheme in Cumbria: the CATFISH prospective longitudinal cohort study)
• adults (see How effective and cost-effective is water fluoridation for adults? A 10-year retrospective cohort study)

Environmental impacts

The Environment Act 2021 places a duty to have ‘due regard’ to the environmental principles policy statement when developing policy. We have identified potential environmental effects of expanding community water fluoridation in the north east and used environmental principles to inform this consultation.

Fluoride is a naturally occurring mineral found in water and some foods. The amount of naturally occurring fluoride in water varies across the UK due to geological differences.

There may be environmental impacts from the introduction and operation of new fluoridation plants, as well as the wider supply chain - for example, increased transport from delivery lorries. However, there is an existing framework of requirements to protect the environment and public health that would apply and are explained below. This proposal would be integrated into the existing framework helping to prevent or mitigate impacts.

The Water Supply (Water Quality) Regulations 2016, as per WHO’s recommendation, allow for up to 1.5 mg of fluoride to be present per litre of water, whether present naturally or as a result of water fluoridation. The Water Industry Act 1991 also sets out a requirement that the compounds used in the process must meet the relevant British standards.

In 2011, the European Commission Scientific Committee on Health and Environment Risk review concluded that fluoridation of drinking water is not expected to lead to unacceptable risks to the environment.

More recent research by Trinity College Dublin in collaboration with University College London, has quantified the environmental impact of water fluoridation and compared it to the environmental impact of other ways of increasing fluoride, such as fluoride varnish and toothbrushing programmes. The researchers found that water fluoridation had the lowest environmental impact of the 3 interventions.

Community water fluoridation reduces tooth decay. It is therefore expected to contribute to a reduction in the carbon footprint of dentistry. Analysis of the carbon footprint identified both patient and staff travel and resource intensive treatments such as fillings, replacement of extracted teeth and dental materials as a major contributor to greenhouse gas emissions.

The main route for fluoride to enter the environment would be water going to sewage and then to wastewater treatment works. Based on the concentration that would be dosed in drinking water, releases of fluoride to the environment will not exceed the Environment Agency’s non-statutory quality standard, which is set to protect aquatic life.

To assist water companies who dose supplies in line with agreements, the Drinking Water Inspectorate (DWI) has published a ‘Code of Practice on Technical Aspects of Fluoridation of Water Supplies 2021’ (on the DWI Guidance and codes of practice page). This outlines principles and minimum expectations to be followed by water companies and licensed suppliers operating fluoridation schemes. Fluoride levels in drinking water supplies are also carefully monitored by water companies and this data is assessed monthly by the DWI so that they do not exceed safe levels.

We have considered currently available evidence suggesting minimal impact of the intervention, particularly when compared to other interventions that improve dental health. Further environmental screening would be considered further as part of any subsequent implementation.

Ethical arguments

Despite the evidence that water fluoridation is a safe and effective public health intervention for reducing tooth decay, some people disagree with adding fluoride to drinking water. Some people hold the view that water fluoridation limits the rights of individual people.

Others make a counter argument that adding fluoride to public drinking water is the ethical thing to do because it prevents pain and suffering caused by tooth decay and because it can reduce inequalities in dental health. It is also particularly intended to improve health outcomes for more vulnerable groups, such as children or the elderly, who are not always able to make healthy food choices, maintain adequate tooth brushing or benefit from other targeted interventions. Decisions to introduce the intervention require a trade-off that balances personal preference with the ability to improve outcomes for the whole community.

Given the strong scientific evidence, the government considers that the ethical balance favours water fluoridation. This is due to the large potential health benefits, particularly for more vulnerable groups. Parliament has also confirmed that the Secretary of State can introduce water fluoridation schemes provided that specific steps are followed before they are implemented.

Impact assessments

A consultation stage impact assessment has been published alongside this document. This sets out the costs and benefits of expanding water fluoridation in the north east of England as proposed. It estimates the expected impact on reducing tooth decay, assesses the health benefit to individuals, cost savings to the NHS and improved productivity. It also considers the costs of implementation and the value for money of the proposal.

An equalities impact assessment has also been published.

This consultation seeks responses on whether there is further scientific evidence available to inform final impact assessments.

Feasibility and technical reports: summary

The Department of Health and Social Care (DHSC) commissioned feasibility and technical reports from NWL as part of identifying an operable and efficient scheme for this proposal. A summary of these reports is available on the main consultation page.

Further information available on request by emailing waterfluoridationconsultation@dhsc.gov.uk.

Consultation questions

Question

Do you live, work or study in an area where fluoride is already added to the water?

• Yes
• No
• Don’t know

Question

Are you employed by an organisation that has an interest in the proposal to expand fluoridation in north east England?

• Yes
• No
• Don’t know

If you said yes, how is your organisation affected by the proposal to expand fluoridation in the north east of England - for example, is it located or does it operate in an area affected by the proposal? (Maximum 100 words)

Question

To what extent do you agree or disagree with the proposal to expand water fluoridation to other areas of north east England?

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree
• Don’t know

What are the main reasons for your answer? (Select all that apply)

• Reducing tooth decay
• Reducing the number of dental treatments such as tooth extractions or fillings
• Reducing oral health inequalities
• Reducing costs to the NHS
• Improving other health outcomes
• Concerns about negative health impacts of water fluoridation
• Concerns about the environment
• Ethical arguments
• Other, please specify

Please explain your answers and provide any supporting evidence, including weblinks, you have to support your views. If you selected ‘ethical arguments’ please explain these. (Maximum 250 words)

Question

If you have any scientific evidence or evidence on the cost-benefit analysis for us to consider in our final impact assessment, please provide this. (Maximum 250 words)

Question

Is there anything else you would like us to consider in this consultation? (Maximum 250 words)

How to respond

Please respond using the online survey.

If you require any clarification on the consultation document, email waterfluoridationconsultation@dhsc.gov.uk. Do not send any personal information or consultation responses to this email address.

The consultation is open for 12 weeks. The deadline for responding is 11:59pm on 17 June 2024.

Privacy notice

Summary of policy

There is a legal duty for the Secretary of State to publicly consult on any new water fluoridation schemes. This process is set out in regulations. This notice sets out how data collected through this online consultation will be used.

Data controller

DHSC is the data controller.

What personal data we collect

You can respond to the consultation online.

We will collect data on:

• whether you are responding as an individual member of the public or on behalf of an organisation
• the name of your organisation, where your organisation operates or provides services
• the sector of your organisation, if responding on behalf of an organisation
• the country you live in and the first part of your postcode
• your internet protocol (IP) address (this is for security purposes and will not be attached to your survey response)

If volunteered by you, we will also collect data on:

• your personal characteristics (including your age, sex, ethnicity and whether you consider yourself to have a physical or mental health condition)
• your email address
• any other personal data you may provide in response to open-ended questions in the survey

How we use your data (purposes)

Your data will be treated in the strictest of confidence.

We collect your personal data as part of the consultation process:

• for statistical purposes, for example, to understand how representative the results are and whether views and experiences vary across demographics
• so that DHSC can contact you for further information about your response, to allow you to amend or delete your response and/or to send you a reminder before the consultation closes if you have not submitted your final response, if you have given consent

Legal basis for processing personal data

Under Articles 6 and 9 of the United Kingdom General Data Protection Regulation (UK GDPR), the lawful basis we rely on for processing this information is:

• necessary task in the public interest or controller’s official authority 

Data processors and other recipients of personal data

Responses to the online consultation may be seen by:

• data analysts and officials in DHSC supporting water fluoridation policy
• DHSC’s third-party supplier (SocialOptic), who is responsible for running and hosting the online survey

International data transfers and storage location

Storage of data by DHSC is provided via secure computing infrastructure on servers located in the European Economic Area (EEA). Our platforms are subject to extensive security protections and encryption measures.

Storage of data by SocialOptic is provided via secure servers located in the United Kingdom (UK).

Retention and disposal policy

DHSC will only retain your personal data for up to 1 year.

SocialOptic will securely erase the data held on their system 5 years after the online consultation closes, or when instructed to do so by DHSC if the data has served its intended purpose (whichever happens earlier).

Data retention will be reviewed on an annual basis. Anonymised data will be kept indefinitely.

How we keep your data secure

DHSC uses appropriate technical, organisational and administrative security measures to protect any information we hold in our records from loss, misuse, unauthorised access, disclosure, alteration and destruction. We have written procedures and policies which are regularly audited and reviewed at a senior level.

SocialOptic is Cyber Essentials certified.

Your rights as a data subject

By law, data subjects have a number of rights and this processing does not take away or reduce these rights under the EU General Data Protection Regulation (2016/679) and the UK Data Protection Act 2018 applies.

These rights are:

• the right to get copies of information - individuals have the right to ask for a copy of any information about them that is used
• the right to get information corrected - individuals have the right to ask for any information held about them that they think is inaccurate, to be corrected
• the right to limit how the information is used - individuals have the right to ask for any of the information held about them to be restricted, for example, if they think inaccurate information is being used
• the right to object to the information being used - individuals can ask for any information held about them to not be used. However, this is not an absolute right, and continued use of the information may be necessary, with individuals being advised if this is the case
• the right to get information deleted - this is not an absolute right, and continued use of the information may be necessary, with individuals being advised if this is the case

Comments or complaints

Anyone unhappy or wishing to complain about how personal data is used as part of this programme, should contact data_protection@dhsc.gov.uk in the first instance or write to:

Data Protection Officer
1st Floor North
39 Victoria Street
London
SW1H 0EU

Anyone who is still not satisfied can complain to the Information Commissioner’s Office. Their postal address is:

Information Commissioner's Office
Wycliffe House
Water Lane
Wilmslow
Cheshire
SK9 5AF

Automated decision making or profiling

No decision will be made about individuals solely based on automated decision making (where a decision is taken about them using an electronic system without human involvement) which has a significant impact on them.

Changes to this policy

We keep this privacy notice under regular review, and we will update it if necessary. All updated versions will be marked by a change note on the consultation page. This privacy notice was last updated on 25 March 2024.