Open consultation

Equalities impact assessment

Updated 24 April 2024

Applies to England

Introduction

The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due regard to the need to:

• eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the act
• advance equality of opportunity between people who share a protected characteristic and those who do not
• foster good relations between people who share a protected characteristic and those who do not

Summary of the proposal

In November 2022 the government confirmed it wanted more of the country to benefit from community water fluoridation. The Health and Care Act 2022, provides powers for the Secretary of State to introduce, vary and terminate water fluoridation schemes. We are consulting on the proposal to request the water company, Northumbrian Water Limited (NWL), to enter into fluoridation agreements and to vary existing agreements to expand community water fluoridation schemes across the north east of England.

Background

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.

The World Health Organization (WHO) has recommended a drinking water guideline value of 1.5 milligrams per litre (mg/L). This is intended to be protective of health for the whole population for a lifetime of exposure. This value is used by many countries in the world, including the EU and the UK, as the basis for a fluoride drinking water regulatory limit. The target level of fluoride in fluoridated drinking water in England is 1.0 mg/L. This is below the drinking water maximum regulatory limit and the WHO guideline.

Water fluoridation in parts of England began in the 1960s, following piloting in England, Scotland and Wales. Approximately 6 million people currently receive a fluoridated water supply through 5 water companies, mainly in the West Midlands and the North East. Approximately 300,000 people in England drink water with naturally occurring levels of fluoride similar to water fluoridation schemes. Other countries with fluoridation schemes include the USA, Canada and Ireland. It is estimated that around 400 million people in some 25 countries are currently served by water fluoridation schemes. There are an additional 50 million people, worldwide, consuming water with naturally occurring fluoride at or around the same level as used in fluoridation schemes.

The Water fluoridation: health monitoring report for England 2022 together with other strong scientific evidence provides details of effectiveness. This report shows it reduces prevalence, severity and consequences of dental caries. It supports previous findings that the benefits are greatest in the most deprived areas, contributing to reducing dental health inequalities. In 2021, the 4 UK Chief Medical Officers confirmed that on balance there is strong scientific evidence that water fluoridation is effective for reducing prevalence of tooth decay and improving dental health equality across the UK.

There is a legal obligation to monitor the health impacts of water fluoridation schemes every 4 years. The next report will be published in 2026.

Oral health inequalities

Like many other non-communicable diseases there are significant inequalities related to deprivation in the levels of tooth decay in England. The impacts of poor oral health disproportionately affect vulnerable and socially disadvantaged individuals and groups in society. Levels of tooth decay tend to be lower in fluoridated areas across all social groups, with those from more deprived groups tending to benefit the most.

Evidence

Inequalities in oral health in England considered available evidence at that time. For most of the protected characteristics there was no available evidence, or inconsistent evidence, on associations between oral health, care services and the protected characteristic. For vulnerable groups including homeless people, prisoners, travellers and looked after children, the available evidence was very limited, with existing studies showing that these populations have considerably poorer oral health across all assessed outcomes and face substantial difficulties accessing dental care.

Consistent monitoring of existing water fluoridation schemes in England (see the Water fluoridation: health monitoring report for England 2022) shows strong evidence for a clinically significant reduction in tooth decay resulting in reduced prevalence, severity and hospital admission for tooth extractions. The greatest benefit was seen in the most deprived areas, supporting previous conclusions that water fluoridation is an effective public health intervention for tackling dental health inequalities.

Water fluoridation reduces tooth decay in the population covered by a scheme. Evidence suggests that populations with some of the protected characteristics for example certain ethnic groups have higher rates of tooth decay. For those with protected characteristics there may be a larger scope for oral health benefits.

There are no proposals to include costs of expanded water fluoridation in customer bills. We do not therefore expect people who are financially vulnerable to be negatively impacted by the proposal and who may also see reduced direct and indirect costs of dental care.

Analysis of impact

Age

We consider there would be a positive effect, particularly for younger age groups and vulnerable adults.

The Water fluoridation: health monitoring report for England 2022 concludes 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. 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 decay than in areas without a scheme. These effects were seen at all levels of deprivation, but children and young people in the most deprived areas benefitted the most.

Tooth decay can affect people of all ages including older people. Water fluoridation reduces tooth decay in adult teeth. Water fluoridation could be helpful in supporting good oral health in the increasing number of people that are living with natural teeth into older age.

Disability

We consider there would be a positive effect. Vulnerable groups in society are also more likely to suffer from poor oral health, for example, people with disabilities or those with poor mental health. As a population-based intervention, water fluoridation offers scope to bring disproportionate benefits to people in these groups.

Sex

We consider there would be a neutral effect. The prevalence and severity of tooth decay is similar between boys and girls. Further evidence published in the National Dental Epidemiology Programme for England. We are not aware of any evidence suggesting a positive or negative impact on the basis sex.

Pregnancy and maternity

We consider there would be neutral effect for babies. Authoritative reviews have included consideration of evidence regarding potential neurological effects of water fluoridation, for example:

• Fluoridation: an update on evidence from the Office of the Prime Minister’s Chief Science Advisor in New Zealand (2021)
• Impact of community water fluoridation on systemic health excluding oral health, an evidence review from the Irish Health Research Board (2022)

The conclusion of these authoritative reviews is that there is no convincing evidence that fluoride in drinking water at levels used in fluoridation schemes in England is a cause of adverse health effects.

Race

We consider there would be a positive effect. Oral health inequalities are associated with ethnicity. The national 5 year old survey data shows that children from Asian or Asian British (and the ‘other’ category) backgrounds had worse oral health than their white or black or black British, Caribbean or African counterparts.

Religion

We consider there would be a neutral effect. We are not aware of any evidence indicating that tooth decay differs by religious belief, and therefore expect the water fluoridation would not have a differential impact regarding this protected characteristic. 

Belief

We consider there could be a negative effect for some. Water fluoridation schemes have been opposed by some, particularly where there are beliefs focused on mass medicalisation or limiting choice and inability to opt out.

However, Parliament has provided powers to introduce, vary or end water fluoridation schemes subject to meeting certain conditions. This includes public consultation as part of the democratic procedure laid down. Ministers are also receiving external, expert considerations as part of the consultation analysis.

Sexual orientation

We consider there would be a neutral effect. We are not aware of any evidence suggesting people with different sexual orientation have different experiences of tooth decay, and therefore they would not be differentially impacted by water fluoridation.

Marriage and civil partnership

We consider there would be a neutral effect. We are not aware of any evidence suggesting those married or in a civil partnership have different experiences of tooth decay, and therefore they would not be differentially impacted by water fluoridation.

Engagement and involvement

A 12-week consultation has been launched to gather views on the proposal to expand water fluoridation. In this consultation we ask specific questions about any missing evidence to inform final decision making.