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Community Water Fluoridation

HCC Briefing

October 2016

Author: Tim Fielding, City Health and Wellbeing Manager Acknowledgement: This briefing is based primarily on several Public Health England (PHE) reports that are listed at section 11.

Contents

1. Introduction

2. Summary

3. What is fluoride

4. Current situation re fluoridation in UK

5. Evidence regarding the effect of water fluoridation

5.1. Dental benefits

5.2. Impact of water fluoridation on inequalities in oral health

5.3. Dental fluorosis (mottling)

5.4. Other (non-dental) health effects

6. Cost benefits

7. Ethical issues regarding fluoridated water

8. Funding for water fluoridation schemes

9. Key agencies and stakeholders and their roles

9.1. Key agencies in legislation

9.2. Other key stakeholders

9.3. Other relevant agencies

10. The process for an area considering implementing water fluoridation

10.1. Key steps towards introducing a new fluoridation scheme

10.2. Joint decision-making by local authorities

11. References and sources of further information

Appendix 1: Map – Areas of fluoridation schemes and naturally occurring fluoride

Appendix 2: Outline of statutory and other processes for a local authority wishing to propose a scheme of community water fluoridation

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1. Introduction: This report is intended as an internal HCC briefing document to summarise the facts regarding

water fluoridation in a balanced manner. It is not intended to make the case for or against

water fluoridation in Hull, but to ensure that relevant officers and elected members have the

necessary information to inform them.

The briefing provides a summary of the evidence, legislation and issues regarding water

fluoridation. For more detail or to discuss any aspects of the report or water fluoridation,

council officers and elected members are encouraged to contact Tim Fielding, City Health and

Wellbeing Manager or Julia Weldon, Director of Public Health.

This briefing is based primarily on several Public Health England reports that are listed at

section 11. The key documents for an oversight of the issue and the steps involved for any

area considering introducing water fluoridation are the ‘Water Fluoridation: Health monitoring

report for England 2014’ (PHE, 2014) and ‘Improving oral health: a community water

fluoridation toolkit for local authorities’ (PHE, 2016).

2. Summary

Fluoride is naturally present in water supplies. In a number of areas the level is adjusted to

improve oral health. This process is governed by primary and secondary legislation. Since

April 2013 decision-making regarding fluoridation rests with upper tier and unitary local

authorities.

Systematic reviews of the scientific evidence have reported that water fluoridation substantially

reduces levels of tooth decay in both child and adult populations served by this measure.

There is also evidence that water fluoridation is associated with improved outcomes such as

reduced levels of child hospital admission for tooth extraction.

A small minority of children in both non-fluoridated and fluoridated areas of the UK have

noticeable dental fluorosis (mottling of the teeth), though severe dental fluorosis is rare. The

rate of fluorosis is higher in fluoridated areas.

Systematic reviews of the scientific evidence have found no adverse impacts on general health

that could be attributed to fluoride in water at a concentration of 1 part per million, whether

naturally occurring or added.

Naturally occurring fluoride exists in all water supplies. Community water fluoridation ensures

that, where the natural fluoride concentration is too low to provide dental health benefits, it is

raised to and maintained at the optimum level (one part per million or 1mg/litre).

Parliament has given its express consent to the deployment of water fluoridation as a public

health measure, by passing legislation to that end. However, parliament has also decreed that

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decisions about particular water fluoridation schemes should be made locally, not nationally,

and only through a rigorous process defined in legislation. From April 2013 the decision-

makers are the local authorities defined in the legislation.

3. What is fluoride

Fluoride is widely present in the environment, ranking thirteenth among the elements in order

of abundance in the earth’s crust. It occurs naturally in virtually all water.

The concentration of fluoride in water is normally expressed as milligrams of fluoride per one

litre of water (mg/l) or in parts fluoride per million parts of water (ppm). One mg/l equates to

1ppm. The concentration of fluoride naturally occurring in water is extremely variable, being

affected by many factors including geology. In some parts of Africa and the Indian sub-

continent, for example, fluoride levels in water may reach 10 or 20mg/l.

In the UK, the naturally occurring level of fluoride in water is typically around 0.1 to 0.2 mg/l,

although in some localities (for example Hartlepool and Uttoxeter) it is about 1.0mg/l and in

some private water supplies (springs, wells, boreholes ) can reach 3 or 4mg/l before correction.

About a third of a million people in England have a water supply in which the naturally

occurring background level of fluoride is around the optimal level of 1mg/l.

The most advantageous level of fluoride in water, in temperate climates, to be one part of

fluoride per million parts of water, or 1mg fluoride per litre of water (1mg/l). At this level the

benefits of fluoride in reducing decay are optimal. Higher levels of fluoride confer little

additional benefit in terms of decay reduction while increasing the risk of dental fluorosis.

4. Current situation regarding water fluoridation in UK

Naturally occurring fluoride exists in all water supplies. Community water fluoridation ensures

that, where the natural fluoride concentration is too low to provide dental health benefits, it is

raised to and maintained at the optimum level (one part per million or 1mg/litre).

Community water fluoridation schemes were first introduced in the US in 1945. Following

successful trials in the UK in the 1950s, pioneer local authorities in England adopted

fluoridation to tackle the problem of tooth decay in children. Birmingham led the way in 1964

and was quickly followed in the same decade by a number of other local authorities, some

urban, some rural. Today, fluoridation schemes in England cover approximately six million

people.

Most of the existing schemes in England were introduced by local authorities. Further

schemes, predominantly in the West Midlands, were introduced by the NHS from the late

1970s onwards. Currently, 26 local authorities have fluoridation schemes covering the whole or

parts of their area with approximately six million people in England receiving a fluoridated water

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supply, principally in the North-East and in the West and East Midlands. A map of fluoridated

areas is in Appendix 1.

Countries with fluoridation schemes include the United States, Canada, Brazil, Argentina,

Chile, England, Ireland, Spain, Australia, New Zealand, Malaysia, Singapore and South Korea.

Major cities around the world with fluoridation schemes include New York, Los Angeles,

Chicago, Washington DC, Philadelphia, Atlanta, Boston, Miami, Rio de Janeiro, Sao Paolo,

Buenos Aires, Santiago, Birmingham, Newcastle upon Tyne, Coventry, Dublin, Cork, Seville,

Bilbao, Hong Kong, Sydney, Melbourne, Brisbane, Adelaide, Perth, Auckland and Wellington.

Over the past ten years there has been an increase in fluoridation coverage around the world,

particularly in the United States, Brazil, Chile, Australia and Malaysia, adding around 50 million

people who receive this public health measure.

5. Evidence regarding the effect of water fluoridation

Fluoride in water can reduce the likelihood of experiencing dental decay and minimise its

severity. Evidence reviews confirm that it is an effective, safe public health measure suitable

for consideration in localities where levels of dental decay are of concern.

The evidence in support of the effectiveness and safety of water fluoridation is considered to be

robust and high quality by Public Health England.

Some fluoride occurs naturally throughout the world in water used for drinking, but the amount

is hugely variable. A very low level of natural fluoride, as found in most parts of England, has

no documented impact on health. At the other extreme, as in parts of Africa, India and Asia,

very high levels of naturally occurring fluoride in water consumed over the long-term can cause

a serious condition called skeletal fluorosis. This is extremely rare in western countries.

Within the UK water fluoridation is endorsed as a public health intervention by Public Health

England (PHE), the British Medical Association Board of Science, the Faculty of Public Health

of the Royal College of Physicians, the Faculty of Dental Surgery of the Royal College of

Surgeons of England, the British Dental Association, the British Society for Paediatric Dentistry

and many bodies representing health professionals. Fluoridation is widely supported

internationally including by the World Health Organisation (WHO).

5.1. Dental benefits

A very large number of studies and ‘reviews’ and ‘systematic reviews’ of studies over the

last 10-20 years have demonstrated a clear dental health benefit from water fluoridation.

The exact estimate of the size of the benefits varies depending on the methodology used,

the time period included and the countries covered. Typical examples of the benefits

identified include:

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• Children in fluoridated communities having fewer decayed, missing and filled

teeth than children in non-fluoridated communities e.g.

o 2.25 fewer decayed, missing and filled teeth among 5-15 year olds across a

range of countries (York Review, 2000, see PHE, 2015)

o between 30% and 50% fewer teeth decayed, missing and filled in 4-17 year olds

in United States (Center for Disease Control and Prevention, 2002, see PHE,

2015)

o 35% fewer decayed, missing and filled baby teeth and 26% fewer decayed,

missing and filled permanent teeth (Cochrane Oral Health Group, 2015, see PHE,

2015)

o 15% increase in children with no decay in their baby teeth and a 14% increase in

children with no decay in their permanent teeth (Cochrane Oral Health Group,

2015, see PHE, 2015)

o On average, five-year olds in fluoridated areas are 15% less likely to have had

tooth decay than those in non-fluoridated areas. When deprivation and ethnicity

(important factors for dental health) are taken into account, five-year olds in

fluoridated areas are 28% less likely to have had tooth decay

than those in non-fluoridated areas. (PHE, 2014)

o On average, 12-year olds in fluoridated areas are 11% less likely to have had

tooth decay than those in non-fluoridated areas. When deprivation and ethnicity

are into account, 12-year olds in fluoridated areas are 21% less likely to have had

tooth decay than those in non-fluoridated areas. (PHE, 2014)

• Reduction in tooth decay in adults living in fluoridated areas compared to non-

fluoridated areas e.g.

o between 27% and 35% lower among those who have lived all their lives in

fluoridated areas (Griffen et al, 2007)

• Reduction in hospital admissions and general anaesthetic for children

o in fluoridated areas there were 45% fewer hospital admissions of children aged

one to four for dental caries (mostly for extraction of decayed teeth under a

general anaesthetic) than in non-fluoridated areas (when deprivation was

accounted for, this figure rose to 55%) (PHE, 2014)

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5.2. Impact of water fluoridation on inequalities in oral health

PHE’s health monitoring report (2014) states:

“The reduction in tooth decay in children of both ages in fluoridated areas appears

greatest among those living in the most deprived local authorities.”

The evidence-base however for the impact of water fluoridation on reducing health

inequalities is less clear than for the overall dental benefits of fluoridation.

5.3. Dental fluorosis (mottling)

There is a well-established adverse association between levels of fluoride in water and the

prevalence of dental fluorosis (mottling of the teeth).

Dental fluorosis is one of a number of different conditions that can affect the appearance of

teeth. In England it is usually seen as paper-white flecks or fine white lines but it can vary

in appearance from barely visible white lines to patches which may be of aesthetic concern.

The risk period for the development of dental fluorosis in permanent (adult) teeth is when

the teeth are growing in the jaws; dental fluorosis cannot develop after teeth are formed.

The first two to three years of life are generally accepted to be the period of highest

susceptibility for fluorosis affecting the front teeth (the incisors).

The impact of milder forms fluorosis on measured quality of life (using the Oral Health

Related Quality of Life scale) is certainly less than that of tooth decay, and may be non-

existent or even positive.

A positive effect on quality of life may seem counter-intuitive but may be explained by the

fact that the white flecking of enamel associated with very mild fluorosis can give the

impression of having teeth that are whiter than average. More severe dental 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 rather than in areas with

community water fluoridation schemes. It should be noted that dental fluorosis can also

occur in the absence of water fluoridation, through ingestion of other sources of fluoride

during tooth formation, particularly toothpaste and other fluoride supplements.

A Medical Research Council report in 2002 concluded that, as far as artificially fluoridated

areas in the UK and Europe are concerned, around 3% to 4% of children may have dental

fluorosis of possible aesthetic concern, compared with around 1% in non-fluoridated areas.

A comparison of (fluoridated) Newcastle and (unfluoridated) Manchester used a scoring

system with a scale of 0-9 for severity and found that the percentage of children with mild or

mild to moderate (score 3) was 6% in fluoridated Newcastle and 1% in unfluoridated

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Manchester. However, the prevalence of higher scores (TF4 or greater) was very low in

both cities – 1% in fluoridated Newcastle and 0.2% in unfluoridated Manchester. Of these,

very few children were seen with a score of 5, representing the lower end of severe

fluorosis scores - 0.1% in fluoridated Newcastle and 0.2% in unfluoridated Manchester and

no children were found with higher scores.

5.4. Other (non-dental) health effects

There have been a number of reviews of the scientific evidence regarding the impact of

water fluoridation on general health stretching back to the early days of water fluoridation in

the UK. None have found evidence that water fluoridation is a cause of general ill health.

Some 370 million people worldwide, including six million in England and 200 million (70% of

the population) in the United States, have an artificially fluoridated water supply and there is

over 50 years’ experience of the measure. Routine monitoring of health in these areas has

not revealed any health problems associated with water fluoridation.

PHE is is required by legislation to monitor and report on the effects of water fluoridation

schemes on the health of people living in the areas covered. The summary of the impact of

fluoridation on non-dental health outcomes from their most recent report (2014) is included

below. There is no evidence of any harm to health, though there was some evidence of

improved rates of kidney stones and bladder cancer in fluoridated areas.

Table 1. Summary of non-dental health effects of water fluoridation

Health condition

Evidence

Hip fractures

There was no evidence of a difference in the rate of hip fractures between fluoridated and non-fluoridated areas.

Kidney stones

There was evidence that the rate of kidney stones was lower in fluoridated areas than non-fluoridated areas.

All-cause mortality

While there was some evidence that the rate of deaths from all recorded causes was lower in fluoridated areas than non-fluoridated areas, the size of the effect was small.

Down’s syndrome

There was no evidence of a difference in the rate of Down’s syndrome in fluoridated and non-fluoridated areas.

Bladder cancer There was evidence that the rate of bladder

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cancer was lower in fluoridated areas than non-fluoridated areas.

Osteosarcoma (a form of bone cancer) among under 25-year olds

There was no evidence of a difference in the rate of osteosarcoma between fluoridated and non-fluoridated areas.

Osteosarcoma (a form of bone cancer) among people aged 50 and over

There was no evidence of a difference in the rate of osteosarcoma between fluoridated and non-fluoridated areas.

All cancer

There was no evidence of a difference in the rate for all types of cancer between fluoridated and non-fluoridated areas.

(PHE, 2014)

6. Cost benefits

The cost-effectiveness of any fluoridation scheme is dependent on the local costs of the

scheme compared to the savings in the treatment of dental decay and disease, reduced

hospital admissions and the indirect or societal costs of the disease and its consequences.

The cost-effectiveness of fluoridation will be greater in areas with poorer dental health. These

are generally areas with high levels of deprivation.

Work is ongoing locally to calculate the estimated potential costs and savings from water

fluoridation to inform decision making.

7. Ethical issues regarding fluoridated water

The topic of water fluoridation can prompt ethical debates about adding a relatively small

amount of fluoride to local water supplies and arguments that individuals have a right to drink

water without added fluoride and that the local authority would be interfering with this right.

This is needed to be balanced against arguments claiming that any such concerns are

outweighed by the need and opportunity to prevent avoidable pain and suffering from tooth

decay with a safe and effective public health measure.

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8. Funding for water fluoridation schemes

At present PHE meets the capital cost of schemes and recovers the operating costs from local

authorities. Local authorities also pay for the cost of feasibility studies.

The initial feasibility study commissioned from Yorkshire Water by Hull City Council will provide

estimates of the capital and operating costs of potential local fluoridation schemes.

9. Key agencies and stakeholders and their roles 9.1. Key agencies in legislation

The legislation as it stands prescribes specific roles for and duties of various actors in all

aspects of water fluoridation. The three principal actors in the legislation are:

Upper tier and unitary local authorities

• propose and make decisions to implement new schemes

• make decisions about existing schemes and bear the running costs of schemes

• work jointly with other local authorities affected by any proposed/agreed scheme

Water companies

• advise on the technical feasibility of schemes and, when requested to do so

• implement and operate them in accordance with the Act and regulations

The secretary of state for health

• determines whether the arrangements which would result from a local authority’s

initial proposal for a fluoridation scheme would be operable and efficient

• confirms that the necessary procedural steps have been taken by the proposing local

authority, and, if so, requesting a water undertaker to enter into arrangements with

him to implement the scheme (or to vary it) or giving notice to the water undertaker to

terminate arrangements (as applicable)

• enters into arrangements with the water undertaker, negotiating the terms of those

arrangements, and consulting the Water Services Regulation Authority (OFWAT) and

affected local authorities in relation to those terms

• notifies local authorities in relation to maintenance of schemes in certain

circumstances and giving notice to the water company to terminate the scheme

where the local authorities affected decide not to propose maintaining the scheme

• monitors the health of populations covered by CWF schemes and reporting the

results

• The secretary of state currently also provides the capital funds for new schemes and

the refurbishment of established schemes, but may choose to recover these from

local authorities.

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Public Health England (PHE), as an executive agency of the Department of Health, does

not appear by name in the legislation. However, most of the secretary of state’s fluoridation

functions are exercised on his or her behalf by PHE.

In particular PHE:

• provides evidence-based advice about the safety and effectiveness of fluoridation

• monitors the performance of water companies in meeting legal agreements for

established fluoridation schemes

• provides advice on request to local authorities interested in establishing the technical

feasibility of new fluoridation schemes

• negotiates the terms of legal agreements for new schemes

• monitors and pays water company bills for the running costs of fluoridation schemes,

recovering these costs from the local authorities whose populations are benefiting from

the schemes

• monitors and manages fluoridation capital investment

• undertakes monitoring of the health effects of water fluoridation schemes and reports at

four-yearly intervals on those effects including inequalities

• provides support, through PHE centres, to local authorities in developing strategies to

improve oral health and reduce inequalities in oral health, including the use of fluoride

Local authorities can access support and advice from PHE via their PHE centre director,

whose team includes consultants in dental public health, and who can also access national

support from PHE.

9.2. Other key stakeholders

• Local NHS and clinicians

• Public, patients and representative groups

• Health and Wellbeing Board

9.3. Other relevant agencies

The Drinking Water Inspectorate (DWI)

DWI, an agency of the Department for Environment, Food and Rural Affairs, does not

feature in the fluoridation legislation. However, as the body responsible for assuring the

quality of public drinking water supplies in England and Wales, and for advising local

authorities on the quality of private water supplies, it has a central role in monitoring levels

of fluoride in water, be those naturally or artificially occurring, and taking or advising on

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compliance action in the event of breaches of the drinking water standard for fluoride. DWI

also publishes the technical code of practice on the design and operation of fluoridation

plant and may provide technical advice to PHE on such matters.

The Water Services Regulation Authority

The Water Services Regulation Authority (OFWAT) is a non-ministerial government

department and is the economic regulator of the water sector in England and Wales. Its role

in water fluoridation is that of a statutory consultee on the terms to be included in the

proposed legal agreement for a new fluoridation scheme and, in particular, terms which

affect the operation of the water undertaker's supply system.

10. The process for an area considering implementing water fluoridation

Local authorities were the driving force behind the introduction of water fluoridation schemes in

England in the 1960s. In 1974 the responsibility for fluoridation was transferred to the NHS.

The Health and Social Care Act 2012, by amending the Water Industry Act 1991 (the Act),

returned responsibility for those decisions to local authorities with public health responsibilities.

10.1. Key steps towards introducing a new fluoridation scheme

Upper tier and unitary local authorities are responsible for determining the need for new

fluoridation schemes. They are required to undertake public consultations before they

make a final decision. This applies when just a single local authority is involved and when a

number of authorities receiving water from the same sources are involved. In the latter

case, they must form a joint committee to oversee the process and make the decision.

The consultation process is defined in the legislation. It is essential that a local authority

considering a fluoridation scheme understands the legislation and obtains independent

legal advice throughout the whole process.

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Table 2. Summary of key steps towards a new scheme

Phase Content

1 Preliminary scoping phase (non-statutory) and informal discussion with any other affected local authorities.

2 Commencement of statutory process – making an initial proposal, perhaps with multiple proposers.

3 Assessment of operability and efficiency, including agreement of secretary of state to proceed.

4 Consultation with other affected local authorities (if any), and securing their consent to proceed.

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Public consultation and subsequent decision-making including, in the case of multiple local authorities, joint committee arrangements. In the latter instance, decisions may need to be made by a process of weighted population voting.

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Making an agreement between the secretary of state and the water company including issuing an indemnity to the company.

7 Scheme implementation.

Further detail regarding the process for implementing a new fluoridation scheme is at Appendix 2. As at September 2016, Hull City Council is still within Phase 1, undertaking preliminary scoping.

10.2. Joint decision-making by local authorities

Because their boundaries are defined by water distribution systems, not by administrative

boundaries, water fluoridation schemes usually extend beyond the boundary of a single local

authority. All formal consideration of proposals for fluoridation arrangements covering more

than one authority has to involve each of the affected local authorities in a way prescribed in

the fluoridation legislation, and in the absence of unanimity about a particular proposal, has to

be determined in a way again prescribed in the legislation.

In a multi-authority situation where one or more of the authorities concerned believes that a

new scheme should be introduced, it is necessary for at least one of the affected authorities

initially to make a formal proposal to the secretary of state for the desired action. Except in

circumstances where it would not be necessary to undertake a public consultation about the

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proposal, the proposer first has to consult and secure the support of the other affected

authorities to undertake public consultation.

It will be important to ensure that all affected authorities are actively involved in that

consultation. In the absence of unanimity the regulations prescribe that the matter should be

resolved by a process of weighted voting between the authorities, each authority having in

effect a single block vote the size of which is determined by the proportion of the whole

population affected by the proposal which is resident in the area of that authority. It is

necessary for the proposal to secure at least 67% of the total block vote to succeed. The

method of calculating the voting is set out in the schedule to the regulations.

Should it be determined that the formal proposal should proceed to public consultation, it is

then necessary for the authorities affected to agree on and establish joint committee

arrangements for progressing the matter. The options for joint committee arrangements are

defined in s88F of the Act.

Following public consultation, decisions about the outcome are taken in the joint committee

established for that purpose and have to take account of certain matters prescribed in the

legislation. In the absence of unanimity the outcome decision is again taken by the process of

weighted voting between the affected local authorities. Each authority represented on the joint

committee has a single block vote the size of which is determined by the proportion of the

whole population affected by the proposal which is resident in the area of that authority. It is

again necessary for the proposal to secure at least 67% of the total block vote to succeed.

11. References and sources of further information

Specific references regarding water fluoridation:

• Public Health England (2014), Water Fluoridation: Health monitoring report for England 2014.

• Public Health England (2015), An overview of water fluoridation [nb. this briefing was written specifically for the information session held for Hull Councillors in November 2015. Contact Tim Fielding for a copy]

• Public Health England (2016) Improving oral health: a community water fluoridation toolkit for local authorities.

References regarding improving oral health at a local level:

• Public Health England (2014),Local Authorities Improving Oral Health: Commissioning Better Oral Health for Children and Young People

• NICE (2014) Public health guidance – Oral health: local authorities and partners

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Local documents and references:

• Hull’s Oral Health Action Plan 2015-20

• Dental Health sections of Joint Strategic Needs Assessment (JSNA):

o Full chapter on Dental health

o Oral Health Needs in Hull summary 2015 [Contact Tim Fielding for a copy]

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PHE (2016)

Appendix 1.

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Outline of statutory and other processes for a local authority wishing to propose a scheme of community water fluoridation (CWG)

Statutory obligations are contained within The Water Industry Act 1991, as amended by

The Water Act 2003 and The Health and Social Care Act 2012. This is supplemented by

statutory requirements about the processes of proposing and consulting on a scheme

which are set out in The Water Fluoridation (Proposals and Consultation) (England)

Regulations 2013.

This document outlines the current process that is required to be followed for a local

authority wishing to propose a scheme of community water fluoridation. This is the process

as it is understood based on guidance documents and discussions with partners including

Public Health England. Further legal advice would be required to confirm the interpretation

of the process before proceeding to key stages.

Phase Summary description Water

Industry

Act 1991

(the “Act”)

Content of phase.

NB unless otherwise indicated, all

actions are the responsibility of the

local authority1

Key decision points

NB unless

otherwise

indicated, all

decisions are the

responsibility of the

local authority1

Preliminary (non-statutory) phase

1 Scoping Assessing oral health needs (which

may be included within a JSNA or

other pre-existing documentation)

Consideration of strategic approach to

improving oral health, including

options for action on dental decay.

Preliminary decision that feasibility of

CWF for the local target area should

be investigated.

Decision to

investigate

feasibility of CWF

Initial (e.g. desk-top) feasibility from

water company to assess scheme

coverage and approx. costs (operating

and capital) and whether the company

believes such a scheme would be

operable and efficient from its

perspective.

Commissioning an

initial feasibility

study from the

water company

City Council

Appendix 2.

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Establishing whether other LAs would

be affected, and quantifying the size

of affected population in each LA.

In light of feasibility and likely scheme

coverage, decision as to whether to

formally pursue water fluoridation

and commence the process defined in

legislation.

Decision that CWF

a preferred option

to progress

Initiating LA may, if it wishes, seek to

secure buy-in of other affected LA(s)

to making a joint formal proposal.

Commencement of statutory processes

2 Sponsoring LA(s)

makes formal (initial)

proposal to Secretary

of State for Health

(SoS)

s88B(2)-(4) Formal step which enables proposal to

progress into stages defined in

legislation. Specifies the water

company and area(s) to be

fluoridated.

Making a formal

proposal to SoS

(N.B. No

requirement that

proposal be in

writing but in

practice it would

be in LA’s interest

to put the proposal

in writing).

Securing opinion of water company that the proposal would be ‘operable and efficient’ and

agreement of Secretary of State for Health to proceed

3 Initial consultation

etc by proposing

LA(s) with water

company and SoS on

whether the

intended

arrangements are

operable and

efficient.

s88C May need more detailed feasibility

study/additional information to

supplement information acquired in

the scoping phase to inform water

company, LA and SoS and enable them

to comply with requirements of s88C

of the Act.

Commissioning

more detailed

information/a

detailed feasibility

study (if necessary)

LA sets out proposed arrangements

for achieving the proposal.

s88C(2)

and (3)

LA seeks views of company and SoS on

whether the arrangements from

implementing the proposals would be

operable and efficient

s88C(4) Consultees must provide LA with their

opinions.

Water company

opinion received

s88C(5) LA notifies SoS of water company

opinion.

s88C(6) SoS (advised by PHE) forms opinion as SoS opinion/

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to whether or not the proposal would

be operable and efficient. If not,

proposal falls.

Clearance to LA to

proceed to next

stage

Phase required if any other LA(s) would be affected by the proposal

4 Consultation by

proposing LA(s) with

other affected LAs (if

proposal covers

more than one LA

area and other LAs

are not joint

proposers)

s88D(2)-(3) Consult other affected LAs by giving

them certain information about the

proposal and allowing them a period

of at least three months for a

response as per Regulations1 (Reg 3).

Each LA decides whether it wishes to

proceed to public consultation on the

proposed scheme and notifies the

proposing LA of its views.

See Regulations 3(5) and 4(2)

Requires LAs

representing 67%

or more of

affected

population to

agree to proceed

to public

consultation.

Undertaking public consultation

5 Public consultation s88E(2) LA(s) consult public for at least three

months as per Regs.

See Regulation 5 for content and

approach.

s88F Where more than one LA is affected

by the proposal (and wishes to

participate in the process), the LAs

concerned must agree joint

committee arrangements to consider

the outcome of the consultation and

make decisions.

Establishing LA

joint committee

arrangements

Post-consultation, LA(s) make decision

as to whether to implement the

fluoridation proposal as per Regs.,

including whether any modification to

the proposal is required.2

If no unanimous

decision reached,

LAs representing

67% of affected

population must

agree to

1 The Water Fluoridation (Proposals and Consultation)(England) Regulations 2013

2 NB if any modification to the area covered by the proposal would extend or reduce the boundary of the proposal by

more than 20% of the houses included in the initial proposal, full re-consultation would be necessary (Regulations,

Reg 15(1)(b) and 15(2)

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See Regulation 7. implement the

proposal.

s88E(5) If LA(s) decide to proceed, the

proposing LA or joint committee

notifies SoS in writing of their decision

to request SoS to make a request

under s.87(1).

See also Regulation 8.

Formal

notification of SoS

Making an agreement between SoS and the water company to give effect to the arrangements

on which consultation has taken place

6 Making an

agreement between

SoS and water

company.

s88G(2) SoS satisfies himself that LA(s) have

complied with requirements of s88B

to 88F of the Act.

s87(1) SoS makes formal request in writing to

water company to enter into

arrangements.

Formal request

from SoS to water

company to enter

into arrangements

s90(1) SoS, with consent of HM Treasury,

provides an indemnity to the

company.

See s90(1) and the accompanying

Regulations3.

s87(5) SoS via PHE negotiates terms of

agreement with water company.

s87(7) SoS consults WRSA (OFWAT) on terms

of agreement.

s87(7A) SoS consults LA(s) on terms of

agreement.

s87 SoS concludes agreement with water

company.

Formal agreement

for scheme

concluded

Scheme implementation

7 Implementation of

scheme

s87(1) and

s87C

Water company designs and installs

fluoridation plant as agreed with PHE

for SoS.

s87(1) and

s87C

Following commissioning, scheme

becomes operational.

Scheme

operational

November 2015

3 The Water Supply (Fluoridation Indemnities)(England) Regulations 2005.