Craig LizDr LIZ CRAIG (Labour): Anybody who's sat up overnight with a child with a toothache knows exactly how painful it can be not only for the children but also the impact it has on parents and the wider whānau as the child experiences poor outcomes. I think looking back on my previous role monitoring child health what my role used to be is collating all of the available information on children's health outcomes and then providing that to DHBs so they could look at planning. There were two sources of information we used to get: one was from the community of oral health services and what they used to report back was the number of children—the proportion of children who were caries-free at five years and also the decayed missing and filled teeth rate. So looking at the proportion of children who had decayed missing and filled teeth at five years; and then they also took that through to year 8—so when children are about 12 or 13 years of age. Then we also looked at the huge number of hospital admissions for dental caries and we used to see just large numbers—particularly in preschool children but also older children coming in to get dental caries addressed—in operating theatres usually under general anaesthetic. What we used to see was huge inequalities. So much higher rates of dental caries for Māori and Pacific children but also children living in more deprived areas. So it was interesting just looking back and preparing for talking today to see that Cure Kids in their recent report said basically very very similar things. So in 2018 they found only 60 percent of five-year-olds examined by community health services were caries-free. So what that meant is 40 percent of children had evidence of tooth decay and then on average five-year-olds had 1.8 decayed missing or filled primary teeth each. So that is very very significant. It wasn't much better at year 8: only 66 percent of children caries-free and basically on average 3.7 decayed filled or missing permanent teeth. So still huge issues there. They also noted that in 2019 there were 7000 hospital admissions for children coming in to get dental treatment done. They also reported the same large inequalities that we were seeing back when I was doing it—much higher rates for Māori and Pacific children and those living in more deprived areas. They also cited the 2018/19 New Zealand Health Survey and what they found was that less than 60 percent of children brush their teeth at least twice daily with a standard fluoride toothpaste. So I think if we're relying on children's behaviour to top up fluoride it just shows some of the challenges that that involves. Just looking at some of the evidence where does fluoridation come in? Back in 2014 the Office of the Prime Minister's Chief Science Advisor and the Royal Society of New Zealand undertook a review of the scientific evidence of the health effects of fluoridation. What they concluded was from a medical and public health perspective water fluoridation at the levels used in New Zealand poses no significant health risks and is effective at reducing the prevalence and severity of tooth decay in communities where it is used." And they were very reassuring that for communities that weren't fluoridated in terms of their water supplies that they could be confident that this was a safe option and it would save significant costs in terms of dental health issues—particularly for those that are experiencing quite high levels of dental caries. That was 2014 so what's happened since then? Well recently the current Prime Minister's Chief Science Advisor commissioned another review and what was looked at there was they said "We have considered new research on fluoridation and comprehensive reviews published subsequently" and they found that the conclusions of the Royal Society in 2014 "remain appropriate." So nothing really changed. Fluoridation is still good at reducing dental caries and improving health outcomes in terms of oral health. So where do we go with this bill going back to when it was originally introduced? What was being proposed was that Part 2A of the Health Act was being amended so that DHBs could be the decision makers and then they could direct local authorities in terms of fluoridating or non-fluoridation of their water supplies—because at the moment it is territorial authorities that have that decision making. But back then it was noted that the problem there was that you'd have inconsistent decision making around the country so that only 54 percent of the population back then was receiving fluoridated water. And they were commenting back then that basically it hadn't changed in the past 15 years. So there was a real sense that we needed to do something. So what they argued was if you had DHBs that were the ones making the decisions then you'd actually have a much more public health - focused approach in terms of that decision making; and that was the rationale for moving to DHB decision making. However I think as Minister Ayesha Verrall has indicated the Government's intending to introduce a Supplementary Order Paper (SOP) that would actually transfer this decision making to the Director-General of Health. I think that makes a lot of sense in the current proposed health reforms because it means that you've got one central decision-maker and you can look at a nationally consistent evidence-based approach. I think even if we weren't moving to bringing our DHBs together as one what actually doesn't make a lot of sense is to have each of the individual 20 DHBs having to separately weigh up the evidence on fluoride and then make an individual call. It's actually much better to have that consistent approach across. So what the SOP proposes is that the director-general would have the responsibility of directing local authorities to fluoridate—or not—their drinking water. But in doing so before they made a decision they would have to consider a range of things. I think the first one is just specified in the SOP: scientific evidence on the effectiveness of adding fluoride to drinking water and it's reducing the prevalence and severity of dental decay. Just highlighting again you want to do this once and well; you don't want to do this 20 times around the country. But then they also have to weigh up whether the benefits of adding fluoride outweigh the financial costs taking into account the state of oral health in the population within the area that the territorial authority is responsible for and also weighing up how many people would be affected by the water fluoridation. Then also looking at the likely financial cost but then weighing that up against the savings. But when you're doing that making sure that you also take into account the ongoing management and monitoring costs of that. So basically what the direction would need to be is quite specific to the territorial authorities—to talk about the date by which they must comply. But that also has to take into account what's practicable for the territorial authority themselves in implementing it. They also need to specify the level of fluoride that must be added because we want to keep that within a reasonably narrow range. Also the direction can allow that the territorial authority has one or more specified site where non-fluoridated water could be available so that there's some choice at that level. But they also need to engage with the local authority and so before making the decision the director-general needs to invite comments from the local authority. Some of those comments need to centre around what the likely cost would be. That includes as I said before ongoing maintenance and management but also when they could in practical terms comply with any direction. Then they need to give that authority at least 40 working days to provide comments back. If they do get those comments back within 40 days then the director-general needs to take that into account in any decision making. So basically what the issue is there then is that the local authority isn't required to go out and consult with its community on that but rather if that decision and direction is made then it just needs to comply with that direction. So this is really an important bill and I think what it does is make sure that that decision making and weighing up the evidence base that gets—basically that occurs once. That means you know in terms of efficiency perspective we're not doing that in 20 places around the country. But it also allows engagement between the Director-General of Health and local authorities so that there is a conversation and weighing up of—in that particular region—what the number of people affected would be what the oral health status of that community is and what the costs including ongoing monitoring and maintenance would be before making a decision. Certainly in the work I've seen with child health there is a potential here for a huge improvement in oral health status for children by just making sure that many many more children can actually have fluoridated drinking water because having dental caries is a really really bad way to start your life. So I commend this bill to the House."