Health (Fluoridation of Drinking Water) Amendment Bill

Members, the House is now in committee on the Health (Fluoridation of Drinking Water) Amendment Bill. We come first to Part 1. This is the debate on clauses 4 to 10 and the Schedule: amendments relating to drinking water. The question is that Part 1 stand part.

Point of order. I seek leave to have all questions taken as one debate.

Leave is sought for that purpose. Is there any objection? There appears to be none. Therefore, the question now is that Parts 1 and 2, the Schedule, and clauses 1 to 3 stand part.

Mr Chair, thank you very much. It’s a pleasure to speak to the House in committee tonight on this very important bill. I think it’s worth just recapping some of past events, because it’s been some time since the bill was last in the House. Just one of the things that I reflected on in our second reading debate most recently was that I think every party that spoke in the debate agreed on the importance of fluoridation as a health intervention to make sure that all people, but particularly young people, are able to enjoy good oral health. In a time when many important health interventions are subject to misinformation, I thought it was a heartening reflection on the state of our democracy that all parties would align themselves with science on such an important decision.

To recap the journey of this bill, the Health (Fluoridation of Drinking Water) Amendment Bill came to Parliament and was submitted in 2016. It sought to respond to the request of territorial authorities to take the decision making from a local government setting into a health setting because the territorial authorities were often lobbied very vigorously on decisions about fluoridation and they felt poorly resourced to be able to respond to those questions.

At the time of this Parliament, the bill had already been to the Health Committee and it had had extensive hearings in the past. In this Parliament, what the Government has sought to do is to move decision making from district health boards, as in the original bill, to the director-general, and we’ve done that to seek a nationally consistent approach. We know that, currently, we have a patchwork of different approaches across the country, with only 50 percent of the population having access to water supplies that are fluoridated.

We also wanted to give the decision to an official who is resourced and equipped to make the decision and take the science of fluoride away from being from being litigated in every part of the country. So that is the purpose of Supplementary Order Paper (SOP) 38 that was referred to select committee.

I want to thank all the members of the select committee who considered the bill. They were focused on the—sorry, that considered the SOP, because the select committee hearing was just on that matter, and I appreciate the time in which they applied themselves to those questions. Of the submissions that they received in relation to the issues in the SOP, the majority, as is documented in their report, favoured the approach that we’re outlining in this SOP—that the decision maker should be the director-general—and mostly from the perspective of promoting national consistency.

I notice the select committee has also made a very helpful suggestion that the director-general should consult with the Director of Public Health. Our intention is to support that SOP as well. It’s a very constructive suggestion and, of course, it reminds us that there may be situations in the future where the director-general is not a public health physician and the opportunity to get that extra advice from someone specialist in public health would add to the consideration that these issues are given.

So I’m very happy to take questions from members on the SOP and the bill.

Thank you, Mr Chair. I had the privilege of being on the Health Committee and hearing the submitters. There were a number, and it was quite emotive at times.

One of the big fears was around the decision making being taken from the community, and I wonder if the Minister can outline beyond the Supplementary Order Paper that has been put forward just what sort of consultation might take place at a local community level, given the sense of distrust that we did see coming from a number of the submitters.

Thank you very much, Mr Chair. It’s a privilege to take a call on this fluoridation bill. It is interesting. As the Minister outlined, we did the first reading in 2016—I think I might have spoken on it back then—and then the second reading in about June or July last year. So, as the Minister outlined, it’s good that the parties are taking a science-based approach and agreeing on the principle of fluoride, but as we know, especially with this Government, the issue is going to be around implementation. With the Government’s announcement of the traffic light system, I think the irony wasn’t lost then when it was about all DHBs going to be 90 percent, and I suppose with this bill as well, it is based on DHBs. Now, tomorrow, a bill will come before this House where DHBs will have a bulldozer driven through them and, unlike the health and disability review, which advocated for maybe five or seven or nine DHBS, we’re going to go down to none. So it will be interesting to hear from the Minister how this will line up with the abolishment of DHBs.

Then, probably, it will be also interesting to hear, of course, how is the actual implementation of fluoride going to work under the proposed three waters programme as well. Who will be responsible if the three waters are going to be taken out of local councils or—I don’t think we can even call them local democracies in this bill now. It changes to “local authority”. So will we have to come back and change this as well?

So there are some competing priorities here, although, as we said, the bill arrived in 2016. But now, in 2021, we face a very different landscape. So we won’t be able to talk about the decision making going to DHBs, because we won’t have any, and who will actually provide the fluoride or who will put it in the water system if we move to three waters and that is moved to some entity that we can’t see in the legislation yet?

I can’t resist taking a call on this bill. I want to congratulate Minister Verrall for getting into what I’d call probably a fight she’ll never win. I’ve been around the fluoridation issue for 20 years now and I’ve never seen a consensus achieved anywhere on fluoridation, and I can’t see it happening now.

But the really interesting thing about the whole fluoridation issue is it’s been with councils. We proposed it went to the district health boards in 2016, I think Matt Doocey said. In my view, that was never going to work. I don’t think this will work either, because I just think it’s such a contentious issue, this fluoridation of drinking water. Frankly, I’ve got to say, I support the fluoridation of drinking water. When you have teeth as bad as I’ve got and you were never in a fluoridated water supply, you’d know why I support it, and it’s pretty obvious that we should support it. So I don’t really have a constructive question of the Minister on it, but I do think it’s worth commenting that I think it’s a very brave move, and I think it’s worth trying anything we can to achieve the objective that this bill sets out to achieve, but I’m just not sure how you’re ever going to get a consensus on it. So that’s all I really wanted to say.

I do think, though, that it’s an issue that we should persevere with as a Parliament, and I don’t think you can make one rule for Bulls, where I live, and another rule for Rātana or for Whangaehu, where you live, Mr Chair. So I think that the issue that we’ve got is it’s got to be consistent across New Zealand, and we should, effectively, where we can, supply fluoridated drinking water, particularly for our young people, because it’s just the way it is. So I don’t want to ask you a question, Minister; I want to congratulate you. Good luck.

Thank you, Mr Chair, and I want to thank Mr McKelvie for that honest contribution and his wishes of good luck—I appreciate it. To address some of the earlier questions, the Supplementary Order Paper does require that the director-general engage with local authorities on their readiness and the cost of implementing change, but, as I stated earlier, it does not relitigate the decision about the public health rationale or science of fluoridation. There will be a need to seek information on the health status of the local population, as well. I’d just note that the original bill did not require any community engagement in its original form, either.

I do not view concerns about the proposed reforms of district health boards as problematic for the passage of this bill; in fact, it is required. It makes an even stronger case for the need for this bill, because there will not be district health boards in the future health system. The three waters bill would change the role of local authorities to that of water entities in terms of the bodies that would be responsible for having to fluoridate water on direction by the director-general, and consequential amendments to change the entity referred to would have to be made through the Water Services Bill, should that bill pass.

Thank you, Mr Chair. Thank you, Minister Verrall, for your answers to those questions. Minister, the concern, I suppose, is the context in which this bill is sitting of a number of centralisations of vocational education, of DHBs, of mandating of vaccinations, and so it’s really a question around implementation. Around the roll-out for COVID vaccinations, there was a vacuum which allowed all sorts of other opinions to grow legs. My concern around this is the implementation of the fluoridation of drinking water. What education or what implementation information is going to go out so that there isn’t a groundswell of people who are anti the fluoridation of drinking water, because we definitely heard in the submissions that a number of people are deeply suspicious, and I suppose, when we see this sitting within the context of a lot of centralised decision-making, it will add to that sense of distrust. So my question is around information sharing, education, and ensuring that people are in the right space to be able to accept fluoridation of water supplies.

Those matters are not directly relevant to the bill we’re debating, but the Prime Minister’s Chief Science Advisor has recently assisted with that important matter of making sure that good information is available to the public by publishing a detailed report of all of the decades of science around fluoridation. So I think there is access to New Zealand - specific, high-quality information, and I think that it is important that those sources remain up to date, as the Ministry of Health has also kept up-to-date sources of information throughout this time, in the many years that the bill has been before Parliament.

The other point to make, though, is that I think it will not be possible to address all of the concern and opposition about the bill in the community, but it is important to have gone through a process of having those proper, evidence-based reviews by an independent person, and that’s what’s been done.

Thank you, Mr Chair, and thank you, Minister. I think we’ve probably seen from experience around the COVID vaccinations that the science and evidence often isn’t enough for communities to be won over, or certain elements of our communities to be won over. So the process of consultation and getting communities on board I think is an incredibly important part of the implementation of this legislation, and I’m not sure that we’ve had spelt out to us how that process is really going to play out.

Thank you very much, Mr Chair. I wanted to talk to Supplementary Order Paper (SOP) 79, which is in the name of my good friend and colleague Dr Shane Reti, who is actively up in the North of the North Island now, vaccinating, and I want to wish him well. Now, what he says in his SOP is to amend clause 4A: “after new section 116E(2)(b), insert: (c) the views of local … authorities legislated to represent regional health interests where the local authority supply is situated.”

I suppose for us on this side of the House, we believe in having strong communities. They’re a place for local democracy. They’re a place of our local economy and, of course, where our public services are delivered from, and it is quite concerning—and I think my colleague Penny Simmonds alluded to this—the continual ideology of centralisation.

I note that in a bill we’ll debate tomorrow, it says about the health reforms that “Government intervention is necessary to address these longstanding issues; indeed, only Government can take the steps needed to reform the structure and operating model of the … health system.” We would argue that it’s not only Government; it’s actually the communities as well that are needed to reform and restructure, and that’s why I think this is a very good SOP that will require the director-general to consider the views of local health authorities in this region.

What we do need is to still consult people in their local communities. There’s probably a feeling that they’re getting dealt to a bit at the moment, and we’ve seen Groundswell NZ be part of that. I think that’s why it is important, as set out in SOP 79, whether it be the centralisation of our health reforms or, of course, what the Government will announce tomorrow for their three waters announcement, that in an issue like fluoridation of drinking water, we should also ensure that our local communities are consulted about this on whether they agree to this or not. I do hope that the parties tonight will have read Shane Reti’s SOP 79 and that they will support local consultation, because, of course, decisions we make in Wellington affect everyone on the ground around New Zealand, and we should make sure that we provide adequate consultation.

Thank you, Mr Chair. Look, this bill has had an interesting history. It was first introduced into Parliament in 2016, at the tail end of the year, and here we are coming towards the end of 2021. I think I’m right in saying that it managed to spend the entirety of the last Parliament on the Order Paper with no progress—I think I’m right in saying that. So here we are, five years later, and time has kind of caught up with the Government because the bill seeks to transfer power to district health boards and away from territorial authorities, but, contemporaneously, the Government is abolishing district health boards.

So I have a very simple question, and I apologise if it’s already been asked by members on this side. It is a very simple question. What happens when this bill is passed and it becomes an Act, and the new Governor-General, Dame Cindy Kiro, gives her Royal assent to the legislation and it comes into force and, then, in a year’s time, district health boards are no longer in existence? What will happen to this Act, or is it the intention of the Government to move an alternative form of legislation? It is a very simple question, and I think people will want to know what the answer is.

The Supplementary Order Paper (SOP) 38, which was recently considered by select committee, does indeed make all those changes that the member is requesting because it is a change to move decision making from district health boards to the director-general. Therefore, the bill as amended by the Supplementary Order Paper does not require the continued existence of district health boards in order to give effect to the increase in fluoridation that we want to see.

I want to return to the contribution of the speaker before last around SOP 79. Firstly, as I previously noted, there are local issues that are relevant to fluoridation decisions, and the director-general is required to take this into account: local health factors, the oral health of the population, the feasibility and readiness to start fluoridation, and its cost. But the Supplementary Order Paper goes further than that and asks us—well, actually, it was Mr Doocey’s speech in relation to the Supplementary Order Paper that was prepared by Dr Reti. Mr Doocey said that it’s not just about local government, but about involving community, but it doesn’t appear to me that that’s what Supplementary Order Paper 79 does. It asks for “the views of local health authorities legislated to represent … health interests where the local authority supply is situated.” So it’s a slightly wordy presentation, but I don’t think the intent of it is about community involvement. No, it’s about representatives I’m not even sure exist, and, in fact, the comment that Mr Bishop was making actually applies to Mr Reti’s SOP, not to the Government’s bill or SOP.

So we will not be supporting the Supplementary Order Paper 79 because it’s not entirely clear what it means, and it’s not clear that it will be an advance on the existing Supplementary Order Paper. It’s interesting to note that this bill started its life out as a National Party bill in which there was no requirement for local consultation, and nor is local consultation enabled by the Supplementary Order Paper.

Thank you, Mr Chair. Minister, if I may: as you’d be acutely aware, I live in Northland and we’ve got some of the worst teeth in the country. Very quickly, and if I contextualise the problem about where I live, a lot of rural New Zealand, especially in Northland, is on rural schemes. Can you speak to, quite specifically—and we’ve canvassed this in the House, and I think it’s going to come up again and again and again. In the Water Services Bill, on this side of the House, we asked for an exemption for 30 end users or less. By virtue of what we’re discussing tonight, there’s a real possibility there will be a penalty regime in place inside that piece of legislation for such things as fluoridation or the absence of it, and I would be interested to know what that will look like, what part of rural New Zealand it will affect, and how this policy would be policed, or the lack thereof.

Thank you, Mr Chair. I’m interested in having the Minister explain to us how there might be consultation and a flow of information up from the communities. She has talked about there not being consultation with the communities, but what if a community should decide they want fluoridation? What is the process and what is the ability for the community to send their message that they want fluoridation in their water?

I move, That the question be now put.

Thank you, Mr Chair. This time I will have a question for the Minister. Just one of the things that occurs to me—and it’s really interesting, because we’re in a sort of interesting time at the moment—is we’ve got the issue with the COVID vaccine acceptance, and, certainly, remoter parts of New Zealand are more difficult to penetrate with respect to that than perhaps Wellington or Auckland.

We’ve also got a bill up later on tonight which deals with statistics, and, of course, people have got to fill out statistics forms. We’ve got in the House, this bill, where there’s an inherent distrust in some people of fluoridation, and you’ve got to wonder whether the real issue we’ve got is that, slowly but surely, people are starting to distrust the Government when the Government makes decisions for them. If I knew the answer to this, I wouldn’t be here, but I think it’s a real challenge for us, because if you don’t fill out your statistics correctly, the Government doesn’t get the information they need to manage the processes we’re talking about here, actually, amongst others. If you don’t get vaccinated, it would appear, then, that other people are at risk, and the same thing applies to this. If we don’t get this fluoridation thing accepted, then we’re going to get to the point where people, effectively, opt out.

So I suppose my question for the Minister is—and it might be very difficult one to answer—that I just wonder: it’s all very well to provide health advice to members of the public, but they don’t accept it, necessarily, and, certainly, the more remotely you live in New Zealand, it appears the less likely you are to accept advice from the centre. So I suppose my worry with this—and, as I said, I don’t have the answer—kind of bill is, if we’re going to put these in place, we’ve got to find a way of generally getting acceptance. I accept we won’t get everyone to accept it, but we need to find ways as we manage these processes of getting people to accept that, effectively, these decisions are made for the better of their own health, just like getting vaccinated is, or filling out your statistics correctly is.

Thank you, Mr McKelvie, for that important question. Look, I’m an optimist about the issue of acceptance, and I think one of the things is that 50 percent of our population already live in places with a fluoridated water supply and, day to day, most people think nothing of it, to be honest, and people who visit, for example, Wellington from around the country where they don’t have fluoridated water don’t seem to raise it as a concern when they visit this great city.

I wanted to address the question about what if a community was to decide they want to fluoridate their own water independent of a direction from the Director-General of Health. While there’s nothing in this bill to stop that; that would still be able to occur as it currently has, and, indeed, a number of cities and towns have rolled out fluoridation on that basis.

To my colleague from ACT, the questions about supplies in rural New Zealand are very good ones. Firstly, this bill only applies to reticulated water supplies, and it excludes private supplies.

I’d also point to one of the requirements for the director-general to consider the cost. Modelling done—an assessment done a few years ago now suggests that the cost-effectiveness of fluoridation gets lower the smaller the population that is served by the water supply. It starts to look to be of lower value at water supplies that serve fewer than 500 people. Now, that isn’t the only factor that the director-general has to consider, but for small water supplies, there may be a discussion about whether or not the costs of fluoridation are, in fact, worth the oral health benefits.

Minister, would you be so obliging: when you just made the iteration about a reticulated supply, in the Water Services Act it very specifically talks about a reticulated supply, and more than one family or dwelling off that supply is deemed a system, and, by virtue of that, it is a reticulated supply. So you can see, going back to my previous remarks about having a caveat for 30 end users or less in the Water Services Act, by virtue of what you’ve just said, it would actually encapsulate everyone other than a single dwelling. Do you want to speak to that, perhaps?

Thank you, Mr Chair. I actually am interested in the answer to the question raised by my colleague Mr Cameron down the back—down the back both in terms of the country but also in the Chamber. But I am also interested in, and I’ve been reading—

💬 Mark Cameron: I’m up the top.

Oh, I mean in terms of Northland. I suppose you’re up the front in some ways. Anyway, it’s a long way away from here is the key point. I wasn’t meaning to be pejorative, Mr Cameron—far from it.

It’s been so long since we’ve considered this legislation. As I said earlier in my contribution, it was two parliaments ago, and I for one am a strong believer in fluoridation. I wonder if the ministry or the Government has conducted an updated cost-benefit analysis (CBA). I’m reading the regulatory impact statement, which is from 2016—in fact, March 2016—which notes that there was a CBA done in 2014 by Sapere Research Group, which found that “extending water fluoridation to those areas that do not currently have fluoridation would be associated with net savings of over $600 million over twenty years”, which is obviously a sizable sum of money, if you think about that. That’s $30 million per year times 20, with most of those savings to consumers and a small amount to Vote Health, and I actually was just reflecting on that.

I found that interesting, because I thought it would be the other way around. I actually thought the majority of the savings would accrue to Vote Health in terms of better oral health outcomes for the kids, for example—so less demand on the public purse for childhood dental services—and, I suppose, also adults as well. Having just had a wisdom tooth extracted last week and endured the pain of that, mainly fiscally, I know that dentistry can be very expensive, and so I was surprised to see that—

💬 Ian McKelvie: Fluoride wouldn’t have fixed it, though.

What’s that—fluoride wouldn’t have fixed it, no. There’s too much sugar in my diet. But I was intrigued to see that the cost-benefit actually shows that the majority of benefit is for consumers.

So I just wonder if there’s been an updated cost-benefit since 2014. It’s now seven years on, and perhaps the Minister could advise the House if that’s the case. If it’s higher than that then that’s a wonderful thing, and if it’s lower than that, then, well, that’s interesting as well, I suppose. Thank you, Mr Chair.

Thank you for that question. It’s always good to be able to talk more about the financial benefits of public health measures. The answer is no. That cost-benefit analysis has not been revisited. That cost-benefit analysis was part of what kicked off this bill in the first place.

But I think the member is correct to think that if there was any change, the change is likely to be in the increasing cost of dental services over that time, so I can only imagine more benefits would accrue to the community than was originally expected.

I move, That the question be now put.

Thank you, Mr Chair. I am interested also in taking the questioning of my ACT colleague Mark Cameron a little further. When the Minister replied that the fluoridation was only for reticulated supplies and not private supplies, and indeed the Water Services Act has the “last person standing” clause in it that requires that if a water supply is going to be abandoned by private suppliers, then, in fact, the local authority does have to take up the provision of that supply. So it may well be that the rural water supplies that my colleague was referring to might fall within this, having been taken over by a local authority.

I guess one of the concerns that we have is that it’s a bill with very good intent: we all want, particularly for our children, to have better oral health, and what we don’t want is for it to be put at risk by a lack of plan or a lack of education or a lack of information or a lack of consultation. Therefore, my questioning really is around that provision of ensuring that the notion of fluoridation in drinking water—that is not now in at the moment—is well sold to the public and that the good intent of the bill isn’t lost by it not being well sold and people being well-prepared for it. So if you could expand on what is being done there, thank you, Minister.

Clearly, permission to start on implementation on the bill will be given when Parliament passes the bill. But I am comfortable undertaking to that member that being able to communicate clearly to the country the benefits of fluoridation and why these decisions are made will be ongoing work for the Ministry of Health. In addition, I’ve already cited the Prime Minister’s Chief Science Advisor’s report, which is a definitive piece of work that reflects several decades of scientific research on this matter. So I don’t believe that there’s any lack of activity on the Government’s part in terms of making sure that the basis for these decisions are clear.

I move, That the question be now put.

Anyone else want a call—no? We’ll go to the question, eh? The question is that the Hon Ayesha Verrall’s amendment to the amendments on Supplementary Order Paper 38 set out on Supplementary Order Paper 76 be agreed to.

Amendment to the amendments agreed to.

The question is that Dr Shane Reti’s amendment to clause 4A in Supplementary Order Paper 38 set out on Supplementary Order Paper 79 be agreed to.

The question is that the Minister’s amendments set out on Supplementary Order Paper 38 as amended be agreed to.

Amendments as amended agreed to.

The question is that Part 1 and 2, the Schedule, and clauses 1 to 3 as amended be agreed to.

Part 1 and 2, Schedule, and clauses 1 to 3 as amended agreed to.

Bill to be reported with amendment.

House resumed.