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Dental Health: Children

Volume 788: debated on Thursday 18 January 2018

Question for Short Debate

Asked by

To ask Her Majesty's Government what action they are taking to ensure that children receive regular dental examinations and any necessary treatment.

My Lords, it seems appropriate that the Committee should be discussing this subject today, as it fits in well with the British Dental Association’s campaign aimed at creating a greater public awareness of the need to ensure that children’s teeth receive the necessary care. In my view, preventive care is at the forefront of this.

I no longer need to declare a financial interest, as I retired from dental practice after about 35 years as a national health dentist on the fringe of the City, in Old Street, now known as the Silicon Valley of London, which underwent complete redevelopment of the 200 year- old small redbrick houses that were there in our day. The local residents were not keen on dentists, and came only when they felt their problems had become urgent. Patients were often not seen until their pain had become intolerable, and emergency extractions under local anaesthetic were fitted in for them between appointments—historically, at half a crown a time.

Sadly, local parents were unaware of the fact that permanent teeth, the first molars, erupt behind the baby teeth, and sometimes they were so badly decayed before they brought the child to the surgery suffering such severe pain that extraction was the only possible treatment. This was the worst possible start for a dentist-patient relationship.

Children who have regularly attended for dental check-ups or treatment are not upset at the thought of a dental appointment and have a much better prospect of taking an interest in their dental health throughout their lives. The system of school dental check-ups for pupils was of value, although one survey established that only one-third of those seen and advised to have necessary dental treatment followed that advice.

Sweets and sugary drinks have always caused damage to teeth, and I recall those vicious dummies—or comforters, as they were called—filled with sugary syrup, bathing the deciduous baby teeth with that damaging liquid. Sweets still seem to be blamed for most dental problems, but I do not intend to spend time on that aspect today, as I am sure others will. As a mother, I know how rapidly sweets become an addiction for children, and years ago I used to give advice that it is the 15 minutes after the sweet that matters, so it may be better for children to have a specific sweet time once a week, when they could have as many as they wanted, rather than the deceptive “just one” doing damage more often. Sweet drinks including an acidic element are a further problem.

In 1968, I was the first woman dentist ever appointed as a member of the Standing Dental Advisory Committee for England and Wales, and I served until 1976. I was an elected member of the General Dental Council from 1984 to 1986 and a governor of the Eastman Dental Hospital. I say that simply to make clear that I have never had any academic dental role, but was very involved as a basic national health practising dentist.

In 1988, I had the privilege of joining your Lordships’ House. I was particularly interested in the passage of the Health and Medicines Act 1988, and I moved Amendment 30 to retain free national health dental examinations for all. Realising that many Members of the House might not know much about the workings of national health dentistry, the day before the debate I spoke to as many Peers as I could find, asking that they attend and listen to the contributions before deciding how to vote. The responses were good and the debate was wide-ranging. My dental colleague, my noble friend Lord Colwyn, made an excellent contribution—I am grateful to him for speaking again today. Other speakers in 1988, the noble Baroness, Lady Masham, and the noble Lord, Lord Stoddart of Swindon, were both very supportive in helping to draw attention to the fact that all forms of health screening were free for national health patients. The amendment to retain free national health dental examinations was carried by 118 to 97, a majority of 21.

Following this, the Deputy Chairman of Committees called Amendment 31 and I intervened to say that he had told us that if Amendment 30 were agreed to, 31 could not be called. His reply was somewhat revealing:

“That is quite right. I was so surprised at the last result”.—[Official Report, 19/7/1988; col. 1239.]

Sadly, when this went to the Commons, the amendment was reversed by 300 votes to 284 and financial privilege was attached, so we were not able to re-debate the matter. I believe that this was the beginning of the end of national health dentistry as we knew it. My husband did beautiful crown and bridge work and patients would often ask him, “If I paid more, could I get a better crown?”. His reply was always, “No, everyone gets the best crown I can do”. He was a gifted silversmith, with his own hallmark and a liveryman of the Worshipful Company of Goldsmiths. He was one of many dentists with successful general national health dental practices really caring for their patients.

All national health dental treatment for children up to the age of 18 remains free now, but there are so many areas where there are very limited, if any, national health dental practices. The children no longer go along with their parents and are examined at the same time, as the parents are not going. There are, as I say, whole areas where NHS dental practices hardly exist. Last year, I was shocked to read that no NHS places for general anaesthetic surgical beds were available in Manchester, as all were taken by children requiring full clearances of their deciduous teeth.

Over some years, I have been asking both Written and Oral Questions on the difference in health patterns between Birmingham and Manchester, and the toothy answers are referred to as DMF—decayed, missing and filled. Birmingham has the best DMF and Manchester the worst. Apart from that—and I emphasise this—there is no difference in the health pattern. Birmingham has had a fluoridated water supply since the 1960s, so it has certainly been tried and tested over a long period. I emphasise that there is an optimal level which has to be constantly monitored and adjusted by the water authority by either adding or removing fluoride from the water supply to maintain this optimal level.

Australia has generally had fluoridated water supplies for many years. I visited a nephew of mine, a Sydney dentist who looks after the pupils at one of the big schools. He told me that he could tell by looking at their mouths the boys that came from country areas where the only water supply was rain water or river water. There was a markedly worse dental condition in those not benefiting from the controlled optimal-level fluoridated water supply. Time has moved on and there are now many fluoride toothpastes which help to maintain dental health, but optimal-level fluoridation of drinking water would be much more effective.

For a number of years, I have tabled Questions, usually for Written Answer, to establish the difference in general health and dental health between Manchester and Birmingham. I have chosen these cities as large successful cities which aim to provide their residents with the best possible healthcare. Birmingham has had a fluoridated water supply since the 1960s and Manchester has not. All health conditions in the two cities follow similar patterns. The one major exception is dental health. DMF in Birmingham is 0.8 and in Manchester—where it is the worst—it is 1.3.

Last year, I found it very disturbing to read that children in Manchester were taking up all general anaesthetic beds in order to clear their deciduous teeth. Apart from the pain and discomfort that these children would have suffered to reach this sad dental state, it will continue to cause problems, even when those teeth are all out, as the presence of the primary teeth maintains the space as the jaws enlarge to receive the larger secondary teeth. Many of the children who have had premature extractions will require lots of orthodontics to enable the secondary teeth to come into normal alignment.

My time is limited, so I shall conclude by quoting the recent statement from Australia’s National Health and Medical Research Council following a comprehensive study which makes clear the optimal and proper level of fluoridation for dental benefit without any adverse effect on general health. The statement that the council has put out is very strong and, as an Australian, I think I am entitled to quote it:

“It shows that community water fluoridation, as it’s used in Australia today, is effective at reducing tooth decay and is not associated with any general negative health effects”.

The headline states:

“With 60 years of data and 3000 studies”—

more than considered anywhere else in the world—

“Australia declares fluoride ‘completely safe’”.

I hope that we will really encourage the authorities here to look into this, as it would help children so much.

My Lords, I declare my interests as a retired dental surgeon, a fellow of the British Dental Association and vice-president of the British Fluoridation Society.

I thank my dental colleague, my noble friend Lady Gardner, for securing this debate. This is very timely, considering the extensive coverage that children’s tooth extractions received in the media just last weekend. This came after the number of youngsters admitted to hospitals to have rotten teeth removed hit a new high. Despite tooth decay being an almost entirely preventable disease, we now see 170 children undergo an unnecessary general anaesthetic because of it every single day. Such operations have cost the NHS £165 million since 2012. As someone who performed thousands of tooth extractions under a general anaesthetic in my dental career, I know as well as anyone that the cost of these procedures goes far beyond the financial impact on our health service: think of the pain and distress for the child, the lost sleep and school time, and the stress and time off work for the parents. Children in many parts of the country have to wait up to a year for their operation, and many kids end up spending months and months on painkillers and antibiotics. This really is not good enough in the 21st century in one of the richest countries in the world.

As the Minister will know, Scotland and Wales have achieved unprecedented improvements in their child oral health outcomes in recent years by introducing the pioneering national programmes, Childsmile and Designed to Smile. The British Dental Association has been calling for England to follow in the devolved Governments’ footsteps for years so that English children can benefit from these simple, tried-and-tested solutions.

Dentists welcomed the first step made in England with the recently launched Starting Well programme, but I share the BDA’s concerns that this new scheme is currently limited to some 13 local authorities in England. I understand that in London only 12 practices in Ealing are taking part in the scheme. This is in the context of well over 4,000 national dentists practising in the capital. So, although the scheme will reach some children in the areas with the worst outcomes, there will still be millions of others across England who will miss out. Will the Government look into expanding the scheme beyond the 13 initial sites so that more children in England can benefit from it?

The other scheme that has recently started is Dental Check by One, which is being championed by the British Society of Paediatric Dentistry and is supported by the Chief Dental Officer. As the name suggests, the scheme aims to ensure that young children are taken to see a dentist before their first birthday. This is important so that the child becomes comfortable in a dental environment from an early age and so that parents can be given advice on how to take care of their offspring’s teeth. If a child’s first visit to a dental practice is traumatic—if they need a filling or an extraction—in many cases this will deter them from going to the dentist later in life. Therefore, it is crucial that their first check-up is a positive experience. With just 20% of children under the age of two having been to the dentist in the last year, it is certainly important that we raise awareness among parents of the importance of taking them as soon as their first teeth come through. However, we need to remember that the total amount of NHS dentistry commissioned in England is limited, and in fact NHS England commissions only enough of it to cover just over half the population. In many areas of the country, people are still struggling to find a dentist who is able to see new NHS patients.

According to a recent study by the BBC, 48% of NHS practices in England are not accepting new adult patients while 40% are not accepting new child patients. Saying that all parents should take their children to the dentist as soon as their teeth erupt is a great idea, but it will not become a reality until the Government ensure that enough NHS dentistry is commissioned for those who need it.

It is important that any national preventive programme is properly and sustainably funded. I understand that the Starting Well initiative will not be receiving any new funds, with all the money coming from existing dental budgets. Underfunding NHS dental services is similarly pointless. NHS dental budgets have gone down in real terms by 15% in the past seven years while patient charges have been going up at an inflation-busting pace. The effect is that every year hundreds of thousands of patients waste precious NHS resources seeking free help with dental pain at GP surgeries and A&E departments, along with an ever-increasing bill for children’s hospital tooth extractions.

Finally, I should like yet again to point out to the Committee that a cost-effective way of improving outcomes and reducing oral health inequalities is the wider use of water fluoridation. Colleagues will know that I have favoured this solution for many years, and we have heard about it from my noble friend Lady Gardner. The evidence for fluoridating water supplies is indisputable. It is safe and good for teeth, particularly in childhood. While the ultimate decision on whether to introduce fluoride into the water supply lies with local authorities, central government could do much more to facilitate local conversations about this and assist those councils which think that this is a measure that would work well in their area. I know that the Minister will have heard all these arguments before, but I hope that she will take them on board and pass them on to her colleagues in the department. Child tooth decay is preventable and it is high time that we started doing a better job of preventing it.

My Lords, 15 years ago, as I sat in the dentist’s chair for my annual check-up, my dentist said despondently that the patient before me had been a three year-old whose teeth he had extracted. Today this is not an out of the ordinary occurrence among children across the country. Children’s oral health has become a major public health issue, so I congratulate the noble Baroness on securing this important debate.

As we have heard, 90% of child tooth decay is preventable, but it is an issue that affects 25% of five year-olds across England, and in some parts of the country it rises to more than 50%. Last year nearly 43,000 hospital operations were carried out to remove teeth in children and teenagers, which is equivalent to 170 operations a day. The excessive consumption of sugary food and drinks combined with poor oral hygiene is a major cause behind these cases.

Good oral health can help children to be more confident and perform better at school, and it can make a significant difference to their long-term oral health. Children with high levels of disease in their primary teeth run an increased risk of developing disease in their permanent teeth, so addressing this issue early can make a real difference to children’s lives. Visiting a dentist on a regular basis is essential to maintaining good oral health. It helps to ensure that oral health problems are identified at an early stage and is an opportunity for dentists to provide advice to parents and children about maintaining a good oral care routine and managing their diet. However, the statistics around dentist attendance are concerning. Many children aged between nought and 17 never see an NHS dentist. This is despite Public Health England’s advice that children should start having dental check-ups when their first teeth appear, normally at around six months.

What can we do to improve this situation? The first thing is to get the message out as widely as possible that not only should children be visiting the dentist but, crucially, NHS dental treatment is free for all children under the age of 18. Equally, if we are encouraging parents to take their children to the dentist regularly, we must ensure that dental practices themselves are welcoming, friendly places where parents feel comfortable. The oral heath profession has to play its role too. To tackle the problem of child tooth decay, everyone needs to work together: health visitors, midwives, community nurses, early years workers, pharmacists and others all have the opportunity to engage with children and their parents. It is essential that they all provide consistent and accurate advice about maintaining good oral health.

Among others, the Faculty of Dental Surgery has called for oral health to be included in health workers’ training and professional development. This is not about training health visitors to be dentists, but about enabling them to identify signs that a child may have an oral health problem and to signpost them to further help. Perhaps the Minister can indicate what the Government are doing to ensure that the public health workforce is properly trained in the importance of oral health and how they can support children and parents in maintaining it.

We need also to address the variation in dental access across the country. Last year, the media reported on the difficulty that people in some areas have in accessing treatment—areas such as Cornwall, where more than 14,000 people are on a waiting list to register with an NHS dental practice. While NHS dental treatment is free for children, if parents themselves do not go to the dentist, for whatever reason, this can be a significant barrier to children’s attendance.

Public Health England has given direction on a range of evidence-based oral health activities that local authorities should be implementing, as demonstrated in Scotland’s Childsmile initiative. However, there appears to be limited national momentum to ensure that all LGAs are undertaking their responsibility for child oral health and prevention. What action are the Government taking to ensure that all LGAs are actively implementing Public Health England’s recommendations at local level? How many LGAs have sustained programmes for tooth brushing and toothpaste distribution, community-based fluoride varnish programmes and supervised tooth brushing in nurseries? What are the Government’s plans to improve oral health education so that parents and children understand the impact of sugar on teeth and the importance of a good oral health regime?

The good news is that child tooth decay is a problem we can all solve, if we work together and get simple things right to prevent the appalling suffering, anguish, loss of school time, depression and unnecessary pain that children are going through today.

My Lords, I thank my noble friend Lady Gardner for bringing this debate to the Grand Committee today. I am pleased to have the opportunity to speak on the important issue of children’s oral health. I refer to my interests as listed in the register of interests.

Looking back over a number of years, I see that attention has continued to be drawn to the impact of sugar on children’s oral health, together with the interlinked growing problem of obesity facing our young children. I wish to take up the issue of advertising, particularly where young people are a captive audience at popular programme times. Good advertising would certainly help to promote the importance of good oral hygiene and support lots of winning smiles.

I welcome the improvement in children’s oral health over the past 20 years, but, unfortunately, 12% of three year-olds still experience tooth decay. We know all too well that dental decay is the top cause of childhood hospital admission for five to nine year-olds, with hospital trusts now spending £35 million on extractions of multiple teeth for the under-18s. It is a massive cost to the NHS. To put it in context, twice as many under-10s have to have extractions as young people who break their arms—that speaks volumes. Significant oral health inequalities continue to exist for children who live in deprived communities when compared with those who live in affluent areas, and this must be addressed. I highlight also those children with disabilities, who have even poorer outcomes.

Unfortunately, young children who have to undergo tooth extraction, and those with high levels of disease, have an increased risk of disease in their permanent teeth. Local authorities are now responsible for commissioning public health services for children and young people, and have the power to consult on proposals, such as water fluoridation schemes and intervention. That does not require behaviour change by individuals, and as such, choice should be offered.

What can be done to improve children’s dental attendance? An important strand must be to work with and support external partners collectively in continual preventive care, especially for looked-after children and children from families living in poverty. It is vital to raise awareness of the fact that children should visit the dentist at least once a year and to make sure that everybody realises that it is free and that children should have check-ups in the first 12 months of life. In particular, I refer to the new “Dental Check by One” campaign, which should have more widespread and prominent advertising.

Close ties with primary and secondary schools are vital. They should promote good oral health and highlight any issues around reducing sugar consumption in food, snacks, drinks, energy drinks and fruit juices. It is estimated that children consume around three times more sugar than the recommended maximum amount. Importantly, teenagers have the highest intake of all age groups, consuming some 50% more sugar on average. For awareness, surely clear teaspoon labelling is needed from our manufacturers, who we hope will come forward in support and give a real step change to their packaging.

The Government have set out a pilot scheme in 75 practices, looking at incentivising care, but many families wish to see a much bigger and quicker rollout, together with a hard-hitting media and advertising campaign that does not only focus on oral health, but targets the obesity challenge. Both of those represent major public issues facing the UK, which could be incorporated into a coherent national strategy.

I want to take the opportunity to thank the Minister, the noble Lord, Lord O’Shaughnessy—who is not here today—for answering my Written Question on what plans there are to introduce new initiatives to improve dental health in areas of deprivation. I thank him for his reply, referring to the “Starting Well” programme. I wonder whether the noble Baroness, the Minister, has any information to hand with the latest number of dental practices now wishing to join that programme.

Finally, even now, it is sad that 41.5% of children aged nought to 17 did not visit an NHS dentist in the 12 months up to 30 September 2017 and 78.7% of children aged between one and two did not visit a dentist. As I referred to earlier, in 2015-16, the cost to the NHS of tooth extractions in young children aged nought to 19 was £50.5 million; that amount must be reduced as quickly as possible. I hope therefore that the Government will consider investing more—not only in prevention, but in earlier intervention.

My Lords, I thank the noble Baroness, Lady Gardner of Parkes, for tabling the debate. I have a number of interests to declare: I am a vice-president of the Local Government Association; I am the chair of ukactive; and last year I published a report on duty of care in sport, which I was asked to complete by the right honourable Tracey Crouch MP, the Minister for Sport in another place, where oral health was reported to me from several different groups of people. I also spoke at a periodontology conference last year, as declared on my entry in the register of interests, where I met Professor Ian Needleman from UCL. That sparked an interesting conversation about the oral health of athletes, which led me to consider the wider impact it could have on the future of elite sport. In my personal experience—without going into too much detail—I found it hard to eat or tolerate any food in my stomach on race days, so I travelled everywhere with a toothbrush. It was not always possible to clean my teeth after I had been sick; my teeth show signs of decay because of that.

Every major Games I have attended has a polyclinic, which includes doctors, opticians and dentists. At the London Games, the polyclinic was designed and built to treat 200 athletes a day; from seven in the morning to 11 at night, it was full. In 2012, it had 3,220 “encounters” with athletes. The biggest proportion—52%—of those were for musculoskeletal issues, but second on the list was dental issues, which affected 30% of athletes. That number is very similar to previous Games, as well as Rio 2016. In their research study, Needleman et al found that 300 athletes showed high levels of disease, and 20% reported that this had had a serious negative impact on training or performance. It is often assumed that athletes will be at the peak of physical fitness, so those numbers are quite shocking. In this context, future consideration needs to be given to the consumption of sports or energy drinks, gels and other products which are invaluable for athletes in training, but come with unforeseen consequences. As an older athlete on a programme, you may get advice on what to use, but as a young person you may not. There are some sports programmes that have quite young athletes and I wonder whether lessons on oral health should be specifically included in the induction process for young athletes. While lots of athletes are checked for various health issues before they go to the Games, my teeth were never looked at. What consideration has been given, beyond the soft drinks levy, to whether children should be allowed to purchase energy drinks, and what encouragement could be given to help them to understand the products they contain?

The figures on the number of children going into hospital for extractions are, quite frankly, shocking—not just because of the numbers, but the cost that has on the NHS and the long-term impact on children’s health. It is not just about cleaning your teeth or going to the dentist; it is also about what you consume. I am very supportive of the Government’s childhood obesity strategy and the soft drinks levy. It could be incredibly useful, but many companies are changing their products to just go under the limit of what they would be taxed on.

In a chance discussion, a friend who is a governor of a primary school said that they have a large number of children on free school meals. More than 15% of children in state schools are eligible for free school meals. When they introduced a breakfast club to increase attendance, they found virtually all those children had very poor oral health. Now they fundraise to buy toothbrushes to keep in school, so children clean their teeth after the free breakfast, and they also encourage them to clean them at lunch time.

We also need to think about children’s activity. If you are eating a poor diet and drinking too many fizzy drinks, you are not going have the energy to be active. This has a huge impact on our children’s health. I would like to draw your Lordships’ attention to the research on what happens during school holidays. For children on free school meals, many do not eat in the summer holidays. It is also very easy to eat a poor diet of pre-prepared meals, which can be high in sugar or salt, or to eat fast food. A charity called StreetGames has set up a programme called Fit and Fed, which ensures that children have access not only to activity but to free, nutritious meals. I chair ukactive, which has produced research showing that, in the summer break, there is a much greater divide between the fitness levels of children from poorer socio-economic backgrounds and those who are more affluent. The poorest 25% of primary school children experience a drop in their fitness levels 18 times greater than the richest 25%. So it is not just oral health—it is what we eat and what we drink—and ukactive is working with partners to open up dozens of school sites across the country this summer to address issues of inactivity among children. We are also going to be looking at how we can educate children on oral health

The inactivity crisis that we are facing, coupled with things like poor oral health, is significantly limiting our children’s opportunities. I realise that the things I have talked about this afternoon cut across a number of government departments, and many issues are for other Ministers, but this is an important area where cross-government work is vital.

My Lords, I thank the noble Baroness, Lady Gardner, for securing this important debate. I declare an interest as a vice-president of the Local Government Association.

Many of us, though not all, will be in the fortunate position of having to clean some, if not all, of our teeth. One of the incentives to look after my teeth was the unwelcome annual inspection at school by the local authority dentist. I remember that, at the end of the day, the school secretary would come in and give out forms to every child who needed some dental attention. The parents of those unlucky enough to be given a form had two options: one, to agree to an appointment with the school dentist; two, to undertake to take the child to their own NHS dentist. In the 1950s, not sending the form back was not an option. Of course, in the 1950s, with sweets still rationed and ice cream soda a rare treat, teeth were under less threat than today.

I lived, as did many of us, in a relatively golden age of dentistry, where it was universal and free at the point of delivery. My own parents prioritised toothbrushes and toothpaste. In England today, there are many gaps in the availability of National Health Service dentists which need to be filled and, in the absence of any regular school inspections, many children and young people are unaware of the state of their teeth until toothache demands the attention of a dentist.

Of course, many parents ensure that their children take care of their teeth through regular brushing and taking care with their diet. They make sure that, for example, their children’s teeth are not regularly submerged in fizzy drinks or coated with chocolate. However, the rise in the need for very young children to have all or some of their milk teeth extracted has a range of very heavy costs, both in human and financial terms.

Many Members will recall when Margaret Thatcher removed free school milk in 1971, earning, sadly, the title “Milk Snatcher”. This policy was eventually reversed and, today, every child under five is entitled to free milk. When we had a similar debate last year, the then Education Minister, the noble Lord, Lord Nash, said that he would look into whether we could provide free school milk for all primary school children, and there was a large article in the Telegraph. Could the Minister tell us where we are up to with the thoughts of the noble Lord, Lord Nash, on free school milk for every primary school child?

The area I live in, the north-west, has some of the highest rates of tooth decay. About 15 years ago, my local authority decided to introduce what is called dental milk, where a medically correct amount of fluoride is put in the milk. Parents had the choice of their child having a carton of dental milk or a carton of ordinary milk. The parents of 99% of the children in my school chose the dental milk. I think 10 local authorities introduced it. When replying, could the Minister tell us whether any evaluation has been undertaken of the dental milk project and where we are up to on its development? I listened to the noble Baroness, Lady Gardner, talk about fluoride in the water supply, and this might be another initiative that we might look at to help prevent dental decay in our children.

It is difficult to imagine how awful it must be for a two year-old to suffer the trauma of hospital admission, general anaesthesia and the extraction of their teeth. The parents will also pay a heavy emotional price as they support their child before, during and after the procedure. In financial terms, the cost of what is a major operation is considerable, and inevitably takes scarce resources away from surgery that is less avoidable.

We all know how difficult it is for adults to get on the list for an NHS dentist in some areas, and how many adults end up paying for regular check-ups, or paying the price for not having them. What we do know is that many parents do not seem to be aware that dental care, as my noble friend Lady Benjamin said, is free for children and that although 60% of practices accept children, 40% do not—40%.

We are always asking today how we can reduce pressures on the NHS. Tooth decay is the leading reason for hospital admissions of young children and the most preventable. Dealing with this issue would help to relieve those pressures on the NHS. I hope that as a result of this really important debate, the Government might come forward with some new initiatives which will deal once and for all with the problem of young children and teeth.

My Lords, like the noble Lord, Lord Storey, I recall school dentists, and indeed our family dentist, who went by the wonderful name of Mr Slaughter.

At this point in this excellent short debate, the awful facts about the state of our children’s teeth in England have been laid before all of us, including the Minister, who I think, like me, must be hanging her head with shame that we are failing our children on such a scale. The fact that so many youngsters suffer from tooth decay and that so many require extractions at such a young age is a badge of dishonour for our health service and for our Ministers. We have failed to confront a wholly preventable disease.

This is not only a childhood problem. We are condemning a generation of children to reach adulthood feeling self-conscious and inhibited by the state of their teeth. That will certainly affect their social relations and indeed could affect their job prospects. The evidence suggests that for far too long the Government have tended to view oral health as an optional extra. For the children lining up for tooth extractions in our hospitals, tooth decay has long-term consequences. Whether they grow up to become solicitors, receptionists, hairdressers, footballers or whatever, the state of their mouths can affect their life chances. In June 2016, a YouGov poll for the British Dental Association revealed that 77% of respondents felt that decayed teeth or bad breath would hinder a candidate’s chances of securing employment in public or client-facing roles, while 62% felt that applicants with visibly decayed teeth, missing teeth or bad breath would be disadvantaged in securing any role and it would hinder their promotion prospects.

The inequalities in tooth decay are stark. For five year-olds in the most deprived areas such as Blackburn and Darwen, 56% have tooth decay. They are almost seven times more likely to have decay in their teeth than their peers in, for example, Jeremy Hunt’s constituency in Waverley, where the rate is 8%. Children from lower income families are much more likely to have dental disease than other children of the same age. At five years old, 21% of children who receive free school meals will have dental decay, while the rate is 11% among all other children; yet according to the Royal College of Surgeons, tooth decay is 90% preventable.

I know that the Minister will tell us about the Government’s new preventive oral health initiative known as Starting Well, but I have to say that when I look at the details of the programme, I cannot see how it will have the same impact that the campaigns being run in Wales and Scotland are having. They are leading the way on improving child oral health with their early intervention prevention initiatives known as Designed to Smile and Childsmile. They have led to unprecedented improvements in outcomes over recent years. If one were being really unkind, one might even suggest that the Government scheme looks a bit like window dressing.

I have some questions for the Minister and I want to echo some of the remarks made by the noble Lord, Lord Colwyn. Why is this scheme being limited to 13 local authorities? Why is it being funded from within existing dental spend when we know that dentistry is chronically underfunded, down 15% since 2010-11? Why has no new money been found when we can all see that that expenditure would fall squarely within the invest-to-save category? Can the Minister confirm that what the Government are doing is asking dental surgeries in these local authorities to volunteer to take part in this scheme? Is that an effective way to proceed? Is there a plan or a budget for a wider rollout of the scheme? If there is, when will that happen, and if there is not, why not? Lastly, what else is there?

Fluoridation needs to be made easier. It has been mentioned by several speakers in the debate, who have been quite right to say that it is a cost-effective public health initiative. I feel that I have to say that, not only because other noble Lords have mentioned it but because my noble friend Lord Hunt is so passionate about this matter—he would not forgive me if I did not mention fluoridation.

Reducing children’s sugar consumption is of course crucial. The average five year-old consumes their own weight in sugar every year. While the soft drinks industry levy is a welcome first step, we need the Government to take much more decisive action in this area, particularly around advertising, marketing and price promotions involving high-sugar products. New restrictions should be introduced on advertising high-sugar products before the 9 pm watershed on television and online, something which we on this side have pledged to do. Would the Minister like to take this opportunity to pledge to do the same?

I congratulate the noble Baroness, Lady Gardner, on tabling this important debate and I commend her for her persistence over many years in these matters. I thank all other speakers and I look forward to hearing the Minister’s remarks in response to the debate.

I apologise at the beginning for the fact that I will have to speak quite fast because I do not have very long and have quite a lot to say. I do not want people to think that I am galloping through it because I am not interested in what I am saying—I am.

I congratulate my noble friend on securing time for this important debate today, and I am pleased to have the opportunity to talk about what the Government will do in this area. We all recognise that poor oral health for children can have a devastating impact on a child’s quality of life.

We need to keep in mind that, overall, children’s oral health is better than it has ever been, with the most recent data from 2015 showing that 75% of five year-old children in England are now decay free. Between 2008 and 2012, the number of five year-old children who showed signs of decay fell by approximately 10%. This is fantastic progress, but it still leaves 25% of five year-old children experiencing decay, which is unacceptable. As was said by my noble friends Lord Colwyn and Lady Gardner of Parkes and the noble Baroness, Lady Thornton, one child needing to have tooth extractions under general anaesthetic due to poor oral health is one child too many. This is why improving children’s oral health is a priority for this Government. The noble Baroness, Lady Thornton, said that the Government do not feel dentistry to be important. However, our manifesto made clear our commitment to support NHS dentistry, improve coverage and achieve better outcomes, especially for deprived children.

The key issue now for child oral health is that of inequality, as the noble Baroness, Lady Thornton, mentioned. Active dental disease is now clustered in deprived groups and areas. Dentists can and do play an important role in improving oral health, but patients understanding the wider issues involved—from diet and good oral hygiene to the role that fluoride can play—is crucial to progress.

The good news is that a good diet and good oral hygiene, together with regular visits to the dentist and access to clinically proven prevention measures such as fluoride, go a long way to eliminating dental disease. The bad news is that, as we all know, the issues surrounding children’s poor oral health are complex, and this means that there is no easy or quick fix for those currently left behind.

Dentists have a vital role to play in providing regular check-ups for children, giving important messages to parents about self-care at home and providing evidence-based interventions, such as fluoride varnish applications, alongside any necessary treatment. Delivering Better Oral Health, Public Health England’s key guidance to dentists, is clear on the need for regular applications of fluoride varnish for all children at recommended intervals. I am delighted that, in 2016-17, 4.7 million children had courses of treatment for fluoride varnish applications, a 13.9% increase on the previous year. Fluoride varnish applications now equate to 41.2% of all child treatments, making them the most common dental treatment for children.

Every noble Lord who spoke today talked about fluoridation in the water. The clinical case for fluoride’s effect on oral health and the benefits of water fluoridation is substantial. The Government and Public Health England would warmly welcome a decision by a local area to fluoridate the water supply. However, such decisions must be made locally. Local authorities were given responsibility for water fluoridation in the Health and Social Care Act 2012. Given the level of debate that water fluoridation has historically aroused, unlike fluoride toothpaste or varnish, it is important that there is clear local ownership of decisions. However, the case continues to be made by Public Health England that we want as many local areas as possible to make sure that it happens. Water fluoridation benefits the overall oral health of the population. NHS England already bears the cost of delivering fluoride where this is done through a dental intervention such as applying fluoride to teeth, and there are no plans for the costs of water fluoridation to be met centrally.

Turning to the issue of access to a dentist, NHS England commissions primary dental services and has a duty to commission services to meet local need. In the 12-month period ending 30 September 2017, 6.8 million children were seen. This equates to 58.8% of the child population. We appreciate that some areas have access difficulties, even for children. I know that NHS England is committed to improving the commissioning of primary care dentistry within the overall vision of the five-year forward view.

I want to mention some of the specific actions being taken to improve access and the care that dentists can give patients once seen. We are committed to introducing a new NHS dental contract, which will improve the oral health of the population and further increase access to NHS dentistry. Seventy-five high-street practices continue to test a prevention-focused clinical pathway, which includes offering all patients an oral health assessment and advice on diet and good oral hygiene. Follow-up appointments are offered where necessary to support patients’ self-care and carry out any necessary preventive treatments.

The new approach aims to increase patient access by paying dentists for the number of patients cared for, not just for the treatment delivered, as per the current contract. It is important to be clear that the scheme will have to demonstrate that it can maintain access and improve oral health, including that of children, in a way that is sustainable for practices, patients and NHS commissioners before any decision will be taken on a wider national rollout.

My noble friend Lady Gardner of Parkes talked about children not attending dentists, and my noble friend Lord Colwyn, the noble Baroness, Lady Benjamin, and many others mentioned the Scottish initiative. However, I would like to talk about the wider reform of the current approach. NHS England is developing schemes focused specifically on children in areas of high dental need.

As it has already been mentioned in the debate, I am sure that many here are familiar with the Starting Well programme. Noble Lords seem to feel that it will not be sufficient, but it is aiming to improve oral health outcomes for young children in deprived areas. The programme will work in 13 high-priority areas, with the aim of increasing the provision of evidence-based advice and interventions for all children under the age of five, but especially for those who do not regularly visit a dentist. This will, where appropriate, include outreach to children not currently in touch with dental practices.

Alongside that, NHS England is also developing a complementary Starting Well core offer. This is a commissioning approach designed to facilitate increased access and early preventive care for young children anywhere in the country where local commissioners decide it is needed. I understand that this offer will be made available to commissioners by NHS England later this year. It will bring to a wider audience the key message that I know the Chief Dental Officer passionately champions—the importance of starting oral health care and dental attendance as young as possible.

Ensuring access to dental services and treatment is the responsibility of NHS England. However, it is important also to talk about the role of Public Health England in improving children’s oral health more generally. This area of public health is very much a priority for Public Health England. The noble Baroness, Lady Grey-Thompson, talked about a joined-up approach to dentistry and other areas, and the noble Baroness, Lady Benjamin, talked about the LGA implementing Public Health England’s recommendations. Public Health England has established the Children’s Oral Health Improvement Programme Board, which brings together a wide range of stakeholders and has an extensive work programme. Public Health England, through the board, co-ordinates all the work being taken forward across the system on improving child oral health. One of the outputs has been the updating of the “red book” to ensure that all new parents receive clear messages about the importance of good oral hygiene and early dental attendance.

Many noble Lords have spoken about sugar. Prevention is a key part of the work that Public Health England leads. Diet is very important—particularly sugar intake, which is the leading cause of dental decay. The sugar levy and the sugar reformulation programme are therefore very important in improving oral health, as well as having an impact on the wider issues of obesity.

Following on from that, the noble Baroness, Lady Grey-Thompson, mentioned energy drinks and the problems that athletes have had. As we know, energy drinks can be high in caffeine and sugar. Alongside our measures to reduce sugar, we will continue to monitor the situation and look at any emerging scientific evidence on the consumption of energy drinks. I hear what the noble Baroness says. As I said, we will monitor this. Since we published the plan on the sugar levy, there has been real progress. The levy has become law and will come into effect in April 2018. Public Health England has formulated a comprehensive sugar reduction programme with the aim of a 20% reduction in sugar in key foods.

My noble friend Lady Redfern talked about what schools can do. We expect all schools to have healthy eating policies. The noble Lord, Lord Storey, talked about milk in schools. Although nutrients in milk are useful for healthy teeth, milk does not per se improve teeth, and calcium, which is needed for healthy growth in teeth and bones, can be found in a number of foods. However, poor diet is a key risk factor of poor dental health, and all children are encouraged to reduce their intake of free sugars. Milk is a safe alternative to sugar and sweetened drinks, is safe for children’s teeth and is recommended for delivering better oral health in the evidence-based toolkit for prevention.

If the Minister does not have the information about dental milk, could she write to me about it?

I will write to the noble Lord on that.

I have only a minute to go, which is a nightmare. The noble Baroness, Lady Thornton, talked about the Starting Well programme. The overall aim of Starting Well is to reduce oral health inequalities. The programme will operate in 13 identified high-priority areas and will be funded through expected dental underspends. NHS England launched the programme in September 2017 with a series of events around the country attended by 158 dental practice teams. Practices have been applying to join the programme, and over £3 million of funding has been agreed locally to support it to date.

My noble friends Lady Redfern and Lord Colwyn talked about the fact that only 20% of two year-olds are being seen by dentists. Public Health England recommend early attendance, as well as an appropriate diet and strong oral health hygiene as the foundation of oral health. This message is being given to parents at the very start of their children’s lives through the personal child health record.

I feel that I have left several questions out and, if I have, of course will write to noble Lords. In conclusion, I hope that I have demonstrated our strong commitment to improving oral health outcomes for children and ensuring that children have access to dental services and important preventive advice. Please let us carry on talking about this, including outside the Chamber, when I have all the time in the world.

Sitting suspended.