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TOWARDS BETTER ORAL HEALTH IN CHILDREN: ANALYSIS OF CONSULTATION RESPONSES

CHAPTER 2: THE CONSULTATION PROCESS

TIMING OF CONSULTATION

The consultation on better oral health in children took place between 24 September 2002 and 28 February 2003. Originally timetabled to end at 31 December 2002, this consultation period was subsequently extended " in response to representations that more time is needed to consider the full range of issues, and extend the opportunity to comment" ⁶. The scale of the consultation was very large and extensive, with responses still being submitted and accepted up until mid-March 2003. Staff in the Public Health Division of the Scottish Executive's Health Department supported the exercise.

NATURE OF CONSULTATION

The consultation document comprised 25 pages (plus bibliography) which strove to promote a mature, constructive and inclusive debate to help inform future policy. It outlined the issue of poor oral health amongst children in Scotland and detailed the problems, causes, current action being taken and additional measures which might be taken in order to improve the situation. The consultation had a written format with respondents invited to comment on the measures they believed should be taken to accelerate progress. Three key areas were highlighted for comments:

DISTRIBUTION AND ADVERTISING OF CONSULTATION DOCUMENT

To launch the consultation over 7,000 documents were distributed. The main bodies which were sent copies of the document are listed at Annex 1. These included NHS Boards and Trusts, Local Authorities, and Local Health Councils, Consultants in Dental Public Health, dental services and other professional bodies. In addition, a large number of copies were sent in response to requests from members of the public. A copy of the publication was also sent to every public library in Scotland and every GP surgery and dental surgery. The consultation document was also available online at: http://www.scotland.gov.uk/consultations/health/ccoh-00.asp

Over 20,500 online consultation "hits" were recorded during the consultation period.

Further advertising of the consultation took the form of a press conference and television and radio slots for the Chief Dental Officer for Scotland. Once the decision had been taken to extend the consultation period, fresh impetus was given to the process by virtue of a re-distribution of the document to an even lengthier distribution list and renewed media interest. All those who had previously received a copy of the consultation document were sent a letter informing them of the extended consultation period.

This structured, focused and extensive distribution was supplemented by further "knock-on" advertising of the exercise in local and national press. For example, specific press articles sometimes sparked of a raft of letters in response, which in turn snowballed into further, often local dialogue and letters, to MSPs and the consultation team. Many of the individual respondents to the consultation noted in their reply the source of their information. Notable amongst these were: The Scotsman, Scotland on Sunday, Sunday Herald, Scottish Daily Mail, Sunday Post, N.E. Fife News, Perthshire Advertiser, Inverness Courier, West Highland Free Press and the Berwickshire News. Some respondents had gleaned details from their respective community council newsletters. Others had been targetted by mail-shots from organisations such as the Scottish Pure Water Association and The Highland Movement Against Water Fluoridation.

Many respondents referred to literature and announcements issued by BMA, WHO and UN in addition to the academic York Report which had been cited in the consultation document. In the main, such references were deployed to support the respondent's anti-fluoride in water arguments.

In the main, the focus of the debate, fuelled by this informal media attention, was on fluoridation of water - singled out by respondents for particular attention, from amongst a number of proposals presented by the Health Department for consultation.

It was evident from responses that a number of public events had been staged to alert people to the issue of fluoridation of water and to discuss the likely implications of such a policy. For example, the group, "Highland Movement Against Water Fluoridation" held a public meeting early on in the consultation period to which selected key speakers were invited. One impact of this and other such events was to skew the consultation to a great extent towards geographic clustering of public responses on the single issue of fluoridation of the water supply. A further probable outcome was to greatly boost respondent numbers, aided in part by the availability of pre-printed response letters, petitions and general support and encouragement.

Running concurrently with the consultation were other developments, this time at the professional level. One key focus within this arena concerned the inaccessibility of NHS dentists, with the Consumers Association reporting confusion and a lack of transparency about whether people were receiving private or NHS treatment ⁷. A further recent report by the Office of Fair Trading criticised private dental charges and concluded that the market was, "not working well for consumers" ⁸.

The extensive consultation "net" described above, featuring not only a broad range of professional bodies but also a large number of individuals located throughout Scotland and beyond, resulted in a high volume of responses, relative to other Government consultations. A description of the respondents is outlined below.

WHO WERE THE RESPONDENTS?

The full list of professional respondents is documented at Annex 2. Respondents could be grouped into broad categories as shown in Table 1.

Overall, 1337 responses were received along with 5 anti-fluoridation petitions. Three out of every 4 responses were submitted by individual members of the public. Dentists, dental hospitals and dental and other health associations and societies comprised 6% of respondents. Some responses represented the views of a group of people, such as employees within an organisation, others presented the opinions of one individual. No weighting system was applied to the responses so that, for example, the consideration of the response from an individual was the same as that applied to a response from an organisation such as a local authority. This reflected the aim of the consultation to solicit a wide range of views from the public and professional bodies alike.

Gender of Respondent

The gender of the respondent was evident in the cases of 854 of the responses from individuals. A gender imbalance emerged with more women (61%) than men (29%) responding to the consultation. Ten per cent of responses from the public were submitted jointly by mixed gender couples.

Geographical Origin of Response

For 91% (935) of individual responses, the geographical origin of the response was apparent. Of these, 98% were Scottish based. Of the remainder, 17 were sent from elsewhere in the UK and 5 from outwith the UK.

Of the responses from professionals and representative organisations for which geographical origin was evident (98%), the vast majority (90%) were Scottish based. A further 7% were sent from elsewhere in the UK, with 3% originating outside the UK.

Figure 1 overleaf, and Annex 3, present a broad picture of geographical origin of the Scottish based responses. A substantial over-representation of responses from Highland region is demonstrated (with 31% of respondents but just 4% of the Scottish population) perhaps indicative of the pro-active anti-fluoride pressure groups operating in that area and the interest of the local press.

Age of Respondent

Whilst a formal record of age and other demographic details of respondent was obviously outwith the scope of the consultation, many respondents proffered such details in their response. Whilst providing only a rough guide to the type of respondent, such information suggested a wide age range of respondent comprising a sizeable proportion of parents and grandparents amongst the respondent population.

Gaps in Respondent Type

A scan of the individual respondent details along with a review of the respondent organisations revealed no obvious gap in the type of consultee. However, whilst the consultation team did invite the views of young people via the Scottish Youth Parliament

Note: Percentage returns of less than 3% have not been shown on the map, but are listed in Annex 3.

and School Boards, an analysis of responses suggested that the concerns of this sector tended to be represented through the responses of parents and educational bodies rather than through the first-hand views of young people themselves. It is suggested that this possible shortfall could be addressed by their involvement at various stages of future development of policy on oral health in children.

NATURE AND FOCUS OF RESPONSES

The final total of 1342 responses could be broken down as shown in Table 2.

Twelve pre-printed response pro-forma were identified from amongst the responses. A pre-printed response was defined as an "off the peg" prepared statement to which a respondent has simply added their signature. All of these responses focused solely on the anti fluoridation of water issue. Examples of the wording of 2 of the most frequently used pre-printed pro-forma are provided in Annex 4.

Response Mode

Although most responses were sent in the post in hard copy (81%), a substantial volume (19%) was sent electronically (Table 3).

The greatest use of electronically sent responses was made by pressure groups. For this sector, half of their submissions were sent in this way. Of the responses from individual members of the public, 17% were sent electronically.

Responses came in a wide variety of forms from "one sentence" contributions to very lengthy documents. Many enclosed attachments with their responses, usually photocopies of newspaper or journal articles, or as on one occasion, photographs of the respondents' child's teeth.

Fluoridation Focus

The consultation responses were dominated by a focus on the single issue of possible fluoridation of the Scottish water supply. Of the 1337 responses (excluding petitions), 2 out of 3 (66%) focused entirely on the issue of fluoridation of water. Differences emerged between the various sectors in this regard. For example, of the responses from individuals, 74% referred to this issue alone. Amongst the dental and dental health association responses, a broader focus was generally the case with only 20% relating solely to water fluoridation.

Depth of Response

A further way of classifying the responses into broad typologies was constructed especially for this consultation and comprised the organising of responses under the following categories:

• Well reasoned response with many constructive solutions

• Moderately reasoned response with a few constructive solutions

• Little or no reasoning with no constructive solutions

Every response (excluding the 5 petitions and 151 pre-printed responses) was examined by the research team and matched against these criteria before sorting into one of these 3 categories. Whilst obviously a relatively crude measure of content of responses, this approach nevertheless provided a broad indication of depth of response and likely usefulness in generating constructive ideas for improving children's oral health. The results of this assessment are presented in Table 4 below.

Of those responses from individual members of the public, around half (49%) were considered well or moderately well reasoned with at least some solutions suggested. Amongst dentists and dental health association responses, 97% were placed in these categories. Whatever the category of response, no weighting was applied to the submissions, each being accorded equal consideration and attention for the purposes of the analysis.

REFLECTIONS ON THE CONSULTATION PROCESS

The Research View

Overall, the consultation responses were relatively difficult to analyse. With the exception of the pre-printed material, the responses did not follow any set formats, they ranged from one liners to very long and intricate arguments, they displayed a huge variety of depth of reasoning and accommodated a substantial body of replies which focused solely on the single issue of fluoridation of water. A major initial task for the research team was to identify and apply an appropriate framework for collating and organising the response material so that the detail could be analysed effectively.

On reflection the wide range and variety of response may have been, in part, a result of the relatively open format of the consultation, designed to encourage wide participation. For example, the document contained no formal response pro-forma and no set list of priority questions for direct respondent response. This would account for the lack of consistent structure of response and topic coverage. This lack of a more prescriptive direction may also have inadvertently paved the way for the overwhelming skew of response towards the fluoridation of water issue and the relatively large size of the respondent caseload, boosted by these single issue responses. Such responses provided a feel for strength of feeling of the anti-fluoridation proponents, but were fairly limited in the production of constructive solutions to the central issue of children's oral health.

The Respondents' View

Amongst the minority of respondents who commented about the consultation process itself, the theme for each was a perception that the exercise had not been adequately publicised. The topics covered by the consultation were seen to be of key importance to the everyday family and some felt that the consultation should have been targetted more keenly at this level. Comments such as those below were typical:

A further avenue of complaint was the inaccessibility of the consultation to the ordinary folk of Scotland. A few respondents were concerned about any expectation that people could access the document on the internet, (note however, the 20,500 electronic "hits" recorded) whilst one articulated a view on what they perceived to be the gloss and inappropriate language of the document:

Of course, putting this in perspective, those happy with the process are least likely to express a view and those documenting their concerns were in the minority. Nevertheless, the issues raised are welcome and are very useful in learning from the consultation process and understanding the context in which the views were expressed.

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