Health and Social Care Committee
Public health implications of inadequate public toilet facilities
PT 1 - The IBS Network
December 2011
From The IBS Network:
Dr Nick Read, MA, MD, FRCP, Chair of The IBS Network
Mrs Gillian Kemp, MA, Supporter of The IBS Network
PUBLIC TOILET PROVISION IN WALES
Public Health Implications of inadequate public toilet facilities
Memorandum to the Health and Social Care Committee
National Assembly for Wales
Introduction
The IBS Network is a national charity which supports people of all ages who are suffering from Irritable Bowel Syndrome (IBS)
Irritable Bowel Syndrome or IBS is the name doctors have given to a collection of otherwise unexplained symptoms relating to a disturbance of the colon or large intestine. IBS affects around a third of the population at some point in their lives. The symptoms of Irritable Bowel Syndrome are various but include an urgent need to visit the toilet with very little time to find one. The closure of public toilet facilities is therefore of great concern to people suffering from IBS with urgency problems.
What are the effects of public toilet provision (or lack thereof) on the health and social wellbeing of a person?
Fighting the taboo
Nowadays we can talk about most things, but there is still a taboo about talking about the bowel and its functions. It is not considered polite even when the bowel is working normally. When there are problems with bowel control the situation is even worse. The unwillingness of people to talk clearly and openly about their illness, even to their GP, means they can feel alienated from family and friends and become depressed and isolated as a consequence. Councils and those in charge of public toilets may therefore assume that because people are not protesting against a proposed toilet closure, there is no need to have them. But the provision of public toilets is an issue of great concern to people living with the unpredictable nature of their IBS symptoms.
Impact on everyday life.
The anxiety of not knowing when a toilet is going to be needed can have a devastating impact on everyday life. Many people with IBS find it difficult to participate in activities away from home unless there is a toilet available, not only at their destination but also along the way.
The diarrhoea associated with IBS is not only unpredictable but can be frequent. The experience of losing control of one’s bowels in public because of the lack of available – and open – toilets is a real one. Lewis Moody the Rugby player who suffers from colitis wrote about his own experience of losing bowel control and the awful embarrassment and shame which he felt when he found toilets in a car park closed [Mail on Line, 29 October 2011]. Not only is a situation like this highly embarrassing, it undermines confidence and self esteem and many people find the easiest way to cope with the possibility of it happening is to remain at home.
Not having access to a toilet can mean that socialising, going shopping, even travelling to work can become almost impossible with the result that a person become isolated from the community.
The need to know the locations of toilets, whether they are still available and, if they are, whether they are actually open at the time of visiting causes anxiety and for many it is easier to stay at home. A lack of adequate facilities at bus and train stations and on board trains, excludes many patients from using public transport
IBS members are issued with a ‘Can’t Wait’ card which has the message:
'Please Help! I have a medical condition which means I need to use your toilet facilities urgently. Your co-operation and kindness would be very much appreciated.'
This card is intended to make it easier for members to ask to use the toilet in shops and offices if the premises do not belong to a Community Partnership Scheme [additional comment later], without having to give a long explanation about their condition. However, it doesn’t guarantee access and some members have been very distressed when access to toilet facilities has been refused.
Is there evidence of people being unable to leave their homes due to concerns over the availability of public toilets? If so, what are the health and wellbeing implications of this?
Isolation:
If people cannot leave their homes because of the fear of soiling themselves because of the worry that they will not be able to find a toilet in time they become isolated from their community.
‘I feel so ashamed I daren’t leave home unless I know where all the loos are’
Mental health
Withdrawal from the community brings with it mental health problems, particularly loneliness and depression.
Work opportunities
Needing a toilet on the way to work is an issue for many people with IBS. It can be a distraction for those who need to travel distances to their place of employment and they can arrive stressed and unhappy. This has a knock on effect as stress can make IBS symptoms worse.
One of the problems with IBS is that you can have good days and bad days but you never know which and it can’t be factored into any activity planning. So, if a job opportunity arises some distance from home, do you take the plunge or do you remain within the known environment? Lack of toilets can limit job opportunities for some people with IBS.
“I felt too embarrassed to talk about my problem to anyone at work, but when my boss put an article she’d written about her own experience of IBS on the notice board, I felt able to ask for help in getting to work”
Physical health
The simple act of going for a walk, encouraged by many organisations and health professionals, cannot be considered by many people with IBS. Are toilets available?
“I have to find out if there are toilets there – they’re usually not advertised in any information provided - because if there aren’t any along the route I can’t go! It’s as simple as that”
Similarly with sports, you can play sport but on the way to and from the sports centre you may find yourself needing a toilet urgently with no toilets available. It’s easier not to bother.
With shopping available on line, you won’t starve, but your body won’t be exercised and other health issues can arise.
Is there equality across Wales – and in relation to all people – in the provision of public toilets?
Toilets are being closed in Wales as they are in other parts of the UK. Some areas such as the Upper Rhymney Valley have no facilities at all. Merthyr Tydfil has only 3 facilities [Merthyr Express, 24 November 2011]
In some areas of the UK, including Wales, there has been a move to introduce Community Partnership Schemes [CPS] where businesses such as cafes, pubs, offices allow members of the public to use their toilets. There are positive and negative reactions to this. The good news for IBS sufferers is that toilets may become available in places where perhaps there have previously been none or the public toilets have been closed down. The bad news is that CPS toilets are not always clearly signposted and so someone, possibly in distress, may not have the appropriate information to access them. Many CPS toilets are only open during office hours and there remains the problem of the night time economy. Many women do not feel comfortable or able, possibly for religious reasons, or because they are accompanied by children – to visit pubs, especially at night. Standards and accessibility of CPS toilets vary greatly and information is not always widely available. In a department store, you have a reasonable idea of what to expect; visiting an office, you are venturing into the unknown – which adds to the anxiety. Some businesses offering a CPS toilet have moved or closed down and the information has not been updated. Many businesses see offering a toilet facility to paying customers as part of the service and do not want having non paying public using their facilities.
The best solution to support people with IBS is to have publicly available toilets open when needed with the location and opening times clearly signposted.
Like everyone else people with IBS need access to a clean, well maintained publicly available toilets. Having toilets in towns, cities, transport interchanges, tourist areas, play areas and motorways will bring people into the area and boost the economy. Having toilets will allow people with IBS to enjoy green spaces with their children, teenagers with the condition will be able to play outside, and they will all have the confidence to participate in activities other people take for granted and take part in community life.
“Public toilets in places like parks and promenades help to encourage people who may need regular toilet access to take exercise and stay physically active” Improving Public Access to Better Quality Toilets: A Strategic Guide (Department for Communities & Local Government, March 2008)
What could the wider effects of inadequate public toilet provision be on public health and the community? e.g. correspondence sent to the Petitions Committee suggests that there is a risk of street fouling and a consequential spread of disease
For people with IBS there is always the risk of street fouling if they cannot find a toilet.
Someone with IBS who has soiled themselves in public finds it horrendously embarrassing and distressing and will make every effort for it not to occur again. This could mean that the person becomes fearful of leaving home preferring to remain ‘safe’ rather than take the risk of such an incident happening again. As we have explained earlier in the Memorandum, staying at home in these circumstances can lead to depression and mental health problems.
The Council, in the meantime, has to clean up the area which involves time and costs. As more and more toilets become under threat of closure or actually close, the situation is likely to become worse.
“Inadequate provision also has a significant effect on public health and environmental issues, particularly in terms of street cleanliness and disease control” Ivan Lewis, Department of Health, Improving Public Access to Better Quality Toilets: A Strategic Guide (Department for Communities & Local Government, March 2008)
People affected by IBS are constantly anxious about suddenly needing a toilet and having very little time to find one. Their lives can be dominated by finding a toilet and the fear of embarrassment. Consequently, this can have a devastating impact on their ability to engage in day to day activities. People with IBS need – and want - to minimise the disabling impact of IBS. They need the reassurance that when away from home they can access a public toilet.
For people with IBS access to toilet facilities is of paramount importance.
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