Health and Social Care Committee
Public health implications of inadequate public toilet facilities
PT 2 - British Toilet Association
December 2011
British Toilet Association
Written evidence provided by the British Toilet Association:
Mr Mike Bone, Director
Mrs Gillian Kemp, Management Committee Member
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 aim of the British Toilet Association [BTA] is to represent the interest and aspirations of ‘away from home’ toilet providers, suppliers and users of all types. The BTA acts as an important link between the private sector toilet producers, local authority providers, local authority policy makers, planners and voluntary campaign groups representing users.
What are the effects of public toilet provision (or lack thereof) on the health and social wellbeing of a person
Elderly people
1 Independence
As we become older we become increasingly likely to develop bladder and bowel conditions. This means that older people have to use the toilet more frequently and with greater urgency. Physically getting to a toilet is also more difficult as mobility becomes restricted because of age. ‘Nowhere to Go’ published in 2007 by Help the Aged [now Age UK] states that 3-3.5 million people suffer from urinary incontinence in the UK and more than half are over 65 with the majority being women. That was 4 years ago and the numbers of older people continue to increase
For many older people leaving the home requires careful planning to ascertain the location of the public toilets in the area they want to visit. Some may have suffered discomfort or embarrassment because of the lack of public toilets and many are anxious in case they do. Toilet facilities on public transport and at interchanges can be poor or non existent and the answer for many older people is to stay at home.
2 Quality of life
In ‘Nowhere to Go’ 52% of respondents agreed that the lack of public toilets in their area stopped them from going out as often as they would like. For those older people who are particularly anxious, the lack of facilities stops them going out at all.
3 Cost
Not going out and not keeping active can result in depression. The cost of health and social care falls on local authorities as well as the national health services. It is therefore important to encourage older people to remain involved with their friends and community
Women
Many public toilets in the UK were established at a time when women stayed at home to raise the family and the men went out to work. Consequently there were many more facilities provided for men than women. The balance is slowly changing but the closure of public toilets affects women in several ways.
1 Time
Women take on average twice as long to use the toilet as men, but there are still too few women’s cubicles compared to the male provision of urinals AND cubicles.
2 Out and about
A survey carried out to support the revision of the British Standard for public toilet provision showed that more women than men are out and about in the community. ENCAMS [now known as Keep Britain Tidy] reported that women outnumber men 70:30 in shopping centres and even higher in some places, yet there are more toilets available for men. A report by the Bladder & Bowel Foundation in June 2008 found that 32% women of a sample of 1040 adults have bladder control problems compared to 13% of men.
3 Particular needs
Women who are pregnant or at the menopause need to use the toilet more often, as do those with other conditions such as diabetes [Clara Greed, Inclusive Urban Design: Public Toilets, Architectural Press, 2003]
In the same publication, Professor Greed acknowledges research by Armstrong & Scott in 1992 and Rothburn & Dunningan in 2004 which found that there is a higher risk of tampon infection if toilets are not available. Yet
at any one time, about a quarter of all women of childbearing age will be menstruating but there is ‘little allowance….for acknowledgement of women’s menstruation and how urination demands might change within the monthly cycle’.
4 Caring
Women often take on the role of carer, whether of older people or children. In these situations they need toilets in accessible locations with facilities to accommodate the needs of those for whom they are caring as well as their own – often with shopping bags and luggage in tow.
Children
1 Sanitary equipment
The BTA has observed that there are very few publicly available toilets dedicated for children’s use with appropriate child sized sanitary equipment. There are an increasing number of low level urinals for boys but there are seldom toilet pans at a suitable height for young boys and girls or low level washing facilities to encourage proper hand hygiene.
2 Baby changing
There are now many separate baby changing facilities included in public toilet premises, although very few actually cater for the carer who also wishes to use the toilet. Carers often have to negotiate a buggy, sometimes with an additional child and its accoutrements into the main toilet area in order to use the toilet.
The closure of a public toilet means that those with babies to change have to find alternative, less sanitary means– such as on a park bench if the weather is fine – with suitable means of disposal. The choice for many in this situation is to leave the soiled nappy behind incurring additional cleaning costs for the local authority.
3 Small children
Small children need a toilet several times a day. They do not have control over their bladders which are still growing and outings can be abruptly curtailed should a child suddenly demand the use of a toilet. If there is no public toilet available, the choice for the carer is either to go home if home is comparatively nearby and spoil the day for everyone, or find a convenient bush; a choice which is understandable but unhygienic and again involves a cleaning operation by the appropriate council department.
4 Older children
Toilet closures affect older children. They may be out on their own and need access to a toilet that takes into account both road and personal safety. Girls may have just started learning to cope with menstruation. Holding on for children, or anyone is unacceptable.
5 Young people
The Bladder & Bowel Foundation reports that 4.8 million people in the UK under the age of 24 years are estimated to have already experienced some kind of problem with their bladder control and a similar number with bowel control [June 2008]. Young people suffer from embarrassment and anxiety about toilet related issues and their need for publicly available toilets should be recognised.
As Adams & Ingham, 1998 and Bartlett, 1999 [Clara Greed, Inclusive Urban Design: Public Toilets, Architectural Press, 2003] suggest ‘children are the last great minority to be “discovered” as worthy of priority policy treatment’.
Disabled people
1 Importance of accessing public toilets
Anne McGuire in the Foreword to Improving Public Access to Better Quality Toilets: A Strategic Guide, 2008 pointed out how access to high-quality public toilet facilities plays an important part in all our lives but a lack of such facilities can prevent or restrict the opportunities to take part in everyday activities such as shopping and leisure pursuits.
According to Professor Greed one in eight (12.5%) of the population is classified as disabled. Whilst only around 3% of disabled people actually use wheelchairs, others have problems with mobility, fragility or lack of stamina which require consideration with regard to accessing public toilets.
2 The value of Changing Places facilities
People with profound and multiple learning disabilities and other severely disabled people cannot use standard accessible toilets. The lack of what has become known as Changing Places facilities which have space, a hoist and the equipment to cater for all ages restricts access to many activities and places not only for the disabled person, but for the carers as well.
3 Bladder and bowel problems
More people suffer from some form of bladder and bowel problems than with asthma, diabetes and epilepsy put together. [Bladder & Bowel Foundation]. Anyone can develop health problems at any age but bladder and bowel issues, because they are not considered a suitable topic for conversation, can have a huge impact on how you live your life.
4 Isolation
Once again, the feelings of isolation and inability to enjoy the community and contribute to the economy because of the lack of suitable toilet facilities can cause depression and stress. The BTA argues that the cost of supposed savings from closing public toilets has to be seen in a much wider context, to include the impact on local quality of life, particularly the health and life style of residents within a community as well as the visitor economy.
Mobile workers
Postmen, carers, bus crews, delivery personnel, taxi drivers, lorry drivers, police officers and other mobile workers need access to public toilets as they carry out their duties. The closure of public toilets impinges on their ability to carry out their work effectively. An article in the Daily Mail dated 31 May 2011 suggested that police officers in a particular county in England were being advised to ‘Try to restrict fluids to prevent visits to the bathroom’. The BTA would argue that this is unacceptable and ill advised on health grounds.
1 Women
Many mobile workers, especially in the cleaning and caring industries are women who would be affected by the issues already discussed above.
2 Cycling and walking
In these days of being environmentally friendly we are being encouraged to leave our cars behind and either become a cyclist or a pedestrian. Neither activity is suitable without publicly available toilets open at times that people need them. A toilet opening at ten o’clock in the morning is no good if you’re on your way to work five hours earlier.
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?
Older people
As mentioned in connection with the first question, having public toilets available can make the difference between being independent or house bound.
1 Living longer
Now that people are living longer but are also developing conditions which require frequent visits to the toilet, public facilities are an essential requirement for every day life. An elderly person’s fear of soiling or wetting themselves in public is a very real one. The long term effect of actually doing so is even worse.
2 Health risks
The lack of public toilets increases health risks and incurs costs for medical treatment because if people feel they cannot leave their homes, they can’t keep physically active. In ‘Nowhere to Go’ mentioned previously ‘52% of respondents admitted that the lack of public toilets in their area stops them from going out as often as they would like’. Attending graves of loved ones in cemeteries or visiting local shops on the bus are inaccessible activities if there are no toilets close by. Losing public toilets in areas such as parks and promenades where older people could take some exercise results in many people becoming inactive and prone to health problems.
3 Isolation
The ‘Nowhere to Go’ report suggests that ‘about half of the over-75 population of the UK lives alone’ with many feeling lonely and trapped within their four walls and that evidence implies that the lack of public toilets is a contributory factor. Depression, states the report, affects an estimated 1 in 8 people over the age of 65.
4 Physical activity
Physical activity, especially in later life, is important. It reduces the demands on local health services and helps older people maintain their independence. Losing public toilets means that many older people are excluded from activities such as shopping which contributes to the local economy.
Women
1 Times
Women need toilets at different times from men – particularly during the day time when they doing the school run, going to full or part time work, looking after children and / or relatives. 52 per cent of the population are women.
2 Night time
Also, as mentioned previously women’s toileting needs are different to those of men due to biological differences. Yet the night time economy caters more for the male population than for women. In many areas, urinals are provided at night with no provision for women. The headline in a local newspaper dated 31October 2011, was ‘Use new Swansea urinals or get arrested’. No mention of any toilet facilities made available for women! Women have 2 options: to stay at home or go out and deal with the consequences in the best way they can.
Disabled People
1 Invisible disabilities
Conditions such as irritable bowel syndrome, ulcerative colitis, and Crohn’s disease affect both men and women and cause many people to stay at home because of the lack of public toilets [Ladies and Gents p54]. These ‘invisible’ disabilities can be intermittent or chronic but the urgent and frequent need to access a toilet means many sufferers feel anxious about being away from home. Others plan their routes very carefully based on the availability of public toilets and even then many will continue to feel anxious and prefer to restrict their outing in case they find themselves in an embarrassing situation. Leaving the security of home is, for many, a stressful experience, especially when journeying somewhere new [Nowhere to Go p5]
Is there equality across Wales – and in relation to all people – in the provision of public toilets?
There is equality in the fact that the closure or lack of public toilets affects everyone as we all have to use the toilet several times a day.
1 Impact of non statutory duty
Public toilet provision is not a statutory duty and as a consequence the type of provision varies greatly from area to area. For many people, especially visitors, finding a toilet in a new area is not easy. For those with medical conditions the choice for many is to stay at home rather than risk an ‘accident’. Grandparents out with their children face similar problems. For public places to be ‘inclusive’ the services provided must include public toilets to ensure they are accessible to all.
2 Inequality for women
Women, as we have mentioned, need more provision than men, due to their biological needs and the fact they are the majority of the population but they are not properly catered for, especially during evening hours. Research by Goldsmith, (1992) suggests that as men have a higher level of toilet provision they drink more fluids than women and therefore may never see the need for a toilet as a problem!
3 Community Partnership Toilets
These are toilets in private premises such as pubs, cafes and offices which can be used by the public without having to make a purchase. The Local Authority pays the owner of the premises for providing the facility which is cheaper than maintaining public toilets. However, some people do not want to enter pubs for a variety of reasons and children may not be welcome. Community toilets may not be able to cope with large groups of people and the premises may not be open when needed. Some local authorities are now finding there are fewer companies willing to allow the public into their premises just to use the toilet. With public toilet closures and no other facilities available those who need frequent access to a toilet are restricted in the length of time they can risk being away from home.
Community partnership toilets should not be used to replace public toilets but may be a useful addition to a particular area if properly signposted.
4 The Disability Discrimination Act
This Act was intended to improve access for disabled people. However, some authorities use it as an excuse to close toilets that do not fulfil the appropriate standards. The effect of this is not only to close down a facility which a large number of people could use but also to take away a facility that some disabled people also used albeit with difficulty. This restricts the activities of disabled people even more!
The Act does not state that non compliant toilets have to close. It asks that reasonable adjustments be made if possible or to include facilities for disabled people where appropriate. This can be the addition of handrails and painting walls so that the hand rails stand out to help poorly sighted people. Neither of these ideas is expensive. All new builds, however, must include facilities for disabled people. This misuse of the Act is causing problems throughout the UK by reducing facilities for everyone and goes against what the law originally set out to achieve.
It is hard not to disagree with a comment in the introduction to Ladies and Gents that ‘denying access to a toilet remains a remarkably effective form of social exclusion’
Many of the needs of these groups have already been addressed but there are some additional points we would like to raise.
1 Keys
The BTA feels it is unacceptable, even discriminatory, for a significant section of the population to have to possess or ask for a key to use a toilet. Some toilets are accessible by a RADAR key but the rest of the population – around 85% - are denied access to ordinary public toilet facilities once they have been locked at dusk or at weekends. Some people feel anxious about asking in case their request is refused and then they will have to spend more time finding another toilet. An incident on this issue was witnessed in a well known department store. The key had been ‘lost’ and the lady in a wheelchair who was accompanied by her husband had to find another suitable toilet; the nearest being at the far end of the shopping centre. This scenario reinforces the lack of dignity and embarrassment this situation engenders.
2 Locking up times
Bladders and bowels function on a daily basis. Therefore locking toilets during afternoons and over weekends can cause problems. Firstly, it can encourage street fouling with its attendant cleaning costs. Secondly, it can affect the local economy because if there are no toilets available people will not stay long. In a survey in 2001, The Association of Town Centre Managers showed that towns with good toilet facilities have a higher retail turnover than those without. Thirdly it can affect those working out of ‘normal’ hours.
3 Queuing
Queues for the women’s toilets are due to the inadequate number of cubicles provided. Women take longer than men to use the toilet and as mentioned before, have specific biological needs which do not affect men. It is rare to see men queuing for the toilet even when a coach party arrives at a ‘comfort’ stop but the women have to wait their turn.
During this time of waiting, they are having to ‘hold on’. This as Anthony and Dufresne [Ladies and Gents p54] remind us can make women a ‘potential candidate for cystitis and other urinary tract infections’ which could progress into something worse should they be allowed to develop. This applies to pregnant women too and of course children, many of whom have difficult in ‘holding on’.
Anthony and Dufresne provide evidence from the National Institutes of Health, 1995, that should someone have to ‘hold on’ to a bowel movement then conditions such as constipation, abdominal pain, diverticulitis and haemorrhoids can result.
We have discussed the various needs of people in our answers to previous questions but one group which we have not mentioned so far is that of Tourists.
1 Importance of tourism to Wales
In her presentation to Welsh Assembly members and Age Cymru on 16 November 2011, Susan Cunningham, founder of All Mod Cons, a campaigning body that pre-dates the BTA said ‘The total tourism spend in Wales in 2008 was £4.3 billion. Tourism means jobs and is increasingly important to the Welsh economy. Visitors have high expectations but sadly, many local authorities in Wales and throughout the UK make disgracefully poor provision.’
2 Who are the tourists?
Tourists include elderly people, disabled people, women, men, and children, and amongst them will be those with various medical conditions requiring access to public toilets. They arrive in a variety of transport and their visit may include walking tours and beaches as well as visits to specific places of interest. The growth of festivals requires thought given to temporary toilet provision – and gender equality – to avoid fouling the area, particularly where there are a lot of people crowded together. Short break holidays are rising in popularity and are particularly enjoyed by those over 55 – an age group most likely to need public toilet facilities. Families on beach holidays also require easy to access toilets. Research carried out by ENCAMS [now Keep Britain Tidy] found that the availability of public toilets was an important factor in choosing a beach to visit.
3 The impressions of the tourist
To be a visitor or tourist to any area just getting there will probably involve a visit to a toilet. Tourists always remember their toilet experience – especially if it is a bad one - as illustrated by letters to various local newspapers!
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
The industrial revolution had caused the population of towns and cities to greatly increase resulting in a need for a dramatic change to the poor standards of health and hygiene of the times. The provision of public toilets grew out of the need to combat contaminated water and diseases such as cholera and typhus. Britain proudly led the way in public toilet provision but sadly that is no longer the case, although the population today is rising and people are living longer.
1 Rural areas
In rural areas the failure to provide toilet facilities in addition to parking areas can lead to public health issues as demonstrated by Councillor Louise Hughes in the television programme X-ray in November this year. In the programme she showed the rubbish – used toilet paper, tissues, faeces, nappies – left by visitors in an area where the public toilets had been closed. Although one can’t condone it, for those in desperate need there appears to have been little option.
2 Night time economy
This topic has already been briefly discussed but there are some additional issues we would like to raise.
In many areas the standards of hygiene in public places can be very poor. Very few towns and cities have 24 hour toilets available. In some areas there are retractable urinals, which rise from the ground for use during the night time - one authority in Wales has also installed plastic urinals for night time drinkers but no facilities for women. As mentioned previously, women are poorly catered for at night. There seems to be an assumption that women do not need toilet facilities at this time. The lack of provision for both sexes results in councils having to provide a clean up operation – which of course involves time and costs. In the meantime those going about their daily busy in those areas have to negotiate streams of urine and worse.
Some elderly people have described their embarrassment at seeing men – and children – relieving themselves in public after the bars and pubs have closed. Many do not venture out in the evenings. They have also described their fear of the possibility of someone knocking at their door asking to use the toilet and not knowing whether it is a real case of need or a distraction burglary. [Merton Older People’s Housing Forum]
Unfortunately street fouling does exist in our society today and much of occurs because of the absence of public toilets. Toilet closures and general lack of funding to support current toilet provision has also meant a decline in hygiene and cleanliness with some premises having no soap, no hot water and no suitable hand drying facilities. The failure to wash one’s hands after using the toilet increases the opportunity of spreading diseases such as Clostridium Difficile and MRSA to name but two. [The Chartered Institution of Wastes Management]. The appearance of a nasty strain of e-coli, which flourishes as a result of poor hygiene has led to renewed efforts to encourage good hygiene and the ‘Now Wash Your Hands’ reminder is appearing once again in many public toilets.
3 Problems of poor facilities
Apart from giving an unwelcome image to visitors and tourists, having poor facilities means that in many cases babies and those with disabilities have to be changed on the floors of a public toilet. This is not only undignified but is totally unhygienic. The question of what to do with the nappy or pad if there are no disposal facilities has then to be addressed.
4 The homeless
The needs of the homeless are seldom mentioned in connection with public toilets, but their toileting requirements do need to be addressed if street fouling is to be reduced.
5 Cleaning
Unfortunately cleaning toilets is considered by many to be a low paid, unskilled task when in fact it is a very important one that should be carried out properly with appropriate training regimes and regular inspections. The annual Loo of the Year Awards recognises many aspects of toilet provision including the efforts made by cleaning staff whose pride in their work and in their Award should be an example to all local authorities. Good cleaning in public toilets reduces the spread of infection and encourages users to maintain the standards within the facility. Yet it would appear that public toilets are not always given the same priority as other health facilities when it comes to hygiene and public health.
A high standard of cleanliness is extremely important for those with catheters and other medical conditions as well as for pregnant and menstruating women in order to prevent spreading any infections.
Ulrich Beck, mentioned by Clara Greed in Inclusive Urban Design: Public Toilets, suggests that those who instigate toilet closures should prove that the action will not cause health risks! .
Conclusion
All around the UK groups such as P is for the People in Wales are campaigning hard to save their public toilets. The efforts these groups put into their campaigns demonstrates how valuable public toilets are in the communities. Whilst public toilets remain a discretionary service, local authorities will continue with the closures without offering an alternative solution. The organisation Keep Britain Tidy argues that the only time public toilets should be closed is if the facility is clearly no longer viable and the community agrees to the closure.
Vandalism is another excuse for closure where the actions of the few cause inconvenience and difficulties for the majority. Many toilets are closed without any recourse to the advice and suggestions available from organisations such as the British Toilet Association.
Closing public toilets is seen by many local authorities as a solution to reducing costs. The BTA argues that the overall cost of closing public toilets should be seen in a much wider context in that they impact on everyone’s quality of life, particularly the health and lifestyle of local communities and their economic well being. There may be a direct cost saving of toilet provision but the potential increased costs of healthcare and cleaning, as mentioned above, must also be considered. Also, residents and tourists will not visit areas without the facilities that they need, which in turn will result in a decline in income for local businesses, as evidenced throughout the UK. Closed shops and other commercial premises are often accompanied by public toilet closures in areas of decline.
Despite the current depressed economic climate many local authorities are continuing to provide high standards of public toilet provision meeting the basic human needs of their residents and visitors in an attractive, clean, safe and hygienic way. Winners in the 2011 Loo of the Year Awards, promoted by the BTA, included Bridgend County Borough Council, Ceredigion County Council, Carmarthenshire County Council, and Vale of Glamorgan Council; all proud to provide award winning toilets.
The provision of public toilets affects tourists and visitors to our towns and cities, and as a result also determines the reputation of Wales and the UK both at home and abroad.
Summary
The British Toilet Association believes that for all of us the lack of public toilets:
We thank the Health and Social Care Committee for the opportunity to contribute to the consultation.