Health and Social Care Committee
Public health implications of inadequate public toilet facilities
PT 3 – Age Cymru
Evidence Paper
Inquiry into public toilet provision in Wales
Health and Social Care Committee
December 2011
Introduction
Age Cymru is the leading national charity working to improve the lives of all older people in Wales. We believe older people should be able to lead healthy and fulfilled lives, have adequate income, access to high quality services and the opportunity to shape their own future. We seek to provide a strong voice for all older people in Wales and to raise awareness of the issues of importance to them.
We are pleased to respond to this inquiry as we believe public toilets play a vital role in ensuring that communities are accessible to older people. As people grow older they are more likely to develop continence issues, including needing to use the toilet more often and with greater urgency. In the UK, 1 in 3 women and 1 in 7 men over 65 experience incontinence.[1] Poor public toilet provision has a significant impact upon many older people as it reduces their ability to remain active and restricts how often, and for how long, they are able to leave their homes.
At present, the Public Health Act 1936 gives local authorities the power to provide public toilets, however it is a discretionary service which local authorities have no duty to provide. We believe that more can be done to ensure that Wales has network of public toilets that are fit for purpose.
In this responsewe have sought to briefly outline the experiences of older people in Wales in relation to accessing public toilets, and the consequences that a lack of provision can have. In the main we have focused our comments on the social impact of a shortage of public toilets, in terms of isolation and exclusion from community and services. Other organisations responding to the Inquiry will have more information on the impact on people with specific health conditions.
We have included a number of comments and experiences from respondents to Age Cymru’s Community Calculator. The Community Calculator™ is a tool designed to enable older people in Wales to assess how age-friendly their local community is. An age-friendly community is suitable and empowering for people of all ages, with a design and facilities that assist people to enjoy health, wellbeing and quality of life. Public toilets were identified by older people as one of 10 key factors which make a community age-friendly. The Community Calculator was distributed and the result collated between December 2009 and September 2010, and a total of 830 older people responded. We would be happy to provide more detailed Community Calculator data to the Committee if required.
What are the effects of public toilet provision (or lack thereof) on the health and social wellbeing of a person?
Adequate public toilet provision is vital to enable many older people to retain their dignity and the confidence to participate in community life. A lack of toilets can make people wary of going out and reinforce social isolation.
Many conditions such as IBS, Crohns disease and prostate cancer can increase how often and how urgently people need to use the toilet. Further to this, medications such as water tablets can have an impact on people’s need to find a toilet at regular intervals.
In order to combat the problem of needing a toilet when there isn’t one some older people report choosing to ‘skip’ medications that exacerbate the need to urinate frequently:
“They make you go often. So when I come out for the day I don’t take mine.”
People who experience incontinence, or need to use the toilet with greater frequency or urgency, are more likely to suffer both anxiety and depression.
Sadness and loneliness amongst people with incontinence is often caused not by the condition itself but by the behavioural changes they feel forced to make to cope with their condition.[2] A lack of public toilets can lead to dramatic behavioural changes, for example limiting time away from home and only visiting certain places. This may exacerbate feelings of isolation and sadness.
In an attempt to limit the risk of ‘accidents’ some older people have indicated to us that they limit their fluid intake in advance of leaving their home and whilst out. There are a number of negative effects dehydration can have on health and wellbeing, especially in older people. These include constipation, faecal impaction and cognitive impairment.[3]
Dehydration is also one of the risk factors for falls in older people, which are by far the greatest cause of hospitalisation among older people and the leading cause of death from injury in older people over the age of 75. Falling is also the primary cause of over 40% of admissions to a nursing home.[4] The risk of falls increases with age and it is important that older people are not deliberately reducing their fluid intake as a result of insufficient toilet facilities.
Dehydration can also lead to urinary tract infections as people need to be adequately hydrated to ensure bacteria are eliminated from the urinary tract. Further to this holding urine for longer than comfortable can result in urinary tract infections. [5]
For some older people the lack of public toilets can limit social activities and lead to a reduction in quality of life:
“The lack of toilets in Powys means that I have to plan any trip very carefully. Even a shopping trip into town must be short and planned between toilets. I don't go "out for the Day" as I would have to travel a long way before finding a toilet stop.”
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?
In a report by Help the Aged in Wales in 2009, 79 per cent of people indicated that they do not find it easy to find a public toilet, and 95 per cent reported that their local public toilets are not always open when they need them.[6] The average score given to local public toilet provision by older people in communities across Wales via the Community Calculator was just 3.23.[7] The impact of this cannot be underestimated. There is a tangible link between incontinence and social isolation and adequate public toilet provision can make an enormous difference, allowing people to live active and independent lives.[8]
Age Cymru receives a lot of qualitative evidence from older people negatively affected by a lack of public toilets in their local area. Many indicate that this has caused them to limit their activity outside the home. In other cases people have informed us that these limits can extend to not feeling confident to leave the house at all. The fear of leaving the house can lead to a failure to engage with appropriate services, for example healthcare and this can initiate a downward spiral in terms of condition management and health experiences.
Clear thought needs to be given to people who, because of a lack of toilets, have faced the indignity of having an accident in public. For anyone this would be a devastating experience, but for some it marks the end of them leading an active life within their community.
Older people tell us:
“Last weekend…all the toilets were locked including the disabled ones. This means many people are effectively housebound because they cannot rely on the facilities being open at their intended destination. In my opinion this action shows blatant discrimination against such people and possibly even contravenes their basic human rights.”
“I know people who only go to places where they know there are toilet facilities.”
“I got to keep running to the loo all the time and I wish that I could get our more but I’m afraid to go too far.”
“I’m frightened; I’m literally frightened to go out because I’m afraid I’m going to get caught.”
Is there equality across Wales – and in relation to all people – in the provision of public toilets?
The number of public toilets in Wales has steeply declined in recent years. There is a lack of recent data available about the exact numbers of public toilets in Wales however, according to the British Toilet Association; the UK’s public toilets have declined by in excess of 40 per cent in the past decade. There is now less than one public toilet for every 10,000 people in the UK.
Age Cymru’s Community Calculator showed a significant range in people’s experiences of public toilet provision in Wales. Comments and ratings from the Calculator identified the issue of public toilets as the primary concern for older people in Wales in relation to their local communities.
53.8% of respondents to the Community Calculator scored provision of public toilets in their community between 0 and 3 out of 10. Perhaps surprisingly, there was no discernible distinction between rural and urban areas, indicating that public toilet provision can be an issue regardless of location.
The range of results across local authorities in Wales was also the largest for any issue explored by the Community Calculator, providing first hand evidence of the variability of standards of toilet provision in communities across Wales. Out of 84 respondents in Merthyr Tydfil County Borough Council the average score was 0.35 out of 10: this stark statistic gives an insight into the inadequacies of provision in some areas of Wales. Pembrokeshire’s toilets were given the highest rating of 6.83 out of ten.
The Welsh Government’s
Public Facilities Scheme, provides local authorities with funds to
issue a limited number of £500 grants to businesses for them
to open their toilet facilities to the public. A total of 217
businesses across Wales took part in the scheme during 2010-11.
Worryingly, four local authorities have not signed up to the
scheme, and a further four have not funded a single business
through it since 2009.
If more than a third of local authorities are not participating in
the scheme it must be necessary to consider whether it is fit for
purpose in ensuring a sustainable network of toilets across Wales,
and we suggest that the Committee may wish to explore the reasons
for the lack of uptake with local authorities.
It has been suggested that the
uncertainty of the funding, which is currently guaranteed until 31
March 2013, may be one reason as some small businesses may question
the benefits of opening their facilities to the public on the
promise of an annual £500 grant that may come to an end next
year.
Offering business rate relief to participants has been suggested as
an alternative model which may be more attractive to businesses
considering signing up to the scheme.
We believe that a properly functioning Public Facilities Grant
Scheme could have an important role to play in increasing access to
public toilets in many areas. Opening more existing toilets in
public buildings and private business should also help prevent
vandalism and increase user confidence in the safety and
cleanliness of toilets.
Other models have also been advanced for protecting public toilets,
including by community groups taking on responsibility for running
and maintaining them, especially in rural areas. In these cases the
costs are met through a combination of charging, donations or a
small addition to local council tax. This may not work everywhere,
but in some instances it has led to toilets being protected and
maintained to a high standard with a strong sense of community
ownership and pride.
Wales can best ensure that there
is an equitable provision of public toilet facilities in Wales by
requiring local authorities to ensure there is adequate provision
in their area of responsibility. Community ownership may work
in some places but should not be regarded as an appropriate
solution for all areas.
Where toilets may be closed or transferred to other ownership it is
essential that the public are adequately consulted and that the
decision is ‘age-proofed’, meaning that express
consideration is given to the potential impact upon the older
people who may use them.
How should public toilet facilities address the needs of
different groups of people (men, women, disabled people, people
with special health needs, children)?
Is there a particular need for improved facilities for specific groups?
Public toilet provision is important to everyone but the impact of poor provision can be particularly pronounced for older people and for those with specific health conditions for example IBS, Crohns disease and prostate cancer. Certain commonly prescribed medications, such as water tablets, also increase the frequency with which people need to use the toilet.
It is important that people with conditions that impact upon their need to use a toilet are able to access services and community life with confidence. Toilets need to be clearly signposted, accessible and clean.
Respondents to the Community Calculator identified poor design and accessibility to public toilets as an area of particular difficulty that prevent them from using the limited toilets available.
“Some of the public toilets are totally inaccessible for me and many close early in the evening time”
“Toilet cubicles too small - especially in bus station …”
“… Rails needed by toilets. More disabled provision needed”
Many comments received via the Community Calculator also raised the issue of poor cleanliness and hygiene in many public toilets around Wales. Dirty toilets are unsafe and unpleasant to use, and increase the risk of isolating older people from their community if they do not feel able to use public conveniences because of poor standards of hygiene.
“Poor standard - dark, dingy, damp”
“There is only one and that is not clean. We can only use the cafes to get a toilet if we have money”
“They are disgusting and smell terrible”
“Not of high standard, ladies toilets have no soap and drying facilities.”
Public toilets, including the floors, seats and walls need to be clean. There should always be toilet paper, and hot water and soap for washing hands. The comments above, and many others received, indicate that these basic standards are not maintained in many public toilets across communities in Wales.
The British Toilet Association has produced a best practice guide to toilets away from home which we feel comprehensively outlines things that can be done to ensure toilet provision is suitable. They also outline the following as making facilities age friendly:
- Adequate toilet facilities for the number of users at the location
- Accessible facilities – no steps or steep inclines
- Safe facilities – attendants on duty, well lit with exposed entrances
- Facilities available when needed – not just 09.00 to 17.00
- Larger cubicles available for the ambulant with wider cubicle doors
- Shelves for bags and hooks for outer clothing
- Door handles and locks easy to use and in good working order
- Automatic or push taps
- A warm, clean, nice smelling environment
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.
Usk town council has recently felt compelled to write an open letter outlining some of the problems that can occur when public toilets close:
“Of greater concern is the fact that it has resulted in anti social behaviour making the area a Health and Safety hazard. Specialist cleansing has had to be employed incurring unnecessary financial costs.”
Older people tell us:
“Quite often people go behind the public toilet buildings in parks to urinate and it is pretty disgusting in the 21 century and should not be necessary. It cannot be beyond the wit of mankind to work a healthy alternative.”
“We got public toilets on health ground because people simply have to pee in the street if these facilities are not provided.”
Some older people report having to find alternatives to public toilets:
“I got a jar to carry around with me…if I go from here to Bath, I go to the toilet before I go and by the time I get to Bath I want to go again. But the toilets are locked. We have to park up and I’ve got my bottle and I have to sit in the car which – there ‘s no other way of doing it, you know. Do it in a jar and then I can pour it out.”
“You know, relieving yourself in public places, well, everywhere in the street is public. But if there’s an alley or something I can go, then I have to. Otherwise I’ll just wet myself and then you’ve got that to contend with for the rest of the time you’re out.”
“I either manage to hang on or else I get behind a tree and go. At one time I thought that was (the) most disgusting thing anybody could do, really. You know, all right if you want to spend a penny, yeah, but nothing else, that’s disgusting. But now I think, well, it’s necessary. And you do it, you know.”
“I was sat there and I was really, really in pain with it, sweating and cussing to myself and hanging on and hanging on. Anyway the cars went and I thought, that’s it, and I had to nip out and rush over and go behind a tree. But I think I would have gone even if the cars had been there and there’d been a dozen people around. You know, it was that bad. It made me feel really ill. It’s dreadful. It makes you feel so horrible.”