Health and Social Care Committee
HSC(4)-02-12 paper 6
Public health implications of inadequate public toilet provision in Wales – Evidence from the Minister for Health & Social Services
Purpose
I welcome the Committee’s decision to conduct this inquiry on the public health implications of inadequate public toilet provision in Wales. I believe it will raise the profile of an issue that affects the health, dignity and quality of people’s lives. At the request of the Committee this paper addresses the following issues:
· What are the effects of public toilet provision (or lack thereof) on the health and social wellbeing of a person?
· 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?
· Is there equality across Wales - and in relation to all people - in the provision of public toilets?
· What could the wider effects of inadequate public toilet provision be on public health and the community?
Health implications of inadequate public toilet provision in Wales
Going to the toilet is a universal need, therefore, public toilets matter to everybody, regardless of their age, class, ethnic origin, gender, mental ability or physical ability. They are, however, even more important to certain sections of our society, including older people, disabled people, women, children and young people and their families, tourists and visitors.
In Wales, we have a higher percentage of older people than anywhere else in the UK. Birth rates have been falling while increases in life expectancy for men are predicted to rise from 76.4 years in 2004 to 80.3 years in 2024 and for women the rise will be from 80.7 years to 84.0 years in the same period. An increasing proportion of the population will be of pensionable age.[1] We are more likely to suffer from conditions such as incontinence, urgency and prostate problems as we age.
In 2006, Help the Aged published a report ‘Nowhere to go – Public Toilet Provision in the UK’ which summarised a survey of older people’s views on public toilet provision in their local area. The survey was sent to older peoples forums and 10% of the respondents lived in Wales. The report showed more than half of older people found that a lack of local public toilets prevented them from going out as often as they would like.
As people get older they become increasingly likely to develop continence issues, experiencing the need to use the toilet more often and with greater urgency. Many older people suffer from incontinence or have continence issues, caused by muscle weakness. It is estimated that 3–3.5 million people suffer from urinary incontinence in the UK. More than half are over 65 and the majority are women. [2] As people age they will experience an increased dependency on public toilets.
Help the Aged’s paper “Nowhere to Go” highlights the social cost to older people of the decrease in public toilets:
Evidence from the Help the Aged survey has lead them to conclude there are large numbers of people who are ‘tethered by an invisible bladder leash’ which restricts their movements to within easy reach of toilets. About half of the over-75 population of the UK live alone, with studies showing as many as 1.75 million older people report feeling lonely. Twelve per cent of older people (1.2 million) feel trapped in their own home, 13 per cent of older people (1.26 million) do not go out more than once a week and about 100,000 older people never go out. Their evidence suggests lack of public toilets is a significant contributory factor in the isolation of older people and the situation will worsen if toilet provision continues to decline.
Help the Aged argue the cost of this isolation is not just a moral one. In their view, if older people are restricted to their own homes, they are more likely to suffer from depression, a condition affecting an estimated 1 in 8 people over the age of 65. The lack of public toilets in places where older people may otherwise take exercise, also means many become inactive. Physical activity is essential in later life, in order to enable older people to remain independent in their own homes for as long as possible. The absence of public toilets excludes older people from economic activities, such as shopping, which they would otherwise be undertaking, preventing them from engaging in the local economy. Help the Aged have concluded older people require toilets to be clean, safe, accessible, open, staffed and located in the wide variety of places where they go.
Disabled people and their carers may also lack the freedom to leave their homes without the reassurance of adequate toilet facilities being available. The National Association for Colitis and Crohn’s Disease (NACC) is a national charity offering support to people who have Colitis or Crohn’s Disease. NACC has previously raised concerns about the lack of public toilet provision. Inflammatory Bowel Disease (IBD) affects approximately 1 in 400 people living in the UK. The sudden and uncontrollable need to use a toilet is a genuine and recognised symptom of IBD and the fear of having an ‘accident’ in public can have a devastating effect on an individual ability to undertake everyday activities such as going to work, shopping or socialising[3].
Poor public toilet provision affects some groups disproportionately such as women, who are more likely to be accompanied by children, elderly adults and disabled people. Children, young people and their families also need access to suitable facilities, including baby change facilities, in both male and female toilets. As discussed previously, somepeople may feel unable or reluctant to leave their homes and visit areas where they fear they will not be able to find a public toilet. This will, in turn, limit their ability to take exercise and travel, particularly when using public transport. Older people, parents, and carers with young children, disabled people and people with chronic health problems, all need easy access to suitably equipped public toilet facilities.
Whilst women make up slightly more than half of the UK population and a higher proportion of older people, the balance of toilet provision for men and women is at best 50:50 and more typically 70:30 in favour of men, because cubicles take up more room than urinals.[4] Women are also more likely to be accompanied by children. Women are likely to outnumber men in ratio 65:35 in shopping areas and up to 80:20 in busy shopping malls (for example before Christmas)[5]. Women take longer to go to the toilet because of a range of sartorial, biological and functional reasons. Women have more functions than men [and] at any time about a quarter of all women of childbearing age will be menstruating, whereas pregnant women, those at menopause and those with diabetes will need to use the toilet more often[6].
Equalities legislation places special responsibilities on public authorities in relation to facilities for men/women and disabled people. There are around 10 million disabled people
in Britain and more than one third of people aged over 50 are registered[7] as disabled in some way[8], and disability rates increase with age. The Disability Discrimination Act (DDA) 1995, which requires service providers to make ‘reasonable adjustments’ to allow disabled people to access those services, has helped to boost the provision of accessible toilets. However there are also around 40,000 people in the UK with profound and multiple disabilities who cannot use standard accessible toilets because they need special equipment and support from one or two carers. The lack of suitable facilities can prevent them from taking part in everyday activities that others take for granted. Better disabled provision not only benefits the disabled themselves, but the rest of the family too, as their carers have often had to limit their journeys when accompanied by disabled relatives6. Anecdotally, the DDA has been cited as an excuse used by some local authorities to close public toilets, rather than bring them up to the standards required by the Act.[9]
The Changing Places Consortium campaigns for public toilets which are spacious and clean, with suitable equipment for severely disabled people, including a height-adjusted adult sized changing bench and hoist[10]. People with profound and multiple learning disabilities, as well as other serious impairments such as spinal injuries, muscular dystrophy, multiple sclerosis or an acquired brain injury, often need extra facilities to allow them to use the toilets comfortably.
Changing Places toilets are different to standard disabled toilets with extra features and more space to meet these needs. The consortium wants local authorities to be more proactive in creating toilets for severely disabled people, alongside standard disabled toilet provision. There are currently 14 Changing Places public toilets listed for Wales one of which is located in the National Assembly building. Three more Changing Places public toilets are in the process of development in Wales.
Wider effects of inadequate public toilet provision on public health and the community
Inadequate public toilet provision could have a significant effect on public health and environmental issues, particularly in terms of street cleanliness and disease control. A lack of adequate well located toilets that are open at the time they are needed, may well result in dirty streets that are unsanitary, unpleasant and may present a risk of infection. Cleaning up street fouling is an unpleasant and costly task. Street urination, mainly by men, but sometimes by women too, can be a major nuisance in some areas, particularly after closing time. There are mixed views about whether the cause of street urination is solely because of a lack of public toilets but lack of adequate toilet provision makes it a harder problem to tackle.
Public toilets that are poorly designed, inadequately maintained and poorly located, can create an atmosphere of neglect that discourages public use. These conditions attract vandalism, graffiti, criminal damage and anti-social behavior. These issues, if not tackled effectively, can generate a cycle of decline, leading to more entrenched social problems, and seriously impairing quality of place and quality of life for local people. Public toilets need to be seen as a benefit not a problem. They must not be allowed to degenerate into a location for crime, vandalism and anti-social behaviour.
Accessible clean public toilets that are well located in places like parks, promenades, cycle trails and walking routes, will help to encourage people who may need regular toilet access to take exercise and stay more physically active. Public toilets help to encourage people out of their cars and back onto more sustainable public transport, cycling and walking.
Equality in the provision of public toilets across Wales
The provision and maintenance of toilets in public places in Wales is at the discretion of local authorities who have, under section 87 of the Public Health Act 1936, a power to provide public conveniences, but no duty to do so. It is, therefore, for individual local authorities to decide whether or not to provide public toilets and, if so, how many.The provision of public toilets in Wales will, therefore, vary according to the local authority.
Some local authorities in Wales have championed the provision of good public toilets. I am pleased to note that in 2011 Ceredigion County Council won the UK Overall Winners Trophy in the British Toilet Association Loo of the Year Awards. Ceredigion was only the fourth council to win the Award, in the 24th Anniversary Loo of the Year Awards competition to find the very best 'away from home' toilets in the UK. The British Toilet Association (BTA) is a campaigning body established in 1999 and has 160 members, of whom 64 are local authorities. Since 2006, it has held an annual “Loo of the Year” award.
The Welsh Government has sought to increase the provision of free public access to toilet facilities in Wales and to improve the quality and accessibility of these facilities by encouraging local authorities to work, in partnership, with local businesses to allow public access to their facilities. The Community Toilet Grant scheme was established by the Welsh Government in 2009-10 for three years and all local authorities in Wales were invited to participate. It reimburses local authorities (to a maximum of £17,500 per local authority per year) for payments of up to £500 made to local businesses, for allowing free public access to their toilet facilities (although local authorities may provide a higher level of funding at their discretion from their own resources). The scheme has been extended for another year from April 2012. Businesses in receipt of a grant mustallow public access, free of charge, to the toilet facilities for a number of hours agreed with the Authority. The toilet facilities provided must have acceptable standards of safety, hygiene, accessibility for disabled people and provision for both sexes. Businesses must clearly publicise the availability of the facilities and the opening hours, so that the information can be seen clearly by people from the outside the premises, and display the bilingual sign designated by the Welsh Government.
Conclusion
There are public health and environmental costs to the wider community of not providing public toilet facilities. However, the effect of any decline in provision is likely to be disproportionate affecting, in particular, the elderly, disabled, those with medical problems and parents / carers of young children. Local authorities should be encouraged to allocate sufficient resources to keep public toilets open, accessible, safe, clean and usable. They need to consider all aspects of equality when planning their public services and use appropriate guidance and legislation when doing so. The provision of greater access to public toilets across Wales could have positive health benefits. Greater provision would help older people, parents and people with health problems to maintain a more active lifestyle and confidently enjoy their local environment. Public toilets help to encourage people out of their cars and back onto more sustainable public transport, cycling and walking.
January 2012
[2] Nowhere to go: Public toilet provision in the UK (May 2007)
[3] Memorandum by the National Association for Colitis and Crohn’s Disease to CLGC 2008
[4]Taking Stock: An Overview of Toilet Provision and Standards, Dr. Clara Greed 2005.
[5] A COP for Public Toilets in Britain Dr Clara Greed UWE
[6]Memorandum by Clara Greed, Professor of Inclusive Urban Planning, UWE, Bristol to CLG
[7]The Disability Discrimination Act defines a disabled person as ‘someone with a mental or physical impairment which has a substantial, long-term adverse effect on the ability to undertake normal day-to day activities’.
[8]Family Resources Survey, commissioned by the Department for Work and Pensions.
[9]House of Commons ‘The Provision of Public Toilets CLG 12th report 2007-8’.