Cynulliad Cenedlaethol Cymru The National Assembly for Wales
Y Pwyllgor Iechyd a Gofal Cymdeithasol The Health and Social Care Committee
Dydd Iau, 19 Ionawr 2012 Thursday, 19 January 2012
Cynnwys Contents Cyflwyniad, Ymddiheuriadau a Dirprwyon Introduction, Apologies and Substitutions Goblygiadau Iechyd Cyhoeddus o Ddarpariaeth Annigonol o Doiledau Cyhoeddus: Tystiolaeth Lafar Public Health Implications of Inadequate Public Toilet Facilities: Oral Evidence Goblygiadau Iechyd Cyhoeddus o Ddarpariaeth Annigonol o Doiledau Cyhoeddus: Tystiolaeth Lafar Public Health Implications of Inadequate Public Toilet Facilities: Oral Evidence Goblygiadau Iechyd Cyhoeddus o Ddarpariaeth Annigonol o Doiledau Cyhoeddus: Tystiolaeth Lafar Public Health Implications of Inadequate Public Toilet Facilities: Oral Evidence Papurau i’w Nodi Papers to Note
Cofnodir y trafodion hyn yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir cyfieithiad Saesneg o gyfraniadau yn y Gymraeg. These proceedings are reported in the language in which they were spoken in the committee. In addition, an English translation of Welsh speeches is included.
Aelodau’r pwyllgor yn bresennol Committee members in attendance
Mick Antoniw	Llafur Labour
Mark Drakeford	Llafur (Cadeirydd y Pwyllgor) Labour (Committee Chair)
Rebecca Evans	Llafur Labour
Vaughan Gething	Llafur Labour
William Graham	Ceidwadwyr Cymreig Welsh Conservatives
Elin Jones	Plaid Cymru The Party of Wales
Lynne Neagle	Llafur Labour
Lindsay Whittle	Plaid Cymru The Party of Wales
Kirsty Williams	Democratiaid Rhyddfrydol Cymru Welsh Liberal Democrats
Eraill yn bresennol Others in attendance
Mike Bone	Cyfarwyddwr, Cymdeithas Doiledau Prydain Director, British Toilet Association
Chris Brereton	Dirprwy Brif Gynghorydd Iechyd yr Amgylchedd, Llywodraeth Cymru Deputy Chief Environmental Health Adviser, Welsh Government
Graeme Francis	Pennaeth Polisi a Materion Cyhoeddus, Age Cymru Head of Policy and Public Affairs, Age Cymru
Dr Sara Hayes	Dirprwy Brif Swyddog Meddygol Dros Dro (Iechyd y Cyhoedd) Acting Deputy Chief Medical Officer (Public Health)
Louise Hughes	Prif Ddeisebydd, P-03-292 Darparu Toiledau Cyhoeddus Lead Petitioner, P-03-292 Public Toilet Provision
Gillian Kemp	Y Rhwydwaith Syndrom Coluddyn Llidus Irritable Bowel Syndrome Network
Karen Logan	Nyrs Ymgynghorol, Pennaeth y Gwasanaeth Ymataliaeth, Bwrdd Iechyd Lleol Aneurin Bevan Nurse Consultant, Head of Continence Service, Aneurin Bevan Health Board
John Vincent	Senedd Pobl Hŷn Cymru Welsh Senate for Older People
Swyddogion Cynulliad Cenedlaethol Cymru yn bresennol National Assembly for Wales officials in attendance
Catherine Hunt	Clerc Clerk
Mike Lewis	Dirprwy Glerc Deputy Clerk
Phillippa Watkins	Y Gwasanaeth Ymchwil Research Service
Dechreuodd y cyfarfod am 9.30 a.m. The meeting began at 9.30 a.m.
Cyflwyniad, Ymddiheuriadau a Dirprwyon Introduction, Apologies and Substitutions
[1] Mark Drakeford: Bore da a chroeso.			Mark Drakeford: Good morning and welcome.
[2] The committee is now in public session. Members will know the drill completely. We are an entirely bilingual committee.
[3] Os hoffai unrhyw Aelod neu dyst siarad yn Gymraeg, mae’n gwbl bosibl gwneud hynny.			If any Member or witness wishes to speak in Welsh, it is quite possible to do that.
[4] We are not anticipating a fire alarm or any of that sort of thing, so if anything like that should happen, we will be helped to know where to proceed by the clerks to the committee.
9.31 a.m.
Goblygiadau Iechyd Cyhoeddus o Ddarpariaeth Annigonol o Doiledau Cyhoeddus: Tystiolaeth Lafar Public Health Implications of Inadequate Public Toilet Facilities: Oral Evidence
[5] Mark Drakeford: I welcome our first three witnesses this morning. Louise Hughes is the primary petitioner in this case, and we are grateful to her for coming. This is the first time since last May’s elections that this committee has responded to something that has come our way from the Petitions Committee. We are pleased to respond to this; it shows the importance of the Petitions Committee and the process that it sets in motion.
[6] What we are responding to today is the part of the petition that highlighted the public health dimension of public toilet provision. We are not the committee that deals directly with those organisations that make the provision—we do not deal with local government and so on. What we will be thinking about this morning, as a result of the evidence that we will hear, is what we will be writing to the Chair of the Communities, Equality and Local Government Committee about regarding the work that we have done and the case on the public health front that we think may have been established. So, you will find that our questions will focus around that sort of issue.
[7] I now ask Louise to make any brief opening remarks that she would like to make. Before we finish this session at 10.15 a.m., my aim will be to come back to you to give you a chance to round things up and to add any points that we have not managed to cover and so on.
[8] Ms Hughes: Good morning, everyone. I want to thank the committee for giving us the opportunity to talk today about something that is not particularly glamorous, but, let us face it, very important. You all know the reasons why I initially submitted my petition, and why I did my cycle protest up here—although I have not come on my bike today. Once you get beyond the embarrassment of talking about toilets—or lavatories, water closets or whatever term you want to use—you see that the issue affects us all. Every one of us has a toilet anecdote and how it has affected us in our lives. When I met the old lady on the high street in Tywyn in floods of tears because they had closed the toilets and she could not make it to the next one, that is when I thought that it is absolutely wrong that an old lady of 83 was embarrassed and in floods of tears in public because a toilet was not available. I thought, ‘Right, I’m going to do something about this’, and here we are today. I am so pleased that the petition has got to this stage, because it is very important.
[9] Mark Drakeford: Thank you. That is a useful start. Committee members will now have a chance to ask questions about the evidence that we have already received from you, for which we are grateful. As I said, we will come back for a round-up at the end. I now hand over to Vaughan.
[10] Vaughan Gething: My question is really directed to John Vincent. Can you explain how the Welsh Senate of Older People identified the P is for People campaign as one of its main campaigns? What were your members telling you that led to that decision being taken?
[11] Mr Vincent: You will understand from the paper that we provided that the Welsh Senate of Older People represents quite a large proportion of the older people and pensioner groups in Wales, and that we obviously have the means of communicating at the grass-roots level. While there are several issues that come to our notice, one particular issue we felt that we should concentrate on was the toilet situation, which has been getting worse over the past few years.
[12] It was happening for a long time before the recession. In the first place, people were accepting of it, when one or two toilets closed, but wherever you go now there is difficulty finding a toilet. That is a particular problem for older people—not just older people, but certainly for our members. We thought we would try to do something about this first and concentrate on this issue because it will affect not only our members, but all of society. It affects disabled people, who may be younger but who still need toilets. There are families with young children. You cannot tell young children, ‘Wait till we get home’ every time. There are people on medication and people with medical conditions that require them to visit a toilet. There are all sorts of people. That is the general reason for focusing on this. We knew that we were not just talking about us and that we would not be accused of being cranky old people, as we often are in the press. We are talking for everybody and we are trying to do this for everyone in society.
[13] Vaughan Gething: Given the range of people who need access to public toilets, what are your members identifying in particular from their point of view about the challenges that the lack of provision creates? In particular, I am interested in anything on the range of conditions that your members may or may not have and the impact of not having public toilet provision.
[14] Mr Vincent: If there is no toilet at the end of your journey, wherever you are going, whether you are on the bus or you are going to the countryside for a walk, if you have an incontinence problem you are not going to go. Lots and lots of people have incontinence problems. The paper highlights how big this problem is. Bladder and bowel incontinence are widespread problems. If you do not know whether you are going to be able to find a toilet, you are not going to go. In some cases, the situation becomes so bad that there are retired people living on their own who do not go out very far from home. They are losing out on the best opportunity they have had in their lives to do their own thing. They are stuck at home because they dare not go out. We are not talking about one or two isolated cases, but lots and lots of people. There are hundreds of thousands of people in Wales alone who have an incontinence problem. Due to the demographics of Wales, a very high proportion of people are older people, so more people will have incontinence problems.
[15] As I said, if you do not know whether there is going to be a toilet at the other end of your journey, you are not going to go. It is leading to social isolation. When you think about it, we are trying to do our best to get people out. For example, for people with mobility problems we provide ramps, lifts and bus passes so that they can get out, and then we spoil it by making sure that, wherever they go, there are fewer toilets.
[16] Mr Francis: I absolutely agree with what John has been saying. It is probably impossible to overestimate the potential psychological effect this issue can have on people. There is the social isolation angle, which John has talked about at length. Potentially, this affects older people more than some other groups. Social isolation is an area about which we are particularly concerned in relation to older people in Wales. It is very difficult to quantify exactly, but it is clearly demonstrated in the evidence given to the committee by a range of partners.
[17] To take a different angle, I want to pick up on a fact that brought the issue home to me. Age Cymru has been working on this issue for several years, picking up on some work that Help the Aged had done prior to the merger. Despite this work, the amount of evidence given to the Welsh senate and other work that we have done on the potential effect this can have on people because they stop taking medication as a result of concerns—whether they are taking water tablets or other medication that might mean they need to use the toilet more frequently than they would do otherwise—showed clearly that, when they know they have to go out and staying home is not an option, they will take themselves off their medication for a day or a couple of days just to cope. Some of the people who are giving evidence today might tell you more about that than we can, but we are very concerned about the effect that will have on people and the conditions they already have.
[18] Ms Hughes: I have met people who have stopped or reduced their fluid intake in an effort to not need the loo so much. I met a couple of people who were hospitalised because of dehydration and cystitis problems. So, it is a really big concern, particularly as you get older. We are all getting older—we cannot avoid it—and, unfortunately, things do not work as efficiently as they used to when we were younger. We take these things for granted. I have met many people who have said, ‘I looked after myself when I was younger, but here I am with this condition, and my muscle control is not what it used to be, and I am reliant on public toilets’. Let us face it, on a human level, each one of us around this table has been in a situation where we think, ‘I need the loo’, but if you are on medication or you have a certain condition it is incredibly distressing. You can get stomach cramps, your heart rate goes up and you panic, which is very distressing. That distress is magnified at least 10 times if you are disabled or you are on medication. So, this is a problem that we need to take seriously.
[19] Rebecca Evans: I am interested in the equality of provision and of access to public toilets. Do you have any examples of adaptations that need to be made to make public toilets more accessible to people, particularly given that John has already acknowledged that many older people will be less mobile and that there is perhaps no point in having a public toilet if people are unable to use them?
[20] Mr Vincent: These days, some new toilets, such as the one we have in Bargoed, tend to have a toilet for ladies, gents and for the disabled, which is good, but they still do not have the capability of dealing with, for example, severely disabled people, who need a carer to come in with them, or do not offer baby changing facilities for whatever reasons. So, I would say that that is an equality issue.
[21] Mr Francis: Given the range of different needs that people have, it is a big challenge to ensure that public toilets are suitable for everyone—and that goes for new-build toilets as much as existing toilets. You can see a particular challenge in relation to our existing infrastructure, considering how old some of those toilets will be. One thing that is mentioned in some of the written evidence that you have received, which is extremely concerning, is that there is some suggestion that local authorities may have used equality legislation as an excuse to close some toilets, because of the challenges in refitting them and making them fit for purpose. The legislation does not, in any way, state that local authorities should do that, but it becomes potentially a convenient excuse, or part of the rationale, for closing a toilet if modification could not happen. That is clearly an unintended consequence of that legislation, which local authorities or anyone else should be strongly warned against doing.
[22] All toilets that are built now should be as accessible to everyone as they possibly can be. Another concern of ours is that building toilets in new developments still seems an issue of pretty low priority. There are thankfully only a couple of examples that we are aware of in Wales where new developments have been built without any toilet provision, or where toilet provision has been added at the last minute when it was realised that they were missed originally in the plans. Indeed, I think that there is an example of that not too far from here. So, if toilets are not considered by developers or architects at an early planning stage, the challenge of ensuring that the toilets that are built fit every need—and John mentioned people with quite severe needs—will be significant.
9.45 a.m.
[23] Ms Hughes: There is also a gender inequality with regard to toilet provision, given that it takes up less space to provide urinals for men than it does cubicles for women. Women could be pregnant, and if you are bigger, you take up more space. You could have children with you, or shopping, or an elderly relative who you need to take in. So, perhaps cubicles could have wider doors, or grab rails. There is never—and this is a girl thing—a hook to hang your handbag on, and a lot of ladies do not like to put their handbags on the floor. So, there are different ways of looking at it. You could provide fewer toilets, but more accessible ones—if you are in a wheelchair and you come across some public toilets but you cannot get in, they are useless.
[24] Rebecca Evans: Could I pick up on two things? Graeme, you talked about the disability discrimination legislation being used inappropriately, and we have heard that in other evidence as well. I was just wondering how prevalent you think that is. Is it occasional or systemic? John, you mentioned carers, and I would be interested to hear whether any of you have come across particular cases where there have been problems. I have heard of at least one situation where a carer of the opposite sex has had trouble taking the person that they care for into a public toilet, and in one case, the police were even called. Are you aware of that being a problem?
[25] Mr Francis: To take the first one first, we do not have the evidence to say that it is extremely prevalent—certainly not at the moment. When equality legislation first came in, local authorities were re-evaluating everything that they had, and perhaps that was more of an issue then than now. What we do see is that, when authorities are questioned on a decision to close a toilet, that is often part of the reason given—that it is very old and would cost a huge amount to reconfigure, and to fit with legislation, or that it simply would not be possible. Actually, that is not what the legislation says. It mentions ‘reasonable steps’, and changing everything that you can to make it accessible to a wide range of people. What it does not say is, ‘If you can’t do that, then it must close’, without alternative provision being made. To sum up on that, I do not think that it is hugely prevalent. The main reason will always be the cost of vandalism or upkeep, but the legislation is often given as one of the supporting reasons for why a toilet has to close.
[26] Mark Drakeford: Does anyone have any experience on the carers point that Rebecca raised?
[27] Ms Hughes: I know people who have had problems. I have talked to hundreds of people about this, and you do get a lot of repetition—you hear the same stories in different parts of Wales. A friend of mine who is in a wheelchair just does not go out, because he cannot physically get his wheelchair into toilets. There are usually steps, for some reason; you cannot bounce down steps if you are in a wheelchair. It is a huge problem when people cannot come in to assist. Cubicles are made for one person. Even disabled cubicles are sometimes too small for a wheelchair and two people. You also need space to get the person out of the wheelchair comfortably, with dignity, and on to the toilet.
[28] Mark Drakeford: Mick has a point on the disability discrimination Acts and then I will go to Lindsay.
[29] Mick Antoniw: I was actually going to ask about opening hours and charging, if that is okay, Chair. It seems to me that there are a number of issues. What is your experience in terms of opening times? It is all very well having a toilet, but it has to be open. Also, what are your views on different charging policies in different areas? I am sure that we have all been in the situation where you have a £5 note, and that is no bloody good. Are those sorts of things issues as well? What is your general view about the issue of funding?
[30] Mr Vincent: Charging is one of the things that we have raised with our members, and the general impression that we get—I cannot give you any figures—is that people would be willing to pay a nominal fee, of say 20p, to use a toilet if those toilets were clean, hygienic, accessible and open at sensible hours. Most of us who own cars take some change with us in case we need money for the parking machine, and I think that most people would not mind carrying five 20p pieces around with them—that is what they tell us—if they knew that there would be a toilet to put it into. It need not be an issue if it stays at something nominal like 20p.
[31] Mr Francis: We agree with that. If, as part of a solution to this problem, a small charge is required to use some toilets, we do not have a huge issue with that. Clearly, having the right change is an issue. If people know to expect that, they can perhaps keep small change on them, because, when visiting an area, you may not be aware of such a charge. If you are going to introduce a charge for using a toilet, you would need to have some sort of facility to give change. That could be a shop that indicates its willingness to change small amounts of money for people, or, as I saw in Paddington station yesterday, it could be a change machine—though that will not be feasible in every case. As I have said, we do not have a huge ideological problem with charging, but it has to be a reasonable amount and it has to be clearly indicated and signposted. You would clearly have to make provision.
[32] Lindsay Whittle: Thanks for your evidence. I do not suppose that many would disagree with anything that you have said here. Do you have any evidence from parents about difficulties of access for their children? I can speak from personal experience: there is nothing worse, if you have an eight or nine-year-old daughter who wants to go to the loo and you do not want to take her into the gents’ toilet, so you find yourself waiting outside the ladies’ toilet for what seems a very long time indeed—your mind runs riot. You almost get to the stage of wanting to go in, thinking that something is wrong; but of course, nothing usually is wrong. No doubt, the reverse is true for mothers who do not want to take their sons into women’s toilets. Is there any evidence of that? Do you have any ideas about family toilets? That does not sound right, but you see family changing rooms, do you not?
[33] Ms Hughes: I have heard a lot of anecdotal evidence about that problem. It is true. I do not have a boy, but a lady I was talking to this morning told me that she has an eight-year-old son and that he gets a bit embarrassed—he does not want to go into the ladies’ with his mum, and she does not want him to go into the gents’ toilets on his own, for various reasons. As you said, as a parent, you start to panic. That is a tricky one. Perhaps we could have a family toilet. My vision for Wales is that we say, ‘Right, this is a problem; let’s set the standard for the British isles’. Let us say that we can do it right in Wales. Let us have fantastic toilets, as we live in a beautiful country. I live in Meirionnydd, which is one of the most gorgeous areas, and they are extending the coastal path near where I live. A friend of mine has a farm there, and as there are no toilets there at the moment, she regularly sees people going behind walls. So, yes, it is a problem in many ways, but with that one, we need to think outside the box. However, I think that we should take up this challenge and rise to the occasion—I am trying to avoid toilet puns—and set the standard for the rest of the British isles.
[34] Lindsay Whittle: It is an issue.
[35] Ms Hughes: It is a huge issue.
[36] Lynne Neagle: I want to pick up on the point Lindsay made about children. I only know of one example of where they provide a toilet at the appropriate height for a little one to use. It is a bit of a nightmare if you are a parent, holding them on the loo, especially if they have only recently been toilet trained. Do you know of any local authorities that have that kind of provision for little children?
[37] The other point that I want to ask about is geographical variation. To what extent do you see variation between local authorities in the way that they prioritise this issue?
[38] I also want to ask about something else. I am assuming that some people think that you can go to Tesco and places like that now. To what extent are local authorities using that as justification for scaling back toilet provision?
[39] Ms Hughes: It depends on where you live. If you live in a more urban area, you have more toilet choice. In a very rural area, such as where I live, we do not have cafes, pubs, hotels and shops, so that reduces your opportunity to go to the toilet with dignity for a start.
[40] I know that they have the toilets that you are talking about in Germany, and they are absolutely marvellous. As a mum, if you have a baby and a toddler, it is a real panic, is it not? I have seen toilets where there is a little chair of sorts, into which you can strap your child while you go about your business, so that it does not hurt itself, but that is about it. Perhaps this is another area in which Wales can set the standard, because that is also a problem. So, what we are discussing here today is primarily relevant to older people, but there are challenges for each age group.
[41] Mr Francis: I will take those points in order, and will be very quick on the first one, because our organisation does not necessarily gather evidence on toilets for children. However, I will repeat Louise’s point. One thing that has been clear to us in working on this and working with the Welsh Senate for Older People on its campaign is that it is an issue that affects everyone. While there are particular issues that affect certain groups, it is something that is very important across the board. I do not think that I can say more than that on that point.
[42] In terms of variation, a lot of Age Cymru’s figures come from a piece of work that we carried out in 2010, called the community calculator, in which we asked older people across Wales to respond and score 10 elements of what makes a community age friendly in their view and to state how their local community scored against those. One of the 10 elements was public toilets. It probably would not surprise too many people to find out that public toilets scored the worst of all those 10 factors across Wales. There was a significant variation in terms of people’s answers. The average score out of 10 for public toilet provision across Wales was 3.2. The lowest-scoring local authority was Merthyr Tydfil, which scored 0.3 on average, out of 80 or so respondents, and the highest scoring was Pembrokeshire, which scored 6.8. So, we can see the variety in those responses.
[43] One thing that was slightly surprising to us was that there was not a clear variation in terms of whether an area was rural or urban. In responding to the calculator, people were asked not just to indicate their local authority area, but to indicate where they lived either through a postcode or the name of their village or town, so it was quite localised and we could do quite a lot of work to look at the breakdown. There was not a clear pattern. In fact, some of the lowest scores were in fairly urban areas like Merthyr Tydfil.
[44] The other point that arose with regard to that regional variation is the number of toilets. We received some of the responses from an Assembly Member via the Research Service. These showed that, in the evidence that they could gather—in three local authorities, they could not determine how many toilets there were—there was a significant variation going from three in one local authority area to 30 in another. There are also significant geographical variations between authorities, so it is hard to draw firm conclusions from that.
[45] On a more positive note, and another indication of variation, Ceredigion won the Loo of the Year Award from the British Toilet Association in 2011, and I know that you will be hearing from the British Toilet Association next, so perhaps it will say more about how that award works and why that happened. However, Ceredigion was one of four Welsh local authorities that were commended or received awards. So, there are clearly some good examples as well.
[46] I would like to respond to the third point very quickly. We are not particularly aware of local authorities using the availability of toilets in cafes or pubs as an excuse to close toilets. Perhaps we will touch on this in a further question, or I can respond in more detail now, but there is clearly a large variation with regard to how the community facilities grant scheme is used. That leads us to question whether it is fit for purpose in its current form. A number of authorities do not use it at all and have not signed up to it, and a number have signed up to it, but have no businesses in their local authorities that are taking up the grants. So, we question the extent to which it is being used by authorities. However, we think that that is a good aspect of sustainable public toilet provision, and that scheme—if it worked properly and was utilised by all local authorities properly—could form an important part of the provision. Having said that, we do not think that that should replace local authority and central public toilet provision.
[47] Mark Drakeford: John, do you have anything to add?
[48] Mr Vincent: I would just like to add that, where the community toilet scheme is in operation, it is fine for many people, but many older people will not use that facility because they are reluctant to go into a pub or a café, or whatever, and come out without buying anything; they just do not feel able to do that. If they do go in to relieve themselves and then buy a drink, they are back to square one, so they tend not to go in. I can also see that there would be a problem with taking a young child into a pub, or somewhere like that. It is not a complete answer.
10.00 a.m.
[49] Mark Drakeford: No, by no means.
[50] Elin Jones: You have talked a bit about the standard of public toilet provision and an aspiration for Wales to set the bar high. I am interested to know what you would envisage that high standard of provision to be. Would you envisage every middle-sized town or village in Wales having a public toilet, or there being a public toilet every 10 miles, say? You mentioned Ceredigion in your response; Ceredigion County Council is very far away from ensuring that every village in Ceredigion has a public toilet. I am not sure whether there has been an answer to Mick’s question on the opening hours of public toilets, because we do not live in a nine-to-five society anymore, but many public toilets are shut at particular hours. Is there a consensus on 24-hour provision versus nine-to-five provision?
[51] Ms Hughes: In Porthmadog, there was a public toilet that was in a disgraceful condition, and, because Porthmadog is a tourist destination and there is a lot to do in the town, Gwynedd Council decided to refurbish the toilet block and put a 20p slot on the door. Everyone knows about it—there was a lot of coverage in the press about the opening of the new toilet block—and you put your 20p in the slot and the door opens. So, it is always accessible and it is cleaned frequently. I think that that solves the problem: if we were to say to people that it will cost 20p to use public toilets in Wales, people would get to know that, and public toilets would be accessible 24 hours a day. As you say, we do not have a nine-to-five society anymore. I met a lorry driver who was fined £80 for relieving himself in a lay-by after he had been through about five villages where there were no toilets or they were locked. There are public toilets in villages that were built because there was a need for them, but which are now locked, and we have more frenetic lifestyles now—everyone is in a hurry, people travel longer distances and hospitals are further away, so people do plan their journeys along routes where they know toilets will be open. There is a public toilet in Ganllwyd on the main road to Trawsfynydd; if it is ever shut, it will be a disaster.
[52] This committee is the Health and Social Care Committee, and there are two different ways of looking at this. We have already discussed what can happen from a health point of view if you cannot get to a toilet. There is also the social aspect, where people do not go out. We want people to come to Wales, but if a public toilet is locked they will improvise—they will go around the back. I know of dozens of examples where there is a dreadful mess around the back of the toilet block; just because the toilet is locked, that does not stop the need for people to go. Most people I have spoken to have said that a 20p charge would be fine if that means that there is a public toilet open; you put your 20p in the slot, the door opens and the toilet is accessible.
[53] Mark Drakeford: Kirsty, did you have a question on the public health issue?
[54] Kirsty Williams: My question is more about the vision, because Councillor Hughes said that we should have this vision, and I do not think that anyone here does not agree that this is a serious issue. What this committee needs to do, perhaps, is to make recommendations as to how we resolve this issue, because I do not think that anyone would argue that it is not important. However, I do not think that you really answered Elin’s question about what the vision looks like. How do we solve this problem? Whose responsibility is it? What does a proper network of public toilets look like? Where do we start? Do we prioritise toilets in certain locations or on certain road routes? What does your vision, which you have very eloquently said that we need, actually look like in detail, and whose responsibility is it to deliver that? Do you have any idea, based on the extensive work that you and others have done, of what kind of levels of investment we are looking at to make what you are talking about a reality? I do not think that anyone here would say that this issue is not important; it is just a question of how we then solve the problem to create the situation that everyone would, quite rightly, like to see.
[55] Ms Hughes: At the moment, the problem is twofold: each local authority has its own policy and way of dealing with it, and it is non-statutory provision, so it is easy to say, ‘Let’s close a toilet, because that is a bit of a saving’. However, that creates problems, does it not? So, road routes would be a good one to start with. We have some wonderful new roads through mid Wales, and people are travelling in larger numbers, so let us start with that one—or, as the Assembly, you could perhaps make legislation centrally that goes out to local authorities. I do not know what the solution is, but I do know that it is a problem and it needs to be addressed. As many ideas need to be thrown on to the table as possible, and perhaps we will then come up with a workable solution.
[56] Mr Francis: I have a few points on those issues. In terms of how many there should be, and where, I do not think that it is feasible to say that every single village should have a public toilet; there is no chance that we will put that forward, just because of the practical difficulties in building them and servicing them, let alone paying for them. Public toilets on road routes would be a good one in general, but the people to whom Age Cymru talks tell us that the lack of public toilet provision is a barrier to them going out to get essential shopping or to use their local area and community. Therefore, we would see the starting point as ensuring that every town centre has a certain number of public toilets available. We have not crunched the numbers on how close together they would need to be, or how many you would need in an area the size of Cardiff city centre, say, but they should be available in any place where you expect older people go to access services, and wherever that ensures equality of access for older people to shops and those kind of facilities. Therefore, we would be talking about any suburb or village that has a certain number of shops, a doctor’s surgery, a pharmacy and so on. From our point of view, we want to link it to essential services; I guess that that is what I am saying. We have not said that there needs to be one every 10 miles, or anything like that.
[57] I know that the committee is not looking at a duty on local authorities in particular, given its remit, but we have been quite vocal about the need for that. Briefly, the reason why I say that is that, as Louise said, public toilet provision is a non-statutory service delivered by local authorities. If we are to achieve equality of provision and provision in key areas, we will have to mandate it somehow: whether that is by making it a statutory duty, or whether there are other solutions, I do not know.
[58] I have two other points, very briefly. On a standard, people tell us three things: they need to be safe, clean and accessible. That links closely to the question about opening hours, because one of the big challenges—as people will, I am sure, tell you as a committee, and as they tell us—is vandalism, as well as safety and ensuring that the right kind of activities are going on in public toilets, if I can put it that way. That is an issue, and we recognise that that is part of the reason why toilets are not open 24 hours, usually—because they simply cannot be supervised to that extent. However, we do not think that opening hours of 9 a.m. to 5 p.m. Monday to Friday are acceptable, for a number of reasons. Clearly, people’s lives do not revolve around 9 a.m. to 5 p.m., particularly if we are talking about travel and so on. Putting older people’s needs to one side for a second, and thinking about the needs of tourists, if public toilets are not open on a Saturday and Sunday, they are of no use to weekend visitors to those areas. Again, I do not think that there is a one-size-fits-all solution, but if a public toilet was going to be open only between 9 a.m. to 5 p.m. Monday to Friday, there would have to be clear reasons as to why that was the case, and why that was when people would need access to it. I hope that that answers that question to an extent.
[59] Ms Hughes: Perhaps we could have a Wales toilet tsar. That would be a nice job. [Laughter.]
[60] Mark Drakeford: All ideas are worth thinking about. William has the next question.
[61] William Graham: If we accept that the provision of public lavatories is important for health and social wellbeing, what is your evidence on signage? It seems to me that, even if they are already provided, unless there is adequate signage—perhaps giving opening times as well as where they are located in towns—very few of us would know the location of every lavatory in every town and village in Wales. Also, if you are a stranger to the area, you will want to know whether there is provision, when it is open and where it is. So, what is your evidence on signage?
[62] Ms Hughes: There is lots of signage, but, unfortunately, lots of the toilets are closed.
[63] William Graham: So the signs are there, are they?
[64] Ms Hughes: Well, the signs are inadequate. I would like to point out that, in Gwynedd, we have a public toilet in almost every village. We are quite proud of that. An 81-year-old lady in Bryncrug said, ‘Yes, they were built and now they are closing them’. I have heard time and again people say, ‘We’re going back in time; we’re going backwards; it’s not right’. If you have a sign, you have to have a toilet that is open, do you not? Otherwise it is a non-starter.
[65] Mr Vincent: More recently opened toilets tend to have signage built into the planning for them, but many people do not know where the older toilets are. They exist, but people do not know where they are.
[66] Mick Antoniw: I did a walk around Pontypridd as part of a report on disability access. Knowing where they were was a real issue. You need to know where they are in relation to where in town you might be. It was a problem, partly because of the disparate provision across Wales. Sometimes, they are not necessarily public toilets on their own, but are part of another building. However, when you arrive at the bus station, for example, there is nothing to tell you where the toilets are located. It is hit and miss as to whether you see a sign or find the sign or know where it is. That is a problem with regard to how some of our towns are planned and signposted.
[67] Ms Hughes: I think that there is a website where you can check public toilet provision, but not everyone has access to a computer.
[68] Mr Vincent: It is looseeker.co.uk.
[69] Mark Drakeford: That was the point that you were making, was it not, John? These things have developed over time, so more modern developments are well signposted, but, with others, it is assumed that you know where they are. However, you cannot make that assumption.
[70] Lindsay Whittle: Should we be advocating the provision of more public toilets by way of planning gain? I would not like to guess how many millions of pounds have been spent regenerating Tiger bay, which has now become Cardiff bay. It is a lot posher now, but I do not know whether there are any public toilets out there. I only go around this square mile really, but there are no public toilets, despite the millions of pounds spent on buildings. Would it be an idea for us to say not only to the people who design these wonderful buildings but to the contractors who make a lot of money out of building them that, if you are going to build an Assembly building or a millennium centre, you must provide public toilets for the local authority to maintain?
[71] Ms Hughes: That is a very good point.
[72] Mr Vincent: Yes, that is something we have discussed. We would like to see any new development that will be visited by large numbers of the public provide public toilets as a matter of course.
[73] Mr Francis: I am not a planner, but my understanding of the rules is that, when you build a shopping centre or a building such as the Wales Millennium Centre, there are certain rules on what you need to provide. However, when you are talking about the regeneration of a large area, such as Cardiff bay, which was the example given, I am not sure how clear those rules are with regard to whether you can rely on the toilets in particular buildings, such as those in the Wales Millennium Centre, or whether the council or whichever organisation is developing the area is obliged to put public toilets in the open areas as well. That may be something that needs to be considered.
[74] Mark Drakeford: Thank you all very much indeed. We have had a very wide-ranging discussion on this topic for three quarters of an hour. Councillor Hughes, if there are any points that we have not asked about or things that you think we have missed in the discussion that you want to ensure that we hear about before you leave, there is just a minute for that now.
[75] Ms Hughes: Oh blimey, I could talk about toilets for hours and probably bore people to death. I stand by my vision for Wales. We should set the bar high. Let us have people saying, ‘Wow, the toilets in Wales are fantastic!’ A friend of mine goes to run marathons in America and she says that the public toilets there are fantastic. We do not want people coming here and saying, ‘Oh dear, don’t go to Wales—there are no toilets’ or ‘The toilets in Wales are absolutely dreadful’. Let us grasp the challenge and really go for it. Thank you very much for your time. I really appreciate that we have got this far in the campaign.
[76] Mark Drakeford: Thank you all very much indeed. We are very glad to have had your evidence this morning.
[77] As we wait for our next witnesses to come in, may I gently say to committee members that it was absolutely right that we gave the petitioners, given that they were with us first, a chance to talk more widely about the issues that are of concern to them. The two next sets of witnesses are much more specifically focused on the health dimensions of this issue, and, given that that is the aspect on which we will be able to report most powerfully, we will try to concentrate, where we can, slightly more on the health and the public health dimensions of the petition. It will be absolutely legitimate for us to comment on some of the things that we have spoken about, although, in reality, they lie within the remit of another committee.
10.15 a.m.
Goblygiadau Iechyd Cyhoeddus o Ddarpariaeth Annigonol o Doiledau Cyhoeddus: Tystiolaeth Lafar Public Health Implications of Inadequate Public Toilet Facilities: Oral Evidence
[78] Mark Drakeford: Bore da. Hoffwn groesawu Mike Bone, cyfarwyddwr Cymdeithas Doiledau Prydain, Gillian Kemp, o’r Rhwydwaith Syndrom Coluddyn Llidus, a Karen Logan, nyrs ymgynghorol a phennaeth gwasanaeth ymataliaeth Bwrdd Iechyd Lleol Aneurin Bevan. Diolch i chi i gyd am ddod y bore yma.		Mark Drakeford: Good morning. I welcome Mike Bone, director of the British Toilet Association, Gillian Kemp, from the Irritable Bowel Syndrome Network, and Karen Logan, nurse consultant and head of the continence service at Aneurin Bevan Local Health Board. Thank you all for coming along this morning.
[79] We have already had three quarters of an hour this morning to talk to the petitioners, whose work has resulted in our hearing today. As a committee, we are exploring the public health dimensions of public toilet provision in Wales, and we are grateful to all three of you for coming to share your expertise with us this morning. Given that we have received your written evidence, which we have had a chance to look at, we will probably move straight into the questions. Members will have questions for you all, and there will be a chance, just before 11 a.m., when we come to the end of the session, for anyone to make any point that we have not managed to cover in the time that we have with you.
[80] William Graham: Could you tell us whether you feel that the scale of the problem is recognised or, because of its very nature, it is not often commented upon?
[81] Mr Bone: Over the past 10 to 13 years, throughout the United Kingdom, the number of public toilets has reduced by about 40%, which has been highly commented upon in the media. So, people are aware that not only do we feel that public toilets have been decimated, but that it is a fact.
[82] Needing to use a toilet is a basic human need, and, as you have heard previously, public toilets are an essential part of that toilet provision. What we really need is an overall strategy for Wales—and one for England, one for Scotland and one for Northern Ireland—so that we can ensure that all of the components of providing public toilets are accounted for, and there is no doubt that we will talk about them during this session.
[83] Ms Kemp: From my point of view, it is about fighting a taboo—you do not talk about going to the toilet. Whatever your age, there is still this concern that it is not a nice thing to do, and problems with bowels or something like that makes it worse. So, just because people have not protested or said anything does not mean to say that they are not interested. It means that they are perhaps too embarrassed to say anything about it. Once you start talking to someone about a public toilet, they certainly have an opinion, but they will not go public about it.
[84] William Graham: So, can you tell us— [Inaudible.]
[85] Ms Kemp: Irritable bowel syndrome affects all ages, not just elderly people, and it is about the sense of urgency. If you need a toilet, you just have to go, and if there are no toilets, you just do not go out. It is as simple as that. That brings in the health implications of isolation and mental health problems, again, at whatever age—the elderly, in particular, are affected, but so are young people, because they are embarrassed about having to go to the toilet as well. We all think that they talk about sex, and whatever, but the toilet is a different matter. They are inhibited about going out. In terms of toilets in general, holding on should not be an issue—for young children, or for anybody. Then you have, as has been mentioned before, pregnant women, people on medication and people who have a medical condition.
[86] Mr Bone: It is not just people who have illnesses—it is also people who are healthy, but who also run a health risk if there are not adequate public toilets. As you have heard, people will urinate and defecate in public places, which is a definite health risk.
[87] Ms Logan: From my perspective, as a clinical nurse specialist in incontinence, the patients whom I see in my clinics on a day-to-day basis lead lives that are already blighted by incontinence. We know that incontinence does not kill people, but it certainly kills their quality of life. They are already challenged by that and the fact that, when they go out, they do not have access to a public toilet when they need to go. A lot of these people need to go frequently, and have an urgent desire to go, and if they get to a toilet and it is closed, it means they will have the indignity of an episode of incontinence in a public place, and all the consequences of that. So, to reiterate what Gillian said, these people do not go out anymore, and may become quite seriously depressed. I have had one case of a woman who took an overdose and attempted to take her life because her incontinence was so bad. There are many issues, but there is usually one straw that breaks the camel’s back, and it can be that very thing—the fact that they have got to a public toilet, it was closed, and they had an undignified and embarrassing episode of incontinence. That can be enough to tip them over.
[88] Mr Bone: Going to the toilet is a basic human need. We are all the same: we all eat, we all drink, and we all go to the toilet. So, what is the problem with people recognising that you have to provide toilets so that people can use them? It is pretty basic.
[89] Ms Logan: From my perspective, I see people of all ages—children as well as older people. Children are vulnerable because their bladder and bowel are developing, so they need to go more frequently. Pregnant women also need to use the toilet more frequently. With an ageing population, and the bladder and bowel problems that occur in older people, we have a ticking time bomb—almost an invisible epidemic. It really will be a big problem for these older people as time goes on if we do not do something about this now. They cannot be part of their local community. They cannot go to the doctor, or the chemist, or the village with the local shop and the butcher, because the toilet is closed. It is a really big problem for that age group.
[90] Ms Kemp: I totally agree. You plan your journeys depending on the toilet. I do not think that that is right for anybody. If you have to go from A to B, people with my condition plan their toilets en route. If there are no toilets, you just do not go. It is as simple as that.
[91] Ms Logan: There are also financial implications in terms of the broader impact on the NHS. My service provides incontinence pads to patients—nearly 5,000 people in my area are receiving them free of charge from the NHS. People with a problem will have to use more incontinence pads and products to go out, and whether they are getting those from the NHS or purchasing them themselves, that is quite a big financial burden. Not only that, but holding on to a full bladder or bowel increases the heart rate and the blood pressure, and for very old, ill or vulnerable people this could cause a stroke or a heart attack or have other health implications.
[92] Rebecca Evans: You have just answered the question that I wanted to ask, which was on the impact on the NHS and social services of inadequate public toilet provision. Is there anything that you would like to add to that?
[93] Ms Logan: There is an extra burden in the provision of free incontinence pads, which could be an issue, and the personal financial burden for those who are purchasing them themselves is a problem. There is the knock-on effect of other health conditions—for example, not being able to go out into their village, town or community means that they become inactive, and lose their ability to be active, and that has an impact on health and social care. In the future, they become more immobile, ill and depressed, and all that costs money in terms of addressing, treating and managing it. With a lot of these people, if they have to hold on and cannot go, they will be at a very high risk of developing a urinary tract infection. Treating those infections is a costly business in terms of antibiotic provision and so on.
[94] Ms Kemp: Talking about finance, it is also about work opportunities. When you get to your place of work, there are toilets there, but you have to get there first; that limits job opportunities, and you could end up unemployed. It is not overstating the case to say that, if you cannot get to your place of work because there are no toilets on the way, you cannot even apply for a position.
[95] Rebecca Evans: I want to ask about the importance of public toilet cleanliness—where toilets exist—and the availability of hand-washing facilities. I am sure that we have all been in public toilets where there is not any soap or anything to dry one’s hands with. What is the impact of that sort of situation on public health and disease control generally?
[96] Mr Bone: It is recognised that, to wash your hands, you need hot water rather than cold water, and you need soap. You also need to be able to dry your hands. Unless you have all three of those elements, you do not take away the risk of infection being spread by hands. I am sure that, being a nurse, Karen can support that.
[97] Ms Logan: Absolutely. We all know how important it is to wash our hands after using the toilet, so that we do not transfer bacteria and diseases, which is a possibility if those facilities are not available. The other issue for some of the patients and other people that I look after is that they are incontinent and often have to change pads. Many of my patients with bladder dysfunction cannot empty their bladder properly; they have to catheterise themselves several times a day. If they are out, they will often have to do that in a public toilet. That means that they need adequate washing and drying facilities. They need disposal facilities for the wipes and the other things that they have to use, and of course, they are very vulnerable and at high risk of contracting an infection if they have to catheterise in a public toilet that is not clean and does not have the basic hand washing and drying facilities that we all require.
[98] Kirsty Williams: Your evidence, Mr Bone, was very clear, and we all acknowledge the fact that we need adequate provision. What does ‘adequate’ mean?
[99] Mr Bone: Are you talking numerically, facilities-wise or both?
[100] Kirsty Williams: If we were to start, what should our priorities be? If we cannot solve this problem overnight, as it is going to take a number of years to create an adequate network, where should we start and what should our priorities be?
[101] Mr Bone: There needs to be a strategy, be it at Wales level, county level or town or city level. That would include an awareness of the population in an area, mobility in that area, and the places where people congregate in that area. From there, you can start to think about the locations for toilets.
[102] With regard to the volume of toilets, there are some benchmarks. For example, for every 10,000 females, you need a certain number of toilets, for every 10,000 males, you need a certain number of toilets, and the same applies for every disabled person and for those who need baby-changing facilities. So, statistics can be used to calculate how many toilets are needed for a certain population. The important thing is to put the toilets where they are needed in that area. Obviously, a lot of people reside in areas where they have toilets in their homes—that is not where public toilets are needed. Public toilets are needed at transport intersections, where people arrive and depart, near places of entertainment, in shopping centres and so on. It requires a lot of research and understanding to dictate these things. Many of the old toilets evolved many years ago, and our society has changed since then, which means that they are not necessarily located in the right places any longer.
[103] So, having established how many toilets are needed and where they should be, you then need to think about what facilities are provided, and you need to think about being inclusive and about equality issues. That is, you need toilets for males and females, you need baby-changing facilities, and you need accessible toilets for wheelchair users. You also need what are now referred to as changing places toilets. These are toilets where people can be changed by their carers—there are sometimes two of them. So, you need a changing bench, where you can lay the person who needs to use the toilet, and you need a hoist to lift the person from the changing bench to the toilet and back again. This is quite a big area, about 5m x 3m, and it needs a hoist and a bench. It is quite expensive to operate, but there is a need for it. The number of these toilets has expanded from none four years ago to about 350 now throughout the UK. I think that there are around 15 of these in Wales at the moment.
10.30 a.m.
[104] Kirsty Williams: Having created that strategy, is placing a statutory duty on local authorities the only way to achieve an improvement, or are there other ways? For example, we had great success in creating standards for local authorities with regard to library provision. We did not pass any more legislation, but there was a very clear expectation of what a local authority should do to improve its library services, and they were judged against that. Is legislation the only way, or can we do it another way?
[105] Mr Bone: Legislation is not the only way, because there are many local authorities and many towns and cities that have excellent toilet provision, and those local authorities have the same financial constraints as those that provide no toilets or very poor toilets. So, obviously, you do not need legislation in an ideal world, but we are not in an ideal world. This strategy would say that the country, the county and the authority had the responsibility for providing toilets. It would not necessarily be an obligation to provide toilets, but a responsibility. So, in the strategy, there would be a requirement to provide public toilets; there would be a requirement for public buildings to open their toilets up to the public—whether a library, a community centre, a town hall, or whatever—because that is a resource that is not necessarily being used; there would be a requirement that, when commercial companies apply for planning permission, there would be a section 106 clause that would state that planning permission would be given, for example, to build a supermarket, but, as part of that planning permission, they would have to provide a public toilet outside that all can use without having to use the supermarket. So, there are many ways in which the strategy can include provision without necessarily costing the taxpayer.
[106] Mark Drakeford: Gillian, would you like to add anything?
[107] Ms Kemp: There is a British standard already—BS 6465-4—which states the suitable standards for public toilets.
[108] Mr Bone: That is only a recommendation; it is not legislation.
[109] Ms Kemp: Yes, but it is a good start.
[110] Mark Drakeford: Work has been done in the field that Kirsty asked you about originally.
[111] Ms Kemp: Yes.
[112] Mick Antoniw: My question is directed particularly towards Mike Bone, but anyone can respond. In other countries—and perhaps we can talk about our European counterparts, such as Ireland, France, Germany, Italy, and so on, and even perhaps Scandinavia—are there any areas of best practice? What happens in other parts of the world? Are there any exemplars that demonstrate how things should be done and a model that really works? Do you have any knowledge of that?
[113] Mr Bone: Not necessarily, no. The UK, going back 50 or 60 years, was probably an example to the world in that there were publicly provided toilets that met most people’s needs. In many other countries, that has not been the case historically; they have not had the range of public toilets that we have, other than at railway stations, bus stations, and so on. People in other countries tend to use commercial providers for toilets, and that is something that is understood. So, people have no compunction about going onto premises, not buying anything and using the toilets. That is not the culture in this country. There is a different attitude towards, for example, licensed premises in this country. Many of the toilets that people use abroad are in bars, whereas in this country, as has been mentioned previously, many people with young children, many females, and many people with religious concerns about licensed premises will not use them. So, where that is acceptable in some countries, it is not necessarily acceptable here. There are, therefore, some differences.
[114] Ms Kemp: I have experience of Australia, where the Government has a toilet map. So, wherever you want to go, you can find information about toilets there from the internet. Of course, that means that you have to have access to the internet. In New South Wales, all of the toilets were free, well provisioned, and clean. There were also many of them. I understand that it is all done by the Australian Government. If it can do it, perhaps we should, too.
[115] Mick Antoniw: You may not know the answer, but is there a regulatory system that proposes a requirement, standard, obligation, or whatever?
[116] Ms Kemp: I do not know for definite, but it would seem so. The Australian Government does have a toilet map.
[117] Ms Logan: Just to add to that, I do not have a lot of the detail around this, but I recall a consultant urologist further down the south Wales corridor telling me about a presentation that he heard on this very subject at a medical conference in Australia. It is quite clear that the Australian Government had ploughed a lot of money into public toilet provision, and that healthcare clinicians had been involved in lobbying for that piece of work. It was presented at a medical conference, so it was hot news at the time.
[118] Vaughan Gething: I have a simple question, though I am not sure that the answer will be simple. We have heard what you have to say about the additional risks of holding on when you need to go to the loo, and I think that a Help the Aged survey estimated that 5% of people have problems with incontinence, which is a significant proportion. You mentioned a range of additional potential problems, such as urinary tract infections, raised blood pressure, risk of stroke or heart conditions, and so on. How do you quantify that risk? Rather than identifying the potential risk—that is, what may happen—do you have any evidence that we should be aware of that shows the extent of the direct link between those conditions?
[119] Ms Logan: I do not believe that it has been quantified. It is probable; it is supposition. There is no evidence to say how many it might affect, or how many it has affected. It is just that the physiological effect of holding on to a full bladder or bowel is to raise the pulse rate and blood pressure. We know from work that looked at people with high blood pressure what the implications are for them. It is really just proposing what could happen. So, I do think that the evidence that you requested is there.
[120] Vaughan Gething: We heard evidence in the first session about people self-managing, or opting out of treatment regimes for health conditions, so that when they go out, they can manage and will not need to go, as it were. Is that something that you have dealt with in your role, and have you seen the direct consequences of opting out of such treatment regimes?
[121] Ms Logan: No. I rarely see people and patients who have chosen to opt out of treatments for bladder and bowel conditions. They are generally absolutely desperate. By the time they interface with us as clinicians, they will have suffered in silence for many years. They are usually in a desperate state by the time they come to us, and they clutch at any treatment or advice you can offer that will make their symptoms better. So, very few would opt out of best-practice recommended treatment that has been suggested by their doctor or specialist nurse in this specialty.
[122] Ms Kemp: This is not necessarily the case with medication, but if people with IBS have to travel, they stop drinking, and that can lead to problems with dehydration. They may even stop eating. If some people know that they have to go somewhere, they will not eat or drink, just in case. That can lead to problems, too.
[123] Mark Drakeford: Karen, we have a couple of minutes, and given that we are particularly interested in the health dimensions of public toilet provision, could you describe to us the service that Aneurin Bevan Local Health Board provides, the number of people you end up seeing, and the prevalence of people who have the type of conditions that would make the provision of public toilets an issue? What are their ages? Could you paint a picture for us of the scale of this issue? That would help our understanding.
[124] Ms Logan: I am a consultant nurse. I head up the continence services within Aneurin Bevan Local Health Board, and I lead a team of five clinical nurse specialist continence advisers. We run continence, bladder and bowel clinics at numerous locations in Gwent—there are about 15 clinics. The patients who are referred to us may be referred by their GP because they have a bladder or bowel problem, or because they have incontinence. Some refer themselves—adults can self-refer to our clinics. At those clinics, we will assess their symptoms and we will advocate and advise on treatments and best-practice management to help improve or cure their symptoms, or to manage their problems better and improve their quality of life.
[125] In a recent survey by the Bladder and Bowel Foundation, it was estimated that about 14 million people in the UK suffer with urinary problems and symptoms and incontinence. About half of that number—nearly 7 million—suffer with bowel conditions. I did some work a while ago to try to extrapolate some of the global and national figures to see what the picture would look like in my area. That work demonstrated that approximately 22,000 people in my area alone—the Aneurin Bevan, south-east Wales, Gwent area—will have a bladder or bowel or incontinence problem. We serve a population of more than 600,000 people. Some 4,000 to 5,000 people in our area receive free incontinence pads from the NHS, from the Aneurin Bevan health board. We see about 3,000 patients coming through our clinics as new patients per year to access our advice and treatments. Year on year, with the ageing population, this is growing. We are seeing more and more referrals and requests for free incontinence pads from all the different age groups. My service covers everyone from children right the way through the age spectrum to frail elderly people.
[126] Mark Drakeford: That is very useful. Thank you very much. Kirsty and Elin have questions.
[127] Kirsty Williams: Could you expand a bit further on what you have just said? Is the problem in the older people you see simply a consequence of old age? Is it inevitable that, as you get older, you will have problems or are you seeing people because they have medical conditions? What leads a person to have a problem that means that they end up in your clinic?
[128] Ms Logan: I will start with the children and go through the ages where we see the most people in terms of age and prevalence. Very often, children come to us because of bedwetting. Nocturnal enuresis is a very common problem in children. Some of them also have daytime wetting as well as night-time wetting. Constipation and soiling are also big problems with children due to poor diet. Those are real problems. Because it is so painful, once a child has had an episode of constipation, they carry on withholding and their constipation basically continues through their lives. We have these children on our books almost forever with problems of long-term constipation and soiling.
[129] The next group we tend to see is women with post-natal incontinence. After they have had babies, some women incur obstetric and pelvic floor damage. We see many women around that stage with urinary and anal and faecal problems because of third and fourth-degree tears, forceps delivery and that sort of thing. That is a big workload for us. The next time we see a lot of people is around the menopause. Women may tick over okay until they get to the menopause when the drop in oestrogen affects their bladder, their urethra and their pelvic floor; they become very prone to incontinence at that age. Men are pretty okay until they get to about 60. With the enlarging prostate, that is when they start to have problems with the lower urinary tract, and with frequency, urgency and incontinence. There is a big workload around that age group.
[130] Then there are the neuropathic patients—the people with MS, Parkinson’s disease, multiple sclerosis and spinal injuries. They have terrible bladder and bowel symptoms, and they need ongoing care. The next group is the elderly. Unfortunately, although it is not inevitable that we will all be incontinent when we are old, it is very probable. That is because the physiological effects of ageing on our bodies also affect our bladder, our bowel and the nervous supplies to them. So, we are very likely to have bladder and bowel and incontinence problems as we get older. It is not inevitable for everyone. There are people who do not have those problems, but the majority of people will have some problem. We should bear in mind that, around one in five of us around this table will have symptoms of an overactive bladder. That does not mean that we are incontinent, but it may mean that, if we are drinking a bit too much tea or coffee, we have frequency and urgency issues, and that means that we need to go more frequently with an urgent desire. We might be dry, but it is a very common problem in all age groups. Again, it is not talked about or discussed.
[131] Mark Drakeford: So, in terms of the service you provide, you will be seeing the most severe end of that wider spectrum you have just described. Therefore, public toilet provision is an issue for the wider spectrum.
[132] Ms Logan: It is.
[133] Mark Drakeford: However, you see those with the most severe difficulties.
10.45 a.m.
[134] Ms Logan: Yes, we deal with the more severe end. However, as people are more aware, through using the internet and media attention, of where to get information, they are now more mindful that treatment is available. So, some people, being very proactive and sensible, will come in a little earlier. We would like to get the message across that we would rather see them sooner than later, because we can do a lot more with them if we can treat them proactively in the earlier stages of their symptoms and conditions than if they have left it 20 years or more. If they come in later, then they are much harder to treat.
[135] Elin Jones: I want to return to something that Karen Logan said about patients with severe incontinence, and possibly those with chronic conditions, who have to plan their journeys according to the public toilet provision. However, even if journeys are planned, and the person knows where all of the public toilets are in advance, those toilets could well be closed when that person visits, which can have a devastating effect. From the anecdotal evidence that you have, planning journeys around public toilet provision is what a lot of the people who you see do. In an ideal world, that should not have to be done. However, although they have checked in advance the locations of public toilets, they can very be often closed, which can have quite devastating impacts.
[136] Ms Logan: Every patient will tell you that they make a mental route-map of where every public toilet is, and they will not go anywhere until they have that route-map right in their head. They will know where the toilets are in every town and shop, and which ones are the clean ones—where they are in Marks & Spencer. So, they will have all of that information, and they often tell us about it. If we ask them, they will certainly tell us that they will not go anywhere until they know where the toilets are. Very often we hear that they have managed to get to the toilet that is on their mental route-map in time, but that that toilet was closed. The effects then are absolutely devastating for them.
[137] Mark Drakeford: Mike, I want to ask you a question about your evidence regarding mobile workers. Gillian spoke about people who are travelling to work, but you referred to people whose jobs involve them travelling around a lot. Can you say something about that and also about the problems faced by homeless people, which you also refer to in your evidence? I am interested to hear a little more about that.
[138] Mr Bone: People such as road sweepers, road maintenance people, lorry drivers, taxi drivers, policemen and so on will need to go to the toilet. So, in performing their duties during a normal shift, whether it is eight or 12 hours or whatever, they will need to know that there is a toilet available that they can use when they need it. There are reports that, for example, the police have been told that they must go back to the station to use the toilet if they cannot find one. You can imagine the cost of that in terms of their time, and in the fact that they are not available to deal with crime when they are doing that. We have already heard this morning about a lorry driver who was fined for using a lay-by to go to the toilet after he had tried to find a toilet in five different towns. So, this is a big issue. It also applies to homeless people, who do not have access to a toilet at home. So, whenever they go to the toilet, it will be away from home—it will either be a public toilet or a toilet in commercial premises. If they are people who perhaps do not look or smell too nice, then they might not even have the option of using a commercial toilet, because they will be refused access. This is a real issue.
[139] Ms Kemp: I have come across an incident where a police constabulary was told not to drink too much so that they did not keep coming back to the police station to use the toilet, which is totally unacceptable.
[140] Mark Drakeford: Are there any final questions that any committee member wants to ask? I see that there are none. In that case, if there is something that we have not raised with you, any points that you have not had a chance to make, or things that you think it important for the committee to be made aware of, then you now have the chance to make them known to us. Gillian, do you want to start?
[141] Ms Kemp: One reason given for the closure of public toilets is vandalism, and it is often used as an excuse. A few years ago, I worked with the police and we produced a guide that is available free of charge from the BTA—that is my little advertisement here—‘Publicly Available Toilets—Problem Reduction Guide’, which gives suggestions as to how the effects of vandalism can be mitigated and how to ensure that it does not happen quite so often, not just for new toilets but also when you come to revamp older ones. It includes a very good selection of ideas.
[142] Mr Bone: Gillian mentioned that vandalism is sometimes given as a reason for the closure of public toilets; the other reason is cost, as we have mentioned. I do not think that the provision of toilets ought to be considered a cost; it ought to be considered a basic need and presented in such a way that there is no alternative other than to provide public toilets. We are provided with street lighting, refuse collections, education and health, and we do not argue about that, so why argue about providing public toilets? I think that it is that significant.
[143] Ms Logan: I am a member of the Association for Continence Advice, which is a national organisation for professionals. It is doing some work on lobbying—Mike will elaborate on this—to make public toilet provision a statutory duty in England. Mike has previous experience of trying to lobby for that for a number of years, so he can elaborate on that in a moment.
[144] What we had in place previously has not worked, and we need to learn from that. My understanding is that there are Government grants of £500 for premises such as cafes and pubs that allow the public to use their toilets. That clearly is not working. Certainly, in our area, it is not advertised and the retailers—shops, cafes, pubs and so on—do not know that they can access the grant. Also, the people who want to use the toilets do not know which premises have signed up to the scheme. It is not advertised, it is not clear, there is no governance around it and it is clearly not working.
[145] Therefore, from my perspective, it needs to be made a statutory duty for local councils to provide public toilets. However, many of my patients in clinics tell me that they would be more than happy to pay to use the toilet, and that they would prefer to pay to use a toilet than not to have a toilet at all.
[146] Ms Kemp: I think that a figure of 20p was mentioned earlier, and that would be perfectly acceptable to our members.
[147] Mr Bone: I know that the question of a charge was mentioned earlier, when we were watching up in the public gallery. That can be the solution in many places. A small charge, such as 20p, in a high street toilet more than covers the cost of that provision. In fact, there is no cost to the taxpayer; it just needs someone with initiative and responsibility to implement it. We have heard people ask, ‘What about change?’. In all of the Network Rail main line stations, there is a charge for using the toilets but there is a change machine at each one beside the place where you put your money in. So, it just needs a bit of forethought and initiative to overcome most of these problems.
[148] Mark Drakeford: Thank you all very much; it has been a very interesting and useful session for us, and we are very grateful to you for coming here.
[149] Rydym yn mynd i gael egwyl fach yn awr am 10 munud.		We will now take a short break for 10 minutes.
Gohiriwyd y cyfarfod rhwng 10.53 a.m. a 11.07 a.m. The meeting adjourned between 10.53 a.m. and 11.07 a.m.
Goblygiadau Iechyd Cyhoeddus o Ddarpariaeth Annigonol o Doiledau Cyhoeddus: Tystiolaeth Lafar Public Health Implications of Inadequate Public Toilet Facilities: Oral Evidence
[150] Mark Drakeford: Bore da a chroeso. Rydym yn agor y sesiwn olaf y bore yn awr. Croesawaf Chris Brereton, dirprwy brif cynghorydd iechyd yr amgylchedd, Llywodraeth Cymru, a Dr Sara Hayes, dirprwy brif swyddog meddygol dros dro ym maes iechyd cyhoeddus.		Mark Drakeford: Good morning and welcome. We now open the last session this morning. I welcome Chris Brereton, deputy chief environmental health adviser at the Welsh Government, and Dr Sara Hayes, acting deputy chief medical officer for public health.
[151] Welcome to you both this morning. This is our final session in the brief inquiry that we have been holding into the public health consequences of the changing nature of the public provision of toilets. Thank you both very much for coming. There will be a couple of moments at the start if either of you want to make some introductory remarks, and then we will go to questions from around the table. We aim to finish this session by 11.50 a.m. at the latest. As we draw towards a close, there will be a chance, I hope, for you to remind us of any points that we have not managed to raise with you in questions, or to give any last thoughts on points that you think that we ought to cover. Dr Hayes, are you going first?
[152] Dr Hayes: I will, yes. I had intended to give a short presentation this morning, but you have heard a lot of evidence from the people who came before us, and our paper for you has drawn a lot on their work in the first instance. We support their stance, and have nothing further that we can add to what they were saying, in many ways. So I will say no more than that, but I am happy to answer questions.
[153] Mr Brereton: I am of a similar mind, Chair. You have heard some excellent evidence this morning, and I do not think that we have anything to add, other than to answer your questions.
[154] Mark Drakeford: Thank you. We will go around the table for questions, starting with William.
[155] William Graham: I will start with a question that I appreciate you may not have the answer to. We heard in evidence that the average reduction in provision was about 40% across the United Kingdom; do you have any figures for the reduction in Wales?
[156] Mr Brereton: To be honest, no. When I was in local government years ago—back in 2000—we used to have to provide figures on the number of public toilets that were provided by local authorities, but I think that that requirement ceased. As part of preparing to give evidence today, I have looked across Wales to see whether there is evidence of how many toilets local authorities are providing currently, and you can get a good picture of what is available from their websites and by making a few enquiries, so I have current figures, but, as to a decrease, I would have to look retrospectively, and the figures are not available for me to do that. It may be that local government colleagues would have that information at their fingertips, but I do not. I think that provision in Wales looks to be slightly better than in England, looking at the statistics that have been quoted in other evidence.
[157] William Graham: So, your advice would be to gather information from local government colleagues.
[158] Mr Brereton: Yes, I think so.
[159] William Graham: I have a slightly wider question. Do you think that there is any real conflict between the Assembly Government and local authorities in terms of what they do provide and what they can provide?
[160] Mr Brereton: I do not think that there is conflict, as such. Decisions about the provision of local services, including public toilets that are under the ownership of local authorities, are best made locally, and they have to be made with due regard to demands for other services and the demand for public toilets locally. Local authorities need to take a strategic approach to such provision. So, I do not think that there is a conflict as such.
[161] Kirsty Williams: We heard earlier from a nurse consultant who had tried to extrapolate figures for her own health board area from national statistics for people who experience incontinence. Do you have any figures available on a Wales-wide basis on the prevalence of incontinence problems suffered by the population?
[162] Dr Hayes: We do not. As you saw from our submission, we have extrapolated figures from national surveys and individual studies. You heard the Aneurin Bevan LHB story; we do not have anything to add to that. We would expect that one in five people may experience problems at some point in their lives, and they may have ongoing problems, but we do not have a hard and fast number for us to say, ‘This is it’.
[163] Also, we know that there are issues through the course of one’s life. As you heard, you may have a problem as a child, and you go through that and cope with it, and then you can have another problem later on. The picture is a varied one, but the figures we have put in the document are estimates.
[164] Kirsty Williams: Mr Brereton, we have heard examples of people who, because of a lack of toilets, are acting in a way that is probably inappropriate and going to the toilet in places where we would not want them to go. I am certainly aware of the case in my constituency in which a famous public toilet was closed. It was beside a trunk road, and coachloads of people used to pull up there. It is closed now, so when a coach pulls up, the people disembark and they all go behind the old toilet, because you can no longer get into it. Is there any evidence of incidents arising of public health concerns that we should know about from people going to the toilet where they should not?
[165] Mr Brereton: We could all draw on anecdotal evidence of street urination; that seems to be a particular problem at night, when people leave licensed premises having drunk quite a lot of alcohol. They wander up the street and, 200 yd or 300 yd later, even though there is a perfectly good toilet in the licensed premises, the call of nature comes and they look for somewhere to go. The problem is that they cannot return to the premises, particularly in town centres where there may well be controls on entry, re-entry and permitted numbers, as well as door staff. You could be queuing for a taxi, for example, in Cardiff city centre on a Friday or Saturday night and you find that you need to go. That is when problems occur. Certainly, there is evidence of the police having to take action; we have heard about £80 fixed penalty notices being served for urinating in the street and for fouling. There are offences, and action can be taken, but it is difficult for the police to enforce it when there is not a reasonable alternative. We heard about the taxi driver in the lay-by this morning. It is difficult to take a reasonable approach when public toilets are not available to people walking the streets.
[166] In terms of risk, there is the issue of insanitary streams from urination, but faecal fouling is going to be a particular problem. It depends on where it is done, but people will have to clear it up. Clearly, particularly on the faecal side, there is a risk of infection that Dr Hayes may wish to comment on. In terms of evidence, however, I suppose that you could look for the number of fixed penalty notices served by the police. I think that we all know from our own experience that it happens, and it happens for the reason that toilets are not available when people need them at night. However, it is also because people are not making the sensible decision to go before they leave the premises. It does not occur to them; and they regret it 300 yd further up the street.
[167] Dr Hayes: I would add that the health implications of fouling on the streets are the risk of infection, particularly for children who play in the area where this has taken place, on a pavement, a lawn or wherever. There is also the issue of a community sense of wellbeing. If the people living in an area regularly encounter fouling, it decreases the sense of wellbeing, and that has a knock-on effect on how it feels to live in that place. That has a health impact.
11.15 a.m.
[168] Lynne Neagle: We heard from the nurse consultant from Aneurin Bevan Local Health Board that she did not feel that the public facilities grant scheme had really worked. Does the Government have any figures on the uptake of that scheme? Is it being rolled out across all local authorities? Do you have any comments on the other point she made about the scheme, which is that, even when businesses have taken it up, it is pointless because the public does not know that it is possible to go there? That is, it is not promoted.
[169] Mr Brereton: May I comment on that? As I said before, I had a look at local authority websites and made some enquiries about the take-up of this scheme. It is not something that is within my policy area, but I thought that, out of interest, it would be good to see the results. I looked at local authority provision generally—toilets that are in the public sector now; not those owned by shopping centres, but those in local authority ownership—and there are just under 600 local authority-provided toilets. However, the community toilet scheme adds another 232 on top of that; bearing in mind that there are 600 local authority-provided toilets, over a third again are provided by the private sector.
[170] I agree on the issue of signage. It is a condition of the scheme, as I understand it, to provide adequate signage to say that the facilities are available for members of the public. That cannot be hidden; it has to be prominent as a condition of the scheme. Most local authorities list the toilets that are available under the scheme and have photographs of the premises. When local authority websites are good, they are very good. They have a photograph, a map, opening times, and they list all of the premises and advertise the scheme. I have seen that happen. Other local authorities merely say something like ‘We have three public toilets’, but they do not say where they are. I had to chase up those authorities to ask where they were and when they were open. So, it is hit and miss. Some local authorities certainly have not taken up the scheme, which is a shame, because others have and they are doing very well.
[171] Mick Antoniw: I have a couple of quick questions. Many toilets in Cardiff and some of the big towns were the product of the Victorians attempting to improve public health. Is there any evidence of deterioration in public health or a growing public health risk as a result of the lack of toilets? Secondly, are there any exemplars in other countries, or examples that you think we could learn from in terms of good practice? Thirdly, particularly with villages and smaller towns, is there a basis for saying that, perhaps, there should be a greater role for community councils with regard to provision and maintenance?
[172] Mr Brereton: I may respond to your questions out of order. In terms of the older public toilets from the Victorian era and so on, although some, such as the Hayes island underground toilets in Cardiff, which are still very popular, do not comply with the Disability Discrimination Act 1995, some toilets do comply. You have heard evidence this morning that suggests that some of the older toilets are being closed because, allegedly, they cannot be brought up to a reasonable standard with regard to disability access. There might be evidence of that, but the DDA should not be an excuse to close public toilets. It is only necessary to make reasonable adjustments if you can do so and if it is practical. We do not want to see toilets being taken away from the stock of toilets available on that basis. Certainly, accessible toilets should be provided, but if they are already available, other toilets should not be closed. The cost of maintenance might be higher for an older toilet, but they tend to be quite popular.
[173] When I was researching this subject, I tried to find out the number of public toilets. I looked at Rhondda Cynon Taf, which has around 31 gentlemen’s urinals. In terms of equality, there is very poor provision. However, I tried to look at them on maps to see where they were and they are generally at the end of streets near public houses. They still provide a service, so would you want to take them away because they are probably Victorian and are only one gender-specific toilet? I think not, because they provide a service. In London now, we are seeing that being replicated with pop-up urinals in the street at night. These come out of the ground to try to stop the street urination that we talked about earlier. Once again, there is an equality issue and a disability issue, but, in terms of provision, they meet a need. So, you have to have a strategic approach, in which you try to use all the tools in your toolbox in terms of meeting the need. If it is a case of preserving something that does not meet modern standards but makes some provision, you should keep it until you are better able to provide something that meets all of the community’s needs.
[174] In terms of community involvement through community councils, local authorities currently have the power but not a duty to provide public toilets. All local authorities in Wales would meet that requirement, because they currently do so. However, they should have a more strategic approach to provision, in which all means are looked at, including community councils, the private sector, tourism centres and shopping centres—everything and everywhere that can provide a public toilet. There are many toilets out there but they are not available to the public when they need them. It is about increasing accessibility by opening those doors. There are ways to do that other than by merely making local authorities provide them. You have to look at a very wide strategic perspective to this to get as much accessibility as possible.
[175] Dr Hayes: On your question about old toilets, they need to have running water to flush, running water to wash your hands, soap and blowers or paper towels to dry your hands. If they can provide that, they are worth keeping hold of, recognising that there are other requirements and so on. However, those are the essential requirements for a public toilet to be valuable and worth keeping open. That can be done in most toilets.
[176] Mick Antoniw: On two points that you did not cover, is there any evidence that there is a growing health risk in larger towns from this? Do you have any particular examples or concerns? Do you know of any exemplars that occur in other countries?
[177] Dr Hayes: If we were dealing with an outbreak, we would give specific information about the standards of a toilet, to make sure that we minimised the outbreak. However, those standards apply to institutional toilets in homes or schools.
[178] Mick Antoniw: It is not so much about the toilets but their unavailability to the public and whether people urinating or defecating in public places has led to an outbreak?
[179] Dr Hayes: We have no evidence of outbreaks linked to public toilets. On the other side, you have heard a lot about the impact of not being able to use a toilet because there is no toilet to access. The public health impact of that is completely hidden, because people go through the stress that you heard about, such as when you wait in the car to relieve yourself. People will go through that experience once or twice, but if they cannot guarantee that they will have access to a public toilet next time, they will not put themselves in that position. That stops them from going out or it creates the need for a carer to go with them. The knock-on effect of that is all the things that you have heard about—isolation, being kept at home, not getting exercise and people not accessing their environment. The health and social care burden is the increased need for carers when they need to go out, because there are occasions when those people will have to go out, and they will probably want to be accompanied by someone. It may be a relative or a friend, but it is still a burden that society has to carry. If the public toilet provision was adequate, that burden would not be there.
[180] Mr Brereton: In terms of evidence of practice in other countries, it is not something that jumped out at me when I was looking into this—it normally does; when you are researching something, you often get papers from other countries demonstrating good practice. It may well be out there, but it did not readily come out from the research that I did.
[181] Rebecca Evans: We heard earlier of some strong examples of the problems that people can experience if adequate hand-washing facilities are not available. Can you give us any clinical or scientific evidence of the effects of that, to further strengthen what we have already heard?
[182] Dr Hayes: Hand-washing is known to be the key to minimising transmission of infection—it is a fundamental point that everyone must be able to wash their hands. For instance, we know that outbreaks are linked to norovirus outbreaks where one person has not been able to wash their hands, and they are handling food or even have just been in contact with other people. We know that hand-washing is a key intervention for outbreaks in hospital settings. It is almost a human right that you must be able to wash your hands after using the toilet. It is a straightforward as that. It is a core public health benefit.
[183] Mr Brereton: We have talked about facilities previously, but you need warm running water, soap and adequate hand-drying facilities; what you do not need is something that leaves your hands damp, because it puts you off washing them. There has to be something that dries your hands thoroughly as well, otherwise people will walk away with damp hands or avoid washing them.
[184] Dr Hayes: Transmission is more likely if you have damp hands; you want dry hands.
[185] Rebecca Evans: On a different subject, what are your views on the importance of joint working to address issues related to public toilets and public health across Government departments and health and local authorities, for example? Do you have any examples of good practice or poor practice and problems that might be relevant?
[186] Mr Brereton: As I said earlier, a strategic approach is needed. At the local authority provision level, you have to work with partners to provide facilities. I mentioned the 230 or so toilets provided under the community toilets scheme, which are toilets that, before that scheme was put in place, would not have been available to the public generally without buying something. That is a good example of partnership. Local authorities have other abilities to make toilets available for the use of the public. This could involve working with retail providers or with planners to achieve planning gains through section 106 agreements for the provision of toilets, or they could look at their own estate and make positive letting agreements whereby, if an authority lets premises that it owns to someone else, it could make it a condition that toilets are available to the public on those premises. There are lots of ways of doing this other than direct ownership. The public wants access to toilets, but does not necessarily care who owns them. It wants access to clean, safe, accessible toilets that are there when they need them and where they are needed. So, you have to look at all possible avenues to achieve that, and that involves partnership working—it has to. It involves more than just a statutory duty; it needs a strategic approach to provision that encompasses all partnership and best practice.
[187] Mark Drakeford: I would like to ask you a couple of questions about the leadership role of the Welsh Government in all of this, reflecting on your experience in other areas. Dr Hayes, it seems to me that the Welsh Government has a great deal of national information that it provides in relation to promoting independence, for example, or increasing rates of physical activity, and so on, and we have heard evidence throughout the morning of the way in which, if you suffer from certain conditions and there is inadequate supply of public toilets, your independence and your ability to get about and to lead an active life are compromised. However, we have no national guidance or national framework setting out expectations in relation to public toilet provision. Is there a case for the Welsh Government to explore the provision of a national statement of what would be required?
[188] Dr Hayes: A very clear case has been made this morning, has it not? There is a clear case for, at least, exploring the potential for national level action, but also stimulating local level action. That is very clear. Those working in public health would be very supportive of that.
[189] Mr Brereton: There is evidence of that in England—certainly from the Department for Communities and Local Government’s strategic guidance on the very same issue, which, although it acknowledges on the front that it was written for England, is also available for local authorities in Wales to look at, because the legislation is very similar, as is the good practice. However, we have looked at providing guidance in other areas. For example, for school toilets, I chaired a working group that developed good practice guidance following the E. coli inquiry. So, we have taken action in other areas and it is possible and practical to do it.
[190] Mark Drakeford: Building on that, we have heard different propositions this morning. We have heard the petitioners outline their belief that there should be a statutory duty, and that would be a way to do it; and we have heard suggestions that there might be other ways. That is, a strong framework or a strong sense of national standards being set could mean that you could achieve the desired outcome without necessarily requiring a duty to be imposed. Once again, thinking about your experience in analogous fields in public health, do you have any views or reflections on that?
11.30 a.m.
[191] Dr Hayes: My personal reflection is that we could approach this with a strategy that looks at the various roles of agencies and that fosters joint working. However, there is another element here, which is our relationship with the people. We have heard a great deal about the cultural issues—the fact that people do not want to mention problems and that it is a very secretive, personal issue. There is an added element here that we could explore of opening up the way in which people describe their problems, getting people to be more open about asking to use facilities and getting businesses more ready to make their facilities available. There is a pure public health element here that we need to build in at the same time as looking at what agencies can do.
[192] Mr Brereton: As I have said before, it would not be enough just to say to people that they have a duty to provide public toilets. You have to qualify that duty with guidance or regulation. In any event, you would end up with a form of guidance sitting behind the duty that talked about availability, accessibility and quality, not just mere provision. There will always be a need for strategic guidance—be it through regulation, advisory guidance or codes of practice—sitting behind any statutory duty. On whether there is a need for a statutory duty, all local authorities currently provide public toilets, but they do not provide them to the level and quality we would like to see.
[193] Mark Drakeford: There is one last question from me and then I will see whether there are any final questions from Members. On professional leadership, we have heard a great deal of evidence around the table this morning that this is a topic that does not get well discussed and that people are embarrassed about it and so on. Has there been a deficit of professional leadership in the public health field on this issue as well? Is this an issue that directors of public health throughout Wales ought to be speaking out about a bit more and taking more of a lead on by leading a public debate?
[194] Dr Hayes: I would say that this committee has helped to bring the issue to the fore. It is something we can take to the directors of public health to seek their views. This is an opportunity to prime them and to make a start, certainly at the informal end.
[195] Mr Brereton: From an environmental health perspective, the professional perspective on that would be that local authority environmental health officers are vetting plans every day for retail premises, restaurants and public houses as they are looking at licenses. This is a chance to remind them of the need to consider toilet provision as part of that. They are looking at that in terms of staff, but we have to widen that to ensure that it is looked at in terms of the public as well.
[196] Mark Drakeford: Looking round the table, I do not think that there are any further questions. As you said, you have managed to cover a great deal of the ground that appeared in your very helpful evidence, which I wish to thank you for as well. I know that it comes in the Minister’s name, but I am sure that you both had a significant hand in preparing it. It was very helpful evidence. Are there any final points that you would like to leave with us that we have not managed to ask you about?
[197] Dr Hayes: I simply wish to say that public health would be behind looking at this more fully. We are very supportive of it.
[198] Mark Drakeford: Excellent. Diolch yn fawr iawn. Thank you both very much indeed.
[199] That ends the oral evidence we are going to take on this issue this morning. However, before we move on from this item, I am going to put three propositions to Members. My first proposition—and I will see whether anyone dissents from this—is this: given that our purpose this morning was to test the public health claim made in the petition about the public provision of toilets to see whether it was borne out by the evidence we were to receive, and given the evidence we have heard this morning, the claim that there is a public health dimension to public toilet provision in Wales has been validated. Are we agreed on that? I see that we are.
[200] My second proposition relates to what we do as a result of the evidence we have heard this morning. The original petition went to this committee in relation to the public health dimension and has gone to the Communities, Equality and Local Government Committee in relation to the need for improved provision. Inevitably, a great deal of what we have heard this morning has been about the provision side as well. My proposition is that, as a result of what we have done this morning, we ought to write a letter to the Chair of that committee confirming that the work we have done underscores the public health case for better public toilet provision and saying that, as a result of the evidence we have heard, the case for that committee to go on to do some investigation into the provision side of things has been underscored.
[201] Alongside the letter, we can provide a summary of the evidence we have taken and some links they can use to look at that in more detail. We could copy that letter to the Minister for Health and Social Services, given that we have had evidence directly from her as well. Does anyone want to suggest a different course of action or modify that in any way? I see that Members are happy with that. Good; then that is what we will do as a result of today. I will circulate the letter for committee members to see, and once we have agreed it, we will publish it, and it will be available for the petitioners and others to see.
[202] Here is my third and final point: this is the first attempt that we have made to take a specific issue and give it a one-day focus. We have had approaches from a range of organisations saying that they believe that a one-day inquiry into a—
[203] Mick Antoniw: Chair, before you go on to that, I thought that the third proposition was going to be following on from this. With regard to your second proposition, it seems that it would be helpful if we expressed a slightly stronger view on certain issues that have arisen—for example, the need for some form of reinforced guidance or duty and the need for an all-Wales strategy, and so on I will not go into more detail, but it seems to me that those were two clear points, among one or two others, that we perhaps ought to be suggesting, rather than leaving it to them to come to a specific conclusion.
[204] Mark Drakeford: Certainly. What we have to do is find the right form of words to inform another committee that, in the area for which we have responsibility, we have come to a conclusion—we are satisfied that the public health case has been well made. However, we have also heard evidence that leads us to suggest there are serious issues that the other committee may want to consider. What we must be careful not to do is to not tell the other committee what to do or what to find. You are absolutely right that where we have heard evidence we think the other committee should know about we must ensure that our letter draws those things to its attention. We will try to find the right way of putting it. If, when the letter is circulated, there are other issuesyou think we ought to include in that way, I will be very pleased if anyone is able to make a contribution to the letter.
[205] We move on to my final point, which is to do with future inquiries of this sort and whether we should timetable them for the period between now and the summer. Here is my proposition: I think that this morning has worked well enough for us to at least consider whether we want to do one or two more one-day sessions. We could ask the clerk to prepare a note for us, for the next meeting or the one after, in which we can see the different topics that have been suggested by other organisations and by Members that might fit a one-day inquiry of this sort. We can provide a paragraph of what has been suggested, and then we could come to some decisions next time as to how many of these it is reasonable for us to try to schedule in, and then we would have to make some choices, I guess, between the different topics we can pursue. Are you happy to do that for next time? I see that you are. Excellent. That is a useful conclusion to today’s work and gives us something to build on for the future.
11.39 a.m.
Papurau i’w Nodi Papers to Note
[206] Mark Drakeford: We move on to item 5.
[207] Mae llythyr gan y Pwyllgor Plant a Phobl Ifanc wedi dod atom. Bydd y pwyllgor yn cynnal ymchwiliad i wasanaethau newydd-enedigol—mae hanner y maes ar ein hochr ni, a hanner ar eu hochr nhw. Mae gennym hefyd bapur yn sgîl ein sesiwn gyda swyddogion y Llywodraeth ynglŷn â’r Papur Gwyn rhoi organau.		We have had a letter from the Children and Young People Committee. The committee will be undertaking an inquiry into neonatal services—a field that is half on its side, and half on ours. We also have a paper following our session with Government officials regarding the organ donation White Paper.
[208] Rebecca, you have something you want to note as a result of that further information on organ donation.
[209] Rebecca Evans: I was grateful for annex A, which contained a list of the organisations whose attention was specifically drawn to the consultation. It seems that, on the whole, they were organisations that are either explicitly in favour of presumed consent or that represent voluntary health organisations, which is absolutely right. However, I am concerned that they have not specifically drawn it to the attention of the people who represent individuals on the fringes of society, who may be disenfranchised or disengaged, and whose informed consent might be difficult to establish. Those people include homeless people, rough sleepers, people with chaotic lifestyles and so on. So, I would like to hear the views of the voluntary sector organisations that represent those disenfranchised people to see whether they think we could presume the consent of the people they represent. However, I am not sure how we should take that forward.
[210] Mark Drakeford: Thank you for your comments. The first thing we should do is write to the Welsh Government asking what steps it has taken to consult hard-to-reach groups of people. We heard from officials when they were here that the consultation will not simply stop at the end of this round and that they intend to do further work once they have analysed the consultation responses. So, there may be scope for us to nudge them in that direction if we feel that they have not done enough already.
[211] Kirsty Williams: Please forgive me, because I was not present for that briefing, but I think that people in significant parts of Wales would find it difficult to get to the places where the public meetings listed here are to be held, so it is a poor way of consulting. So, I was just wondering whether I have missed—
[212] Elin Jones: There have been more meetings.
[213] Mark Drakeford: Yes, there have been many more meetings, but these are the remaining ones. We have had a list of the ones that had already taken place, which was certainly much longer. However, I do not know whether seeing that longer list would answer your point.
[214] Kirsty Williams: To back up Rebecca’s point, there is a significant leaning in one direction with regard to whose attention was specifically drawn to these issues. There is a group of people for whom presumed consent would be difficult to establish, and there are also legitimate voices on the other side of the argument, faith groups and others, but I notice that they are not the kind of groups whose attention has been specifically drawn to the consultation—although they are probably aware of it now. It is hardly balanced.
[215] Mark Drakeford: Yes, that does reinforce Rebecca’s point. You will remember that we have already agreed to have a further oral session with the senior officials who came before us the first time, so that they can report to us on how the consultation was conducted and what sort of responses they have had, how they are going about analysing them and what they intend to do as next steps once the analysis is concluded. So, we will have a chance to explore these things with them orally, but, in advance of that, and so that they are aware of the concerns that have been expressed, are you happy for us to write to them asking exactly these questions about what steps have been taken to consult harder-to-reach people?
[216] Lynne Neagle: Perhaps we should also ask about ethnic minority groups, given that they were flagged up but that nothing much has been done about it. There are no such organisations on that list.
[217] Mark Drakeford: Thank you for that, too. As you say, we asked specifically about that issue, because we know that there are issues to do with ethnicity in the organ donation field. We will write to them so that they know of our concerns before they come to talk to us and so that they can tell us about any steps they have taken and intend to take to address those issues.
[218] That is it for today. Thank you all for your contributions. We will meet again on Wednesday next week, when we will start with a brief return to a topic that we have looked at once already, which is how we are to pursue our responsibilities in the European dimension of the committee’s work. However, the main purpose of the next session is to have our general scrutiny of the Minister for Health and Social Services. We have already indicated to her some of the areas we want to pursue, but we will also be able to ask her anything that we like within her responsibilities. Thank you very much.
Daeth y cyfarfod i ben am 11.44 a.m. The meeting ended at 11.44 a.m.