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We all take going to the toilet in private for granted - it is a marker of a civilised society. So why, in care settings should our expectations change?

As reported in the November 2006 issue of the Newsletter), a multi-agency campaign led by the BGS and including Age Concern England, the Department of Geriatric Medicine at Cardiff University, Carers UK, Continence Foundation, Help the Aged, Incontact and the Royal College of Nursing, has chosen toilet access and use behind closed doors as a marker of human rights and dignity. The campaign, launched at the House of Lords on 18 April, aims to empower and inform older people about their human rights in this area while educating and influencing care providers and policy makers. By focusing on a taboo subject, we will enable older people to have a better experience in hospitals and care homes. The WASH YOUR HANDS campaign has already demonstrated that there is potential to improve clinical practice with a simple message.

The NHS has changed dramatically over the last few years and older people have seen the benefits and advantages, as well as the disadvantages and weaknesses of provision. The need to meet targets such as the waiting list initiative and four hour trolley waits, while helping older people, has meant that statistics rather than quality of care has driven the NHS. Despite the recognition of their importance in the NHS Plan and the NHS National Service Framework for Older People, processing older patients fast often results in being careless of their dignity and humanity.

Two thirds of people admitted to hospital are aged over 65, many of whom may suffer from physical and cognitive impairment as well as other co-morbidities. The numbers of older people aged over 80, those most likely to be frail and require hospital admission, is predicted to increase by two thirds by 2026. The dependency of older people in hospitals and care homes requires and will increasingly require staff with appropriate skills and behaviours to provide personal care in a sensitive and respectful manner. Yet The Royal College of Physicians National Continence Audit 2 found that few hospitals had identified that they need to do better in privacy and dignity during toileting.

Respecting rights together
The need to provide services in hospital and care homes, which respect and promote older people’s human rights and dignity, is fundamental and has been recognised by the Department of Health’s publication, ‘A New Ambition for Old Age’. This described how some staff still demonstrate deep-rooted negative attitudes and behaviour towards older people.

In our Behind Closed Doors campaign, we aim to achieve a change of culture at every level by not only making older people and their carers aware of their rights, but by ensuring that designers and architects are aware of the importance of sensitive design. Hospital and care home staff will be encouraged to adopt the Behind Closed Doors standard through review of practice and the implementation of change. Hospital and care home managers need to understand that dignity and human rights should be part of the organisational culture and integrate the standards into appraisals. Training programmes should highlight these issues and the views of patients and carers should be sought. Policy makers and regulators will be encouraged to adopt and promote our standards. Our campaign aims to make both the public and patients aware of their rights, to use the audit tools and to lobby for improvements.

The campaign leaflet highlights bad practice such as:

• Ignoring request for assistance to go to the toilet
• Telling people to wait
• Telling people to use incontinence pads
• Insisting people use commodes or bed pans when they could be taken to the toilet
• Not offering choice
• Scolding or humiliating incontinent patients
• Entering closed curtains without ensuring that the patient is not engaged in toileting
• Leaving people on bed pans and commodes for unneccesarily long periods
• Not offering hand washing facilities
• Leaving people in full view when using the toilet
• Leaving people on commodes during meal times
• Using safety as a reason to deny choice.

Best practice should ensure that toilets are adjacent to patient areas and easily accessible as well as being clean and well sign posted, with doors that close. Assessment of toileting needs must include a record of personal choice and preference. Hoists must protect modesty. Staff should respond to requests for assistance promptly and politely and toileting facilities should be proactively offered. If a patient has to go to the toilet behind a curtain or next to a hospital bed, curtains must be fully closed and a notice should be used explaining that personal care is in progress and must not be disturbed.

Following standards
Our standards document states that all people, whatever their age and physical ability should be able to use the toilet in private and that there should be sufficient toilets and equipment to achieve this. People should not be left on bedpans or commodes for longer than necessary. Suitable equipment for transferring should be available and should be used respecting dignity, privacy and modesty.

Lavatories must be clean and patients should be able to wash their hands as well as their bottoms. Language should be respectful and courteous especially in regards to episodes of incontinence.

Our decision aid will enable staff to work with patients in a more thoughtful manner to ensure that their toileting needs are met according to their level of impairment and illness and that their dignity, modesty and privacy are met at all times. Lay people are to be encouraged to use our environmental audit which includes: the width of the door, whether the door can be opened, shut or locked, how well the toilet flushes, the accessibility of toilet paper, washing facilities and general hygiene and cleanliness.

We hope to influence older people’s fora, older people’s champions, community health councils (Wales), educators in all education and training programmes, advocacy and patient support groups, carers’ groups, Royal Colleges and Patients’ Associations. Wide dissemination of our educational leaflets, decision aides, standards and check lists to voluntary groups, patient and carer groups as well as to care staff, will make older people in hospitals and care homes aware of what they should expect. Giving people back control over their most private of functions should enhance their independence and rehabilitation and thus reduce lengths of stay and promote continence. The campaign emphasises the importance of the environment, as well as care practices and will help in the future commissioning of facilities. It will provide commissioners, chief executives and inspectors a measure of good practice and clinical governance.

The primary focus of the campaign is on people receiving care but it must be emphasised that if care staff are to be able to respond to others in a dignified manner, then they too must be treated with dignity. The campaign has produced the following to inform people (all available on the BGS website or in hard copy, from the BGS Office):

(a) The Behind Closed Doors leaflet
(b) Decision aid
(c) Lay person’s tool to perform an environmental audit of the toilets in a care setting
(d) Behind Closed Doors standards
(e) Action Plan.

It is hoped that the campaign will help present and future generations of frail and vulnerable older people to be aware of their rights. It is part of a continuing battle to make the public and the professionals aware that sensitive and humane care is a part of effective care and can never be sacrificed in the name of efficiency and safety.

Jacky Morris
Chairman
BGS Policy Committee