Paying for water. John Middleton and Pat Saunders. Summary. Environmental challenges andrisks to safe water. Introduction

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1 Journal of Public Health Medicine Vol. 19, No. 1, pp Printed in Great Britain Paying for water John Middleton and Pat Saunders Summary Water has been taken for granted as an essential public health need since the Victorian sanitary revolution. Water has come back on to the public health agenda in the United Kingdom because of recent policy changes and their untoward environmental and social impacts; along with water privatization and tough new environmental directives, there have been serious water pollution incidents, water shortages, water debt and disconnection. Along with concern about protecting individual rights to a clean safe water supply, there is concern about the ability of national water resources to meet all our communities' needs, without unacceptable environmental damage. A national plan is needed for the conservation of water and protection of water resources and the environment; adequate central funds are needed to see that this happens. There should be greater emphasis on local water management and a key role for local authorities; there should be fair pricing, protection of water supplies for the poorest and most vulnerable, and a ban on water disconnection to domestic users, on public health grounds. More research is needed into the potential adverse health impact of people on prepayment meters disconnecting themselves. There is a place for water metering as the most rapidly deliverable means of controlling peak demand, reducing overall consumption and avoiding a largescale environmentally damaging solution to supply more water. However, control of leakage offers the largest potential saving and is the most costeffective means to protect existing water supply. We question whether private water companies, geared to maximizing profit and share dividends, can deliver a national plan for the protection and management of water resources, for the good of the environment and future generations. The public health lobby must become more actively engaged in the debate about the supply, protection and price of our most precious public health asset water. Keywords: water, sustainability, environment, disconnection, pricing Introduction Water has come back on to the UK public health agenda. Most of the controversy has arisen with privatization and has centred on price and ability to pay. Pricing is in part determined by the public health need to deliver a water supply which is safe for human consumption but which does not damage the environment and ecosystems. Concern has been expressed about maintenance of water quality standards and protection from pollutants, the possible health consequences of disconnection of the vulnerable and poor through inability to pay and, most crucially, the protection of water supplies to whole communities, as in recent cases in Yorkshire and Northumbria. 1 "" Water cannot be taken for granted as a public health good. Water has been priced for centuries. Water carriers charged a farthing for a bucket in the sixteenth century. Safe and wholesome water is not simply a gift from above and neither does it come free. Only three per cent of the Earth's water is available as fresh water, 97 per cent is seawater. Most of the freshwater is unavailable as the polar ice caps or as prohibitively deep ground water. Human consumption is only a minor part of the water cycle. Human manipulation of water within the water cycle includes consumption, catchment, distribution and treatment. The raising and piping of adequate supplies of water and the movement and treatment of waste involves some of the most demanding engineering and scientific skills. 12 Environmental challenges andrisks to safe water If water is underpriced overexploitation will occur. This has been seen in numerous irrigation schemes around the world. 13 The river Po in Italy runs almost dry in many places owing to the 18 billion m 3 taken for intensive farming. 14 Overexploitation of ground water can lead to salination of supplies, to concentration of pollutants and to soil erosion. 13 ' 14 Ground water can pick up contamination from the soil and rocks it passes through, and runoff from industrial and agricultural land can contaminate water with healthrelated inorganic and organic chemicals, fertilizers, pesticides, etc. Human activity is affecting the water cycle in other ways. Air pollutants, such as oxides of sulphur and nitrogen, become dissolved in rain, producing increased water acidity and acid rain (see Fig. I 13 ). Eutrophication can result in algal blooms and the effective death of aquatic systems. Pharmaceuticals and veterinary products Sandwell Health Authority, Lewisham Street, West Bromwich, West Midlands B71 4NA. John Middleton, Director of Public Health West Midlands Institute of Public and Environmental Health, Medical School, Birmingham. Pat Saunders, Regional Environmental Health Advisor Address correspondence to Dr J. Middleton. This paper was commissioned by the Editors. Oxford University Press 1997

2 PAYING FOR WATER 107 can pass from waste water into drinking supplies. Lead, iron and copper can reach aesthetically and health significant levels in drinking water as they dissolve from distribution pipework or fittings. Add to this the prospect of accidental contamination such as tanker spillage or sabotage, and the potential for chemical contamination is considerable. Waste water needs to be collected and treated, and compliance with the standards imposed by the European Union will cost the water industry billions of pounds. Faecal contamination of drinking water can introduce a range of pathogenic organisms bacterial, viral and parasitic. Even treated water cannot be sterile and many distribution systems will be lined with a microscopic biological film which can be sloughed off and can support grazing nuisance organisms such as Ascellus. 1 ' 12 ' 16 The options for meeting increases in demand each carry environmental risks; new reservoirs, river diversion schemes Renewable resource: rainfall (equivalent to 900mm depth of water across the county, p.a.) 900mm p.a. 440mm (49%) 260mm (29%) <" 150mm (16%) L 50mm (6%) Water returns to the sea via; More development Loss of water quantity Loss of water quality: residential and commercial uses Abstraction and enhanced groundwater schemes all pose risks of altering ecosystems and damaging environments, sometimes in unpredictable ways. 17 Most drinking water quality standards are based on consumption of 2 litres per day. Severn Trent Water pic supplies 2082 megalitres per day to about 7.2 million people in the Midlands, which means that each person is supplied with 300 litres each day. Even when the needs of industry are taken into account, individuals are clearly using far more water than they need to stay alive; all of this water has been subjected to the same rigorous treatment as the water that we drink. It makes considerable environmental sense to reduce consumption and consume appropriate quality water. Pricing is a necessary and effective tool in controlling use of water. The question is not therefore 'Is there a need to pay for water?' but rather 'who pays how much, determined by whom, and with what consequences?' New surface water drainage systems, and loss of soil and vegetation reduce evaporation and transpiration 1 ^ ^^ Water returns to the atmosphere by: I I I I Evaporation Transpiration J o Aquifer recharge toes o( permeable surfaces: more paving o River maintenance surface drainage from impermeable ground increases demand decreases Infiltration increases runoff Increased poluttonof waterways by waste water pollution of aquifer by contamination, leaching and salinatjon (NB rising sea levels) Air pollution affects the quafity of rainwater e.g. acid rain from the sea pollution by runoff from car parks (obs); runoff from farmland causing eulrophfcatfon, loss of water ecology, from river Imp rovem ants' Increased hazard: uncontrolled discharges land subsidence, soil shrinkage, changing underground drainage Increased risk of flood, exacerbated by loss of floodplalns Figure 1 The effects of development on the water cycle. Source: Ref. 15.

3 108 JOURNAL OF PUBLIC HEALTH MEDICINE Political and social issues in paying for water; public perceptions and suspicions Water privatization How much, and how, people should pay for their water generates much controversy. The first reason for this controversy is the adverse public perception that water privatization and water companies have created. 910 The industry is one of the most capitalintensive industries in the country. The industry has a massive investment programme and continues to achieve a generally satisfactory standard of safe and wholesome water for human consumption, and the industry still suffers from a longterm lack of investment from its public sector days. The public view water as an essential natural resource that should not be in the marketplace; there have been public relations mistakes made by the companies, large increases in executive and shareholder payouts at the same time as substantial increases in bills, water worker redundancies and no apparent improvement in service (it is impossible for a consumer to recognize nonaesthetic quality improvements). 9 ' 10 The biggest single consequence of privatization, experienced by all water users, has been a massive increase in water bills: a 67 per cent increase between 1990 and Company profits rose by 20 per cent per year from to and profit margins rose from 28.7 per cent to 35.6 per cent.' 18 Water disconnection and debt The second reason paying for water is so contentious is the disconnection of people who cannot pay, and water debt Disconnections of domestic supply rose sharply after privatization in 1989 to a peak of in The rate of disconnection has since fallen, with households disconnected in This still represents a large section of the community (who are often stressed in other ways) being denied a basic public health requisite. 5 Water companies can also pursue debts through the courts and obtain attachments of earnings and distrainl At the moment, some vulnerable groups have their water bills paid in full (e.g. dialysis patients), and it is clear that some companies can manage their business profitably without regular resort to disconnection. However, some companies clearly wish to keep disconnection as the final sanction even though the people disconnected are 'can't pays' rather than 'won't pays'. 19 Water disconnection remains illegal in Scotland and Northern Ireland. Water poverty The figures also disguise the real extent of 'water poverty'. As companies become more willing to use disconnection, people resort to juggling their debts or depriving themselves of other essentials to avoid disconnection More than one million households were behind with their water payments at the end of 1994; a year when nearly two million households defaulted on their bills. Between 1993 and 1994, more than three million presummons notices were issued by the water companies in England and Wales. 19 Thesefiguresrepresentedan increase of 900 per cent between 1990 and There was also significant variation between companies, in disconnection and water debt. The differences in disconnection rates could not be explained simply by the variation in water debt and appear to be related to company policy, whereas differences in debt levels seem to be related to the circumstances of the consumer. Water debt is more common in lowincome households, with a particular problem amongst unemployed people. Family consumption also has an impact, with debt being more of a problem the greater the number of children in the home. Poor families with children, and in particular single parents, have a significant risk of water debt. Council tenants are more likely than homeowners to have an increased risk of water debt. The difficulty faced in balancing household budgets is illustrated by the fact that most people in water debt had also been in arrears with bills but not on credit cards, suggested that poverty is more important than overcommitmenl Collecting the payments There are other less obvious, but important reasons, for water debt. Following privatization, most councils stopped collecting water rates with rents on a weekly basis, on behalf of the water authorities; many tenants were faced with large, unexpected, yearly or halfyear bills, which they could not pay. Changes in the social security system also had an impact. Before 1988, people on supplementary benefit had their water bills paid. Subsequently, a notional amount had been included in income support to cover water bills. Not only were many poor people now faced with paying a large bill for the first time but the amount included in income support did not reflect the real cost of water. This was particularly acute in those regions where charges were high, as the amount included in benefit was calculated nationally. 18 " 20 People receiving benefit may have regular deductions made directly from their benefit, which can help budgeting, but there is a limit on how much can be allocated; furthermore, housing, gas and electricity take priority over water, with the result that many are denied this facility. 20 In , requests for direct payments were refused by the Benefits Agency. The direct debit system is increasing in popularity, with households using it by However, people without bank accounts, predominantly pensioners and households earning less than 150 per week, are unable to use this system. Some vulnerable groups can ask social services departments to intervene on their behalf. Many were unaware of this and were disconnected before getting any support.

4 PAYING FOR WATER 109 Metering the social consequences Metering is one of the payment options being explored by water companies, as they must move away from the current system based on charges on rateable value by the year Charging for water use is proposed on grounds of environmental sustainability, but it creates inequality in implementation and its effectiveness is questionable. In a study of a Bradford housing estate with new metered properties and older council properties, large families paid much more in metered households than under the old system. 21 Water bills for all the metered households were up to twice those in comparable nonmetered households. In one case, the household bill for a large family was 3.5 times greater ( 260 per year) than it would have been under the rateable value system. Vulnerable groups tried to reduce consumption in ways which threatened their personal hygiene and the public health by sharing baths, cutting down on washing and not flushing toilets. 21 The Office of Water Services (OFWAT) believes metering offers families a choice about how to pay their bills and an opportunity to reduce their costs. In OFWAT's metering study, in which higher social classes were overrepresented, 41 per cent of households did not reduce water use; 91 per cent of metered households had no difficulty paying bills, 31 per cent felt they paid less, 36 per cent felt they paid more, but 65 per cent said they did not worry about their bills. 22 The study was undertaken to demonstrate that fears about water rationing were unfounded, that metering offered families a choice about how to pay their bills and an opportunity to reduce their costs. A small but significant minority of vulnerable families in significant hardship did cut back on water use and compromise their personal hygiene and persona] health needs. Metering disproportionately affects large households and people on state benefits. 22 ' 23 Prepayment systems Prepayment systems are also being piloted by a number of companies. Customers pay for their water in advance using a card that is charged at shops, post offices or water company offices. Most trials have shown customer enthusiasm for this system, presumably as it is a form of regular payment. However, concerns have been expressed about the dangers of selfdisconnection, where customers allow their credit to run out; one study showed that one in ten customers with prepayment devices selfdisconnected for more than 24 hours, far higher than for those on other payment systems. 24 A recent study by Save the Children Fund confirms fears that hygiene standards were sometimes not maintained by people on low incomes in metered households. 23 However, a recent study did not find increased rates of notified disease in metered water areas. 25 It seems that the key factors in people being able to pay their water bills are the level of the bill and the frequency of the payment method. The water companies, 26 and most consumer and health lobby groups, are opposed to metering. 4 " 3 ' 21 ' 23 They believe payment based on property values is easy and cheap to administer, more fairly reflects ability to pay and closely enough reflects level of use. OFWAT and the National Rivers Authority, now part of the Environmental Agency, favour volumetric metering. 27 " 29 Environmental solutions to controlling the cost and supply of water are considered in greater detail later in this paper. Public health concerns The British Medical Association, 4 the Faculty of Public Health Medicine, 30 the Chartered Institute of Environmental Health Officers 31 and The Lancet 5 have all supported calls for water disconnection to be made illegal in England and Wales as it is in Scotland and Northern Ireland. The public health lobby has argued from first principles that clean water is an essential public health need and a health right. Clear evidence of a causal relationship between water disconnection and the dysentery and hepatitis A epidemics which occurred at the same time was not forthcoming. The one published study found no evidence linking disconnection with notified hepatitis A and shigella. It suggested that any association was an effect of poverty and was more strongly predicted by other indicators of social deprivation. 32 " 33 A small study of disconnected households found unreported health problems and suggested that people in disconnected households were less likely to be identified by health systems. 34 " 35 In Sandwell, despite massive action by welfare rights workers, councillors, citizens' advice workers, community groups and public health officials, not one case of water disconnection was reported by a health visitor or general practitioner. A cohort study of disconnected households would have been necessary to plot untoward health effects but would arguably have been unethical, knowing that depriving people of water is incompatible with life. A casecontrol method comparing disconnected with supplied controls might have been possible and ethical but would have been fraught with methodological difficulties. Water is vital to disrupting the chain of persontoperson spread infection; there is no need for a definitive study arising from a grand experiment in social policy. 5 We know that lack of water is bad for public health. In addition, lack of water is bad for personal health protection. People on dialysis, people who are bedridden, people with arthritic conditions, incontinence or skin conditions requiring cleaning pre or posttreatment, and families with young children, have high water demand. The consequences of disconnection were explored by Dr. Chris White in evidence to the public enquiry on the application for drought orders by Yorkshire Water. In the case of the Yorkshire drought order, the public health consequences in gastrointestinal disease were more likely because of reduced availability of water and because of possible contamination through ingress of foul water and other pollutants following lowpressure supply or depressurization. 6 " 10

5 no JOURNAL OF PUBLIC HEALTH MEDICINE 500i* RuS8ia Effect of metering 1 Italy* Denmark' Belgium* France metered Water price as % erf disposable Income Figure 2 Water consumption vs disposable income in countries with metered and nonmetered supply. Source: Ref. 33. Environmental considerations and future supply Questions about paying for water are inextricably linked to the ability of the water system to meet and control demand. This in turn is tied to major environmental strategy. The National Rivers Authority strategy for a sustainable water supply considers three scenarios for demand over the next 30 years. 17 There is a current surplus of water available. A low demand scenario envisages a 2 per cent average growth in domestic demand per year, for the period , with no increase in industrial and agricultural demand, improved leakage management and moderate growth in metering, giving no shortfall in supply. A medium demand scenario assumes moderate growth in domestic and nondomestic usage, and limited domestic metering and leakage control, leading to a shortfall of 142 Ml/day. The high demand scenario assumes high rates of growth of demand and little leakage control or metering, leading to a shortfall of llloml/d. The strategy suggests that local schemes may allow demand to be met up to the low demand scenario. Schemes would include increased use of groundwater where industrial use has declined, for example, in Birmingham and Shropshire. The major environmental options needed to meet high demand are: (1) a SevernTrent diversion; (2) a SevernThames diversion; (3) a SevernThames diversion and diversion towards the Severn of waters from Vyrynwy reservoir, (4) a South Oxfordshire reservoir. The NRA believes the canal system could support small local extra supply needs of the order of 50 Ml/day. It did not consider the canal network could support major new water supply of the magnitude necessary to meet a medium or high demand. The NRA suggested that infrastructure requirements to use the canal network for extraction would be expensive, including headwater supply collection, distribution Austria 1% and purification. This view is not shared by British Waterways, who believes additional extraction of up to 150 Ml/day is readily possible. 36 The pumping of water along the canal network is also possible. The NRA believes the medium demand scenario is the most likely. Water companies are currently planning for between low and medium demand, and the high demand cannot be ruled out. NRA strategy believes major environmentally invasive projects can be avoided if demand can be managed at the low to medium levels. The NRA strategy requires water companies to pursue aggressive demand management through metering, particularly in the south and east, and through leakage control. Water companies' record on leakage is poor, with an averagefigureof 22 per cent loss estimated and a high of 40 per cent for companies such as Yorkshire Water. Identification of leakages is not as straightforward technically as it sounds many leaks are unidentifiable, buried deep underground in older pipelines which may not be fully mapped. Victorian reservoir dams have leaked in Yorkshire since they were built. 10 In the short term, leakage repair may not yield the savings needed to keep demand low to medium. For this reason, the NRA and the Government place their faith in metering. The NRA says metering has been shown to reduce water consumption in studies in the south east and in the Isle of Wight, where per capita consumption was reduced by 21.3 per cent Metering has a particular benefit in reducing demand at peak times; 70 per cent domestic meterage would postpone the requirement for a new water source for 13 years based on average demands; but would postpone a new source requirement indefinitely, based on peak demands. l7>29 The NRA believes safeguards for lowincome families are possible. It advocates a low standing charge and a basic rate for a water supply which constitutes a 'lifeline allowance' or

6 PAYING FOR WATER 111 Table 1 Demand management options (England and Wales) in order of water saving potential 33 Demand management option Saving S&E Saving N&W Total Leakage control Domestic recycling Domestic metering Low flush WCs Option 3 Shower installation Efficient washing machines Controllers on unnals Lowvolume shower heads Total (820) 'public health allowance' set at about 90100m 3 /year. Costs above this should rise steeply to cover nonessential uses such as gardening. This approach has been adopted in the Unites States and by some UK water companies. The NRA also questions the need for and the level of the charge some companies have made for meters at property boundaries compared with 50 for internal meters. Meters are being installed free by some companies. The customer can have indicative bills based on the metered and unmetered rate and make a choice in using the meter. International comparisons suggest that metering does reduce the per capita consumption; metering was introduced in Germany in the early 1980s and has resulted in static demand for over ten years. However, the price of water relative to disposable income is the major contributor to reducing consumption (see Fig. 2) (460) (1280) Water conservation measures Tables 1 and 2 show NRA estimates of water saving potential from some demand management options. Leakage control offers the most potential water saving and is the third most cost effective. Metering offers the third largest saving and is sixth most cost effective. The Government's proposed action on water conservation is set out in Table 3. The Government rejects legislative and regulatory means to reduce water consumption and prevent leakage, except for those appliances and practices which are still part of water bylaw review. It has no plans for restricting industrial effluent to encourage efficient water use (as applies in Germany, France and the Netherlands). It supports only voluntary demonstration projects through the environmental technology best practice initiative. Requirements for metering by the year 2000 Table 2 Demand management options in order of cost effectiveness (excluding environmental costs and benefits) 33 Demand management option Efficient washing machines Controllers on urinals Leakage control Low flush WCs Option 3 Low flush WCs Option 1 Domestic metering (universal) Shower installation Lowvolume shower heads Low flush WCs Option 2 Domestic recycling (existing WCs) Domestic recycling (following WC Option 3) Demand management costs (p/m 3 ) Ratio to resource development costs Low High Cumulative savings S&E N&W Total

7 112 JOURNAL OF PUBLIC HEALTH MEDICINE Table 3 Summary of government measures in water conservation: government action Efficient use of water 0) Additions to the Environment Act 1995: (a) DG powers to: require companies to achieve overall standards of performance; give water companies a duty to promote efficient use of water supplied to customers (ii) Publish a consultation paper on abstraction charging, (iii) NRA and OFWAT to monitor reductions in leakage. (iv) Consideration of economics of replacing waterusing appliances with lowvolume models before developing new resources, (v) Promotion of efficient use of water in industry through DoEDTI Environmental Technology Best Practice Programme (FTBPP) (Waste Minimization). 2. Regulation (vi) Revised Water Bylaws in 1997 with review of (a) reduced volume WCs, low water use dishwashers and washing machines; (b) lowvolume shower heads; (c) waste from unvented hot water systems, (d) waterless sanitary conveniences; (e) inspection and enforcement. (vii) NRA powers to control effluent discharges to the environment are considered sufficient. 3. Water fittings (viii) Review of flow rate for showers in Bylaws. (ix) Shower manufacturers to give information on water consumption. (x) There will be no grants for replacement low flush WCs. (xi) Garden hose manufacturers to promote springloaded tngger mechanism. (xii) Dissemination of cost benefits of tap rewashering and urinal flush controls and consider for bylaws. 4. Metering and charging (xiii) Water companies to install meters and meter boxes when communication or service pipes are replaced. (xiv) Water companies to identify environmental benefits of metering for inclusion in abstraction licence applications to NRA (xv) No change to DG powers over water company charging schemes. (xvi) Guidance to local authorities and housing associations on water efficient housing. (xvii) Statute will be amended to continue rateable value charging beyond (xvni) Council tax banding information will not be provided as a basis for water charging. (xix) Water companies to progress shared metering reading systems. are being relaxed. Responsibility for water efficiency is laid on individual householders, private industry and local government, with no powers nor additional resources to make water conservation happen. Local Agenda 21, land use planning and local water conservation: a role for local authorities Following sustainability principles, much greater emphasis should be placed on local measures to protect water supplies, to capture water and avoid waste. 13 " 15 ' 37 ' 38 There is a major role for local authorities; Fig. 3 shows some of the means through which town planning and building regulation can promote local use of grey water and protect local runoff. Commercial domestic rainwater collection systems are available. 29 Commercial drycomposting toilets are highly effective, with no water requirement and fertile compost as a byproduct. 39 Community enterprises could be encouraged to undertake water audits undertaking modifications to toilet flushes, leaking taps and shower installations, and encouraging grey water uses fitting water butts and other rainwater collecting systems to provide water for washing machines, toilet flushes and car washes. Local authorities could look at lowcost schemes or grants to their own mediumsized enterprises such as schools, residential homes, office blocks, parks and leisure centres, and public conveniences to promote water conservation, tied to cashreleasing savings over planned periods. Health services, as major landlords, users of water and public health authorities can also play a significant role in reducing water consumption. An Audit Commission study of 200 NHS hospitals estimated preventable wastage through leakage and misuse of 10 million per year. Low water usage, lowenergy health service facilities are now under construction. 29 Such local recycling schemes may appear fanciful on a large scale. However, minimal pipedwater housing design is practicable and examples have been built around the country. 40 Water a precious resource During the Worcester pollution incident, large numbers of water bowsers were deployed in one small area. Any larger

8 PAYING FOR WATER 113 White watof reduce consumption of water of drinking quality Black water onsite/local treatment of foul water Gray water recycling of waste water, collection and storage of rainwater (for irrigation, car washing, eta) ~p Surface water tosoakaways paving: minimum area, absorbent Swales and filter stripe earthworks for improved filtration avoiding landscape needing irrigation In summer wildlife habitat conserved Detention and holding basins Natural drainage Land Use Planning to reduce polnt/nonpoint source pollution Figure 3 Watersensitive planning (avoiding endofpipe solutions). Source: Ref. 15. pollution incident would create enormous difficulties securing alternative water supplies (Severn Trent, personal communication). Only local solutions would be immune to serious incidents of pollution or sabotage. Most of the water supply of our wet island is brittle. Availability of water per person is less than for many more arid countries. 29 The battle to convince the public that clean water is necessary for their health may be long won. The battle to protect their right to that water is still with us; and the battle to protect the water supply needs to be rejoined as a public health and environmental issue. Managing water the authors' view for debate If the present system continues, large numbers of people will continue to fall into debt and/or be disconnected, a disproportionate number of whom will be poor and already more prone to illhealth. New methods of payment will work against vulnerable groups, who may well disconnect themselves. More research is needed into the health impact of prepayment meters. Disconnection of domestic water supplies by water companies should be made illegal. Water needs to be paid for but people should not suffer as a result. More frequent payment methods and extending the categories of people entitled to having their bills paid in full, reducing the levels of water debt and ensuring that future payment methods adequately protect people from such debt are real public health issues and should be the basis of discussions between the water companies and the public health community. There is a place for water metering; indeed, it is essential if local water conservation and capture is to develop to protect

9 114 JOURNAL OF PUBLIC HEALTH MEDICINE water supplies for future generations. It is also essential if people are to gain an appreciation of the cost of water and keep demand for water at levels which do not outstrip supply and lead to a need for huge environmentally damaging water projects. Water metering should be introduced with comparable average charges for metered and nonmetered households and with a very low essential use tariff; so far, not all water companies have taken on this message. Metering offers the most immediate means to control peak demand and reduce usage, but control of leakage offers the greatest potential water saving and is more cost effective than metering. Leakage targets should be pursued vigorously. In the longer term, the protection of water supplies is at stake. Massive ecologically damaging schemes to provide new sources of water are not an option. Local capture and protection of supplies is needed along with careful husbandry of the water in our pipes. Local authorities need to be given a much stronger role in water management and they need to understand the importance of this role. Additional central funds are needed to make local water conservation a reality. We question whether we can continue to allow funds desperately needed to protect and improve our water infrastructure to be given to water company shareholders and directors. It appears unlikely that any UK government will renationalize the water industry. However, greater regulation is needed, leading to greater commitment of funds towards water management and less into private pockets. Water companies must be forced to see themselves as water management and not water consumption enterprises. Far more local control needs to be exercised over water resources and water management Even if we do not have a national service, we need a national plan to protect, supply and manage our most precious public health asset water. Acknowledgements We would like to thank David Kay (Professor of Environmental Science, Centre for Environment and Health, Leeds University) and Dr Chris Worth (Director of Public Health for West Yorkshire), for helpful references and comments on the draft paper. We also thank Duncan Mara (Professor of Civil Engineering, Leeds University), Dr Peter Herbertson (scientist, NRA/Environmental Agency), Linda Thomas (the Centre for Alternative Technology, Machynlleth) and Dr John Taylor (British Waterways), for helpful comments and references. We thank Dr Richard Guise (Faculty of the Built Environment, the University of the West of England), and the Local Government Management Board, for permission to use illustrations from Ref. 15. We also thank Dr Herbertson for permission to use tables and figures from Refs 17 and 29. (Thanks are due to Professor Milner for his patience and encouragement.) The views expressed are those of the authors alone. References 1 Public Health Alliance. Water: wholesome, clean, affordable. Birmingham: Public Health Alliance, Johnson W. The privatisation of public health. Radical Commun Med 1986; 25: Lonsdale S. Slum diseases rise. The Observer April British Medical Association Board of Science and Education. Water a vital resource. London: BMA Publications, Editorial. No need for a dry run. Lancet 1994; 344: West Yorkshire Health Authority. Evidence to the Department of the Environment public enquiry, Dewsbury Town Hall, 14 November Rofe BH, Hampson E. Yorkshire Water drought orders 1995: independent assessment report. London: Department of the Environment, September Second assessment report. London: Department of the Environment, November National Rivers Authority. Measures to safeguard public water supplies: a second report to the Secretary of State for the Environment on the drought of London: National Rivers Authority, Wainwright M. Water rota cuts may close schools. The Guardian 21 September 1995: Wainwright M. The dry and the mighty. The Guardian (Supplement) 14 November 1995: Caiman K. Issues to be addressed to protect public health during cuts in water supplies. Letter to Directors of Public Health. London: Department of Health, 28 June BartyKing H. Water: the book. London: Quiller Press, Postel S. Last oasis: facing water scarcity. New York: Norton, United Nations. Earth summit 1992: the United Nations conference on environment and development. Rio de Janeiro: Regency Press, Barton H, Davis G, Guise R. Sustainable settlements: a guide for planners, designers and developers. Bristol: University of the West of England; Luton: Local Government Management Board, Potelon JL. Protection of water sources. Local authorities, environment and health series, No. 4. Copenhagen: WHO Regional Office for Europe, National Rivers Authority. Water: nature's precious resource. An environmentally sustainable water resources strategy for England and Wales. London: HMSO, National Consumer Council. Water price controls: key consumer concerns. London: National Consumer Council, 1994.

10 PAYING FOR WATER Herbert A, Kempson E. Water debt and disconnection. London: Policy Studies Institute, Berthoud R, Kempson E. Credit and debt. London: Policy Studies Institute and Joseph Rowntree Foundation, McNeish D. Liquid gold: the cost of water in the nineties. Ilford: Barnardos Publicity Services, Office of Water Services. The social cost of water metering. Birmingham: Office of Water Services, Cuningham C, Griffin J, Laws S. Water tight: the impact of water metering on low income families. London: Save the Children Fund, Figures from Severn Trent Water. Cited in: Early day motion Notice of motions, 1994, No London: Houses of Parliament, 1994: Mara D. Personal communication, McHroy AJ. Water firms are against compulsory metering. The Daily Telegraph 22 August 1995: Department of the Environment, the Welsh Office. Water conservation: government action. London: Department of the Environment, Byatt I (Director of Water Services). Paying for water: the way ahead. Birmingham: Office of Water Services, National Rivers Authority. Saving water: the NRA 's approach to water conservation and demand management. London: National Rivers Authority, President of the Faculty of Public Health Medicine. Cited in Ref Price H. And not a drop to drink. Environ Hlth 1993; 101: Fewtrell L, Kay D, Dunlop J. Infectious diseases and water supply disconnection. Lancet 1994; 343: Fewtrell L, Kay D, Dyer M. An investigation into the possible links between shigellosis and hepatitis A and public water supply disconnections. Leeds: Centre for Research into Environment and Health, Middleton JD, Saunders P, Corson J. Water disconnection and disease. Lancet 1994; 344: Corson J. Water disconnections of domestic premises and possible link with Shigella infections. A literature review and investigative research. Birmingham:Birmingham University, Taylor J. Regional water transfers. Cardiff: British Hydrological Society 4th national symposium proceedings, Brundtland G, ed. Our common future: report of the World Commission on Environment and Development. Oxford: Oxford University Press, HM Government. Sustainable developments: the UK strategy. London: HMSO, Centre for Alternative Technology. Fertile wastes: managing your domestic sewage. New futures series, No. 3. Machynlleth: CAT, Architype. Eco house, Potters Bar specification for the water system. London: Architype Architects, Ives KJ, Hammerton D, Packman R. River Severn pollution incident April 1994; impact on the public water supplies. Report of the independent inquiry. Birmingham: Severn Trent Water pic, Accepted on 11 October 1996