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Reversing deterioration in continence services

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A survey has found that while the need for continence services is increasing, continence care is receiving less funding, which is affecting service quality


Despite the growing prevalence of incontinence and the recognition that it is a significant factor in admissions to hospitals and residential care, continence care is receiving less funding. This article compares the findings of a continence care survey undertaken in 2007 with one published in 2013. The survey shows there has been a reduction in numbers of specialist continence staff, particularly senior posts, an increased number of patients seeking help, a decrease in funding, fewer continence products being supplied and growing waiting lists.

Citation: Eustice S et al (2013) Reversing deterioration in continence services. Nursing Times; 109: 27, 18-19.

Author: Sharon Eustice is nurse consultant for continence, Peninsula Community Health, Cornwall and Isles of Scilly, writing on behalf of the report authors.


Incontinence can affect men, women or children at any age, and even slight incontinence can have a severe impact on the quality of life of those experiencing it and their carers. Without effective treatment and support, incontinence can have multiple costly health and emotional impacts and can impair the ability to take part in important aspects of normal everyday life, such as employment, education, and social and sporting activities, as well as personal relationships. Many forms of incontinence are curable or can be improved or managed simply and effectively.

In 2007, a continence care survey was carried out across the UK (Absorbent Hygiene Product Manufacturers Association, 2008). The results painted a bleak picture for both clinical staff and patients across many trusts. The survey confirmed existing concerns expressed by clinicians, politicians, charities, patient groups and industry, and led to Baroness Greengross agreeing to support the formation of the All Party Parliamentary Group for Continence Care (APPGCC), to be run in collaboration with charities working to improve continence care. This group was launched in January 2009 and works to break the taboo of incontinence by raising awareness of continence issues for adults and children, and to promote cost-effective funding for continence services and product provision.

In September 2012, the APPGCC commissioned a survey of continence care services in England. The survey sought to provide a snapshot from 89 detailed responses and the summary of its findings and its results were published in May 2013 (APPGCC, 2013).

The scope of the problem

The APPGCC survey (2013) stated:

  • An estimated 14 million people in the UK have a bladder control problem and 6.5 million have a bowel control problem;
  • A significant proportion of cases are curable or can be significantly improved with treatment;
  • Incontinence is a significant factor in admissions to hospitals and residential care settings;
  • Poorly managed continence care in older people and those with disabilities contributes to ill health, falls and fractures, severe infections and pressure ulcers;
  • Continence (bladder and bowel) problems affect about one in 12 children and are associated with bullying, loss of self-esteem and family stress, including domestic abuse;
  • Incontinence is more prevalent than asthma, epilepsy or dementia;
  • While the number of referrals and the costs for management products are increasing, budgets are decreasing;
  • Management products are rationed in many areas and patients must supplement them or pay for them all themselves, which affects the most disadvantaged and vulnerable people.

Benefits of better continence care

Improving continence care:

  • Reduces admissions to secondary and permanent care settings such as nursing homes and homes for children and adults with disabilities;
  • Reduces costly emergency admissions to secondary care caused by urinary tract infections, pressure ulcers and catheter-related infections;
  • Reduces prolonged use of costly incontinence products through low-cost interventions such as physiotherapy and medication;
  • Contributes to independent living and an improved quality of life.

The challenges associated with saving NHS costs for continence services are vividly exposed in the survey, which reveals a deterioration in the level of provision of continence services since 2007.

There is a danger that some of these services will become simply pad providers and the skills to deliver complex treatment and management options will be lost. If these trends continue as the population ages, more older people will present for assessment to fewer, less experienced continence specialists who have fewer resources. This will have serious consequences for patients in terms of an increased risk of health complications as well as loss of dignity and quality of life.

Survey results

The 2012 survey showed a number of changes since 2007 that have affected staff working in continence services. It revealed:

  • Continence team staff numbers have reduced, with senior posts diluted or disappeared;
  • Staff morale is generally low across services and lower than it was in the 2007 survey;
  • Over the last two years, more than three-quarters of continence services have not experienced any increase in staffing levels;
  • The skill mix within the continence teams has changed, with reductions in senior posts;
  • Education of the workforce in continence care has a low priority with poor attendance reported at arranged sessions;
  • Most education for clinicians is accessed through professional associations;
  • Three-quarters of respondents are not able to access full funding for ongoing education.

With regard to the number of patients seeking continence care, the survey showed that:

  • Almost half of services have experienced an increase in the number of patients requiring products;
  • Children seem to be particularly poorly served;
  • From 2006-2007 data revealed that approximately 1.3 million people sought help for continence problems. Data from 2010-2011 shows this has risen to 2.3 million people (Health Survey for England, 2012).

The following problems with funding were noted:

  • Almost half of services that have experienced an increase in patient numbers report that budgets have not increased accordingly;
  • The majority of services report that no funding was available to help promote their services to other professionals or the general public;
  • Service promotion represents a double-edged sword for clinicians, as promotion will undoubtedly increase referrals to an already overstretched service;
  • The majority of respondents report that the level of pad supply is determined by local policy;
  • Products are supplied to a level determined by budget rather than clinical need;
  • Many services no longer supply products for “light” incontinence;
  • Overall NHS costs have increased from £77 million in 2006-7 to £121m in 2010-11 (Department of Health, 2012).

The survey revealed the following effects on waiting times:

  • Nearly three-quarters of services report an average waiting list of between four and eight weeks for clinical assessment;
  • Following assessment, one-fifth of these services have a waiting list for product supply, which has doubled since the 2007 survey.

The future

Recommendations made as a result of the survey findings are outlined in Box 1.

To enable these recommendation to become reality, a new post of ambassador for continence care should be appointed at the highest national level. This person should be able to motivate the workforce and enable the delivery of high-quality, cost-effective continence care, wherever patients are living.

Box 1. Recommendations

Following analysis of the survey results, the following is recommended:

  • Clinical commissioning groups should resource and organise continence services that deliver good practice, as per National Institute for Health and Clinical Excellence ( NICE-commissioning-continence) and Department of Health (2010) guidance.
  • NHS England and the DH should provide commissioning guidance and support clinical commissioning groups around continence.
  • NICE quality standards should include faecal incontinence and broader continence issues, including those affecting care home residents.
  • The Royal College of Physicians’ national audit should be re-commissioned and undertaken annually to drive up standards in primary care, acute hospitals, care homes and mental health trusts.
  • Service providers should monitor patient-reported measures, both outcomes and experience.
  • Commissioners should resource promotion of continence services so that patients can easily access information about their local services and how to manage continence issues.
  • The Care Quality Commission should specifically monitor continence care when assessing organisations, including care homes.

Key points

  • Around 14 million people in the UK have a bladder control problem and 6.5 million have a bowel control problem
  • Many forms of incontinence can be cured, improved or managed
  • Improving continence care would reduce hospital and care home admissions, and the need for continence products
  • The number of specialist continence staff has fallen and less continence training is being offered
  • More patients and less funding has led to waiting lists becoming longer 
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