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Practice comment

Why are we still doing so badly in treating incontinence?


A national audit of continence care has revealed that patients are receiving substandard and patchy care. Guidance is available – it should be implemented, says Doreen McClurg

The results of the 2010 National Audit of Continence Care published last week are a stark reflection on current practice.

The audit was intended to enable those involved with continence, including  managers, commissioners, providers and clinicians, to compare their performance to that of other audit participants and against evidence based standards. Data from specific sites will, for the first time, be identifiable and available in the public domain thus allowing variations in the standards of care and delivery to be highlighted. This should lead to improvement in the standard of care provided.  

There has been considerable organisational change within the NHS over the past four years, which is set to continue. The National Institution for health and Clinical Excellence has published guidelines on urinary incontinence in women, faecal incontinence and on lower urinary tract symptoms in men. However, it would seem that change is not always for the better and guidelines are not always implemented to best effect. One of the main findings of the audit is that only 74% of PCTs commission according to NICE guidelines and many hospitals fail to provide care according to NICE recommendations.

Another common finding was the lack of integration across acute, primary, care home and community settings, resulting in disjointed care for patients and carers. Only four services across the country fulfil all the requirements set out in Good Practice in Continence Services published by the Department of Health in 2000.

How often do we hear of patients being sent home from hospital with inadequate follow-up, or repeatedly having to adapt to different products? Often there is no designated lead in continence services and commissioning is nearly always undertaken with no input from patients or indeed those providing the care. Commissioners, practitioners and patients need to work together to build continence services that can provide joined up and effective care to all patients with bladder and bowel incontinence. An example of a framework that does this is for hip fractures and falls.

Education, or the lack of it, was also highlighted as being inadequate. Structured training in continence care only occurs in 49% of acute hospitals and 39% of mental health care sites. How often do we hear that there is no funding to go on courses, there is no dedicated time to attend study days and validated courses are being cut? How then are staff meant to improve their knowledge and clinical care?

An audit relating to undergraduate continence education is currently being undertaken jointly by the Nursing, Midwifery and Allied Health Professions Research Unit in Glasgow and the Association for Continence Advice as it has become clear that newly qualified staff had had little training in basic continence care. This national audit suggests continence specialists should work with education providers to ensure courses are relevant to practice, which is correct for undergraduate level. However, I would suggest an increasing lack of opportunities for staff to attend study days or in-service training is one of the reasons why we are still doing badly with continence care.

Translation of knowledge is also key to change. There is no point in education and training unless there is encouragement for implementation. Patient empowerment and self-reported outcomes should be the centre of building continence services as it has been shown that involvement in goal-setting, self-management and decision making improves outcomes. Enthusiasm and belief that often a cure is possible needs to be generated from a top down approach as well as at basic clinical and patient level. We need to look more at ways to improve the implementation of guidelines and standards and how to change practice accordingly.  

Author Doreen McClurg, PhD, MCSP, is chair of the Association for Continence Advice, writing on behalf of the National Audit of Continence Care


Readers' comments (2)

  • Continence care for dementia patients seems to be especially bad, and carers are often told they must buy the products necessary, which is a complete outrage. If you are living on a resticted income anyway and spend up to £10 per pack on incontinence pads using 3-4 packs each week, is this fair or right?

    We have in this as in so many other areas, a very long way to go. Is it me, or do we seem to be going backwards in respect of generally good levels of care?

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  • Back in 1995 I completed the ENB 978 Promotion of Continence Course. I then went onto run this course at My local university for mant years along with my clinical colleagues from all areas of continence care. This course eventually ceased when local trusts stopped sending staff on it. If we do not provide on-going education for staff and how can we expect them to be able to deliver the best, most up to date practice for patients.

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