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Commissioning continence services - turning policy into action.

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VOL: 100, ISSUE: 20, PAGE NO: 52

Sue Thomas, BA, RGN, RM, DN, CPT, is nursing policy and practice adviser, Royal College of Nursing, London

Regrettably continence services have for many years been a 'Cinderella service'. Several high profile organisations and prominent individuals have recommended service modernisation and although problems have been identified and recommendations made for action, continence services continue to have a low profile.

Regrettably continence services have for many years been a 'Cinderella service'. Several high profile organisations and prominent individuals have recommended service modernisation and although problems have been identified and recommendations made for action, continence services continue to have a low profile.

A major political campaign to stimulate change was developed by continence organisations, which included the RCN, the Continence Foundation and the Association for Continence Advice (ACA). It achieved success when the Department of Health launched Good Practice in Continence Services (DoH, 2000a).

Good Practice in Continence Services outlines a standard set of principles for improving health and tackling health inequalities in service provision for people with bladder and bowel dysfunction. In order to deliver effective continence care, the document calls for new ways of working and new partnerships, and sets out a proposal for an integrated continence service (ICS) based on four levels of service provision:

- Level 1: Primary care;

- Level 2: Specialist continence services;

- Level 3: Consultant medical and surgical services;

- Level 4: Regional or national centres of excellence.

Reasons for undertaking the survey
Although Good Practice in Continence Services (DoH, 2000a) set out in detail what was required for continence services at each level of the NHS (Box 1), the document was originally published as a statement of best practice and did not outline performance targets and measures that health care providers were required to achieve. This was regrettable and initial thought from the continence stakeholders who lobbied for the guidance was that services might not move forwards. Continence targets were later outlined in the National Service Framework for Older People (DoH, 2001a):

- April 2003 - Health improvement and modernisation programmes (HIMPs) and other relevant local plans should include the development of an ICS;

- April 2004 - All local health and social care systems should have established an ICS.

Methodology for the survey
The survey Is Policy Translated into Action? (Thomas, 2004) was a project jointly conceived by the RCN and The Continence Foundation to elicit how Good Practice in Continence Services (DoH, 2000a) is being implemented. Funding was obtained from The Health Foundation.

The survey took the form of a structured questionnaire administered to primary care trusts and continence nurse specialists. The questionnaires were developed in consultation with continence care professionals drawn mainly from the RCN Continence Care Forum and The Continence Foundation.

A steering group provided strategic, clinical and methodological guidance. The survey tools defined the relevant domains and criteria in the continence guidance within primary and secondary care settings.

The survey was limited to five NHS regions in England (Northern and Yorkshire, Trent, West Midlands, London, and South West). These were chosen randomly.

Respondents were recruited via the chief executive of each PCT who was asked to nominate their 'lead commissioner for continence'. Continence specialists were identified via The Continence Foundation's directory.

Data was collected using hard-copy, structured questionnaires - one version for those working in PCTs and another for continence specialists. Questionnaires were posted to respondents and a telephone appointment made to discuss and complete the questionnaire. The telephone interview enabled any aspects of the questionnaire that were unclear to be explained and gave the interviewee an opportunity to provide qualitative data.

The call also acted as a reminder for respondents to participate in the survey. The hard copy questionnaire was the source of the data for analysis.

Questionnaires for Year One were completed between September 2001 and August 2002 and for Year Two between November 2002 and July 2003.

The responses were compared with the PCTs' HIMP, local development plan (LDP), and strategic and financial framework (SaFF).

Additional qualitative data was collected at regional workshops where PCT respondents and continence service professionals met to discuss how NHS priority areas could be used to influence the local commissioning agenda towards modernisation of continence services.

Ensuring cooperation
The success of the survey depended on respondents completing the questionnaire, and every effort was made to secure the cooperation of individuals and organisations. Although the aim was to collect data from as many PCTs and continence advisers as possible, the data will inevitably be subject to some selection bias. Some continence advisers completed the questionnaires on behalf of a team of advisers. The final sample included data representing 204 PCTs and 200 continence nurse specialists from the five NHS regions (Tables 1 and 2).

The survey took place at a time of significant change within the NHS as primary care groups (PCGs) moved to PCT status, either independently or through mergers with other PCGs.

Strategic health authorities were formed and there were also some geographical rearrangements of NHS regions. To maintain continuity the administration of the questionnaire was limited to organisations that were part of the Year One survey and are referred to within this article as PCTs.

Results
Good Practice in Continence Services (DoH, 2000a) made recommendations for modernising continence services in four key areas:

- Service commissioning;

- Service delivery;

- Service organisation;

- Tools to improve service provision.

This article outlines the progress made within the key area of service commissioning.

Service commissioning The survey revealed a national network of highly qualified continence advisers and interested clinicians who wanted to modernise the current inequitable continence services. Some PCTs have made a concerted effort to review and develop their services but action is still needed at both local and national level to improve continence management in the UK. The programme of work to develop the local ICS has generally been led by key stakeholders in continence service delivery, although some PCTs have been proactive.

Stakeholders - usually continence service professionals including urologists, gynaecologists, and continence advisers - have formed local continence task forces to spearhead development.

The ICS target within the NSF for older people has ensured that geriatricians have become increasingly interested in developments. However, the main aim of the guidance - to develop ICS throughout England - is still in its infancy.

The key drivers for change are partnerships between current continence services, PCTs, local authorities, social services departments, and users and carers. Without effective communication between these groups, ICS will be impossible.

Awareness of the need for change In order to implement Good Practice in Continence Services (DoH, 2000a), PCTs must be aware of both current policy for continence services and the need to modernise. Respondents were asked if they had a copy of Good Practice in Continence Services and if they were aware of its recommendations.

In Year One, 64 per cent of PCTs interviewed said they had a copy of the document and an additional six per cent had either read it or seen it on the DoH website. However, nearly one-third of respondents did not have a copy or were unable to respond to this question.

In Year Two of the survey, the situation had changed significantly and only one per cent of PCTs had no knowledge of the guidance. A possible explanation is that the NSF for older people (DoH, 2001a) included the development of ICS. This NSF has raised significant awareness and provided targets for service delivery.

Implementing good practice in continence services

Strategic action is needed to implement Good Practice in Continence Services (DoH, 2000a). In Year One, 56 per cent of the organisations surveyed said they had plans to develop an ICS. However, only 22 per cent had discussed their plans at PCT board level. The remainder either had not discussed plans (43 per cent), did not know if plans had been discussed (27 per cent), or could not comment (eight per cent).

In Year Two, 91 per cent of the PCTs interviewed stated that they had plans to develop an ICS but not all appeared to have discussed this major development at a strategic level. Some 31 per cent of PCTs stated they had discussed the development of an ICS at their trust board meetings compared with 22 per cent the previous year. In 26 per cent of the PCTs, continence services were being discussed at professional executive committees (PECs), which had not occurred in Year One of the study. This appears to indicate that there was an increased awareness of continence issues.

PCTs are faced with the prospect of implementing wide-ranging NHS policy. Staff working within continence services need to develop their political awareness in order to get continence issues onto the local commissioning agenda. The ability to influence decisions at a strategic level is critical at a time when we are working to develop services to meet the needs of people with bladder and bowel dysfunction.

Much more needs to be done to engage PCTs in continence service development and more effort is required to develop relationships between specialist continence teams and PCTs. In particular, the strategic contribution of continence advisers at PCT board level needs to be increased.

Many continence advisers said they felt excluded from decision-making, and that they lacked influence at PCT board level. The question of how continence services could open up an effective dialogue with PCTs was frequently raised.

Standards within the NSF for older people required PCTs to have a plan for developing ICS established by April 2003 and for it to be in place by April 2004. Changes in service commissioning also require PCTs to produce an LDP outlining their commissioning plans for the next three years.

PCTs need to address key targets set within The NHS Plan (DoH, 2000b), The NHS Cancer Plan (DoH, 2000c) and the NSFs. Although continence is not identified as a specific priority in The NHS Plan, it does form a key part of several priority areas. Poorly managed incontinence often leads to inappropriate hospital or long-term care admission and delayed discharge.

In the first year only one-third of PCTs surveyed said that continence was currently mentioned in their HIMP, and this was confirmed by subsequent scrutiny of HIMP and SaFF plans. In the second year there has been a small percentage rise with 38 per cent of PCTs specifically mentioning continence within their LDPs.

Inclusion of continence in these plans does, however, need to be specific to ensure service modernisation. For example, some PCTs had mentioned continence services in their LDP but had done so for a variety of reasons, not necessarily to promote ICS. These reasons included:

- Providing more continence education and training;

- Assessing the cost or provision of continence products;

- Being a lead PCT for continence services locally.

The priorities This survey has clearly demonstrated that although attention is being given to the development of ICS the emphasis is not as great as if continence was a health and social care priority area. To ensure the development of an ICS it is critical that the way continence impacts on the NHS priority agenda is made clear to individual PCTs.

The Priorities and Planning Framework 2003-2006 (DoH, 2003) identifies key drivers for primary care organisations as:

- Waiting, booking and choice;

- NSFs;

- Financial balance.

There are many good examples of how continence can fit into the priority agenda (Boxes 2 and 3).

The specialist continence team High-quality continence care requires a multidisciplinary team approach that crosses the primary and secondary care interface. Specialist continence team members include continence specialist nurses and physiotherapists, urologists, obstetricians, and gynaecologists.

Care at this level requires contributions from other specialists such as coloproctologists, geriatricians, paediatricians, midwives, and occupational therapists. It also requires the involvement of PCTs, GPs, district nurses, practice nurses, and health visitors. Other team members include those from social services, nursing and residential home carers, people in the voluntary sector, patients and their carers.

Such a disparate team requires a senior team leader or director who is capable of team-building, promoting the continence service at both trust board and strategic health authority level, and developing clear links with social services and the independent care home sector. The ideal ICS would span several PCTs and the leader would need to have access to the PCT board. Good Practice in Continence Services (DoH, 2000a) suggested that the appointment of a director of continence services was central to moving ICS forward.

However, in Year One only six per cent of PCTs surveyed were planning to appoint a director. More than half (56 per cent) said they had no plans to appoint a director, while over one-third did not know.

In Year Two eight per cent of PCTs said they would appoint a director, 59 per cent would not appoint one, and 33 per cent still did not know. The main reasons PCTs gave for not appointing a director were the connotations attached to the job title, and funding.

Only one of the PCTs surveyed in Year One did not have a problem with the title 'director'. The remaining PCTs frequently stated that the term director implied an executive role.

It was felt that if a director was appointed for one service there would be pressure to appoint directors for other service areas. Respondents also said it would be difficult to stretch existing funding to cover a director's salary.

Several continence advisers felt that their existing specialist role encompassed the responsibilities of a director. These specialists were also managing a clinical workload.

Role of the director Modernising continence services requires the director to:

- Work in partnership with all stakeholders;

- Adopt a higher profile within the organisation;

- Get fully involved in all stages of the commissioning process;

- Be included in all organisational and service evaluations;

- Be fully involved in commissioning, board, and executive work.

Directors should also have the authority to ensure that their knowledge, experience, ideas, and values are respected and acted upon. This role requires protected time to undertake these activities. It would be difficult for continence advisers to balance their clinical and managerial functions.

There may be an argument for reconsidering the job title, but the role and function of a 'director' should be viewed as a priority as continence services need leadership and coordination.

Before April 2003, by which time PCTs should have had plans in place for the development of ICS, only three of the regions surveyed had developed a lead post for a proposed integrated service. Of these three areas only one used the title 'director'; the other two areas had appointed continence clinical lead posts.

Qualitative analysis
Throughout the study there has been enormous enthusiasm from respondents. A common remark in the free comment section of the questionnaires was that more help was required to achieve integration.

Service stakeholders wanted help to identify the steps that needed to be taken to move services forwards and for tools to assist with developing plans to present to the PCT professional executive committee or board.

Key recommendations to move services forwards have been highlighted in the report (Thomas, 2004) and The Continence Foundation is helping with external facilitation in order to help organisations.

Steps towards encouraging integration
- Establish a local continence task force (if this has not already happened) to identify action to support the implementation of ICS.

- Consider best practice and means of dissemination.

- Set up regional networks to:

- Share learning;

- Improve coordination;

- Address development priorities.

- Form a virtual ICS (identify all the people who would form part of such a service) and identify a director; designate specialists and start approaching PCTs with proposals aimed at establishing the ICS and moving the continence agenda forward.

- Map out existing continence services.

- Identify professional executive committee (PEC) and board members and consider how staff can work effectively with them and other key stakeholders to improve continence service delivery.

- Identify and get involved with local clinical networks and commissioning team members.

- Work with the public health team to collate data relevant to continence services.

- Be prepared to challenge local decision-making. You will need to be aware of and understand current local and national priorities.

- Develop influencing skills.

- Public involvement is an essential part of The NHS Plan (DoH, 2000b). Modernisation means working closely with local service users.

Conclusion
There has clearly been much progress since the publication of Good Practice in Continence Services (DoH, 2000a) and changes are occurring as a result of this and other policy documents, in particular the NSF for older people (DoH, 2001a) and the Essence of Care benchmarking standards (DoH, 2001b). This should continue to drive the agenda forward.

Given the fundamental nature of the organisational changes now under way, the main priority must be to ensure that appropriate arrangements are in place to maintain progress towards developing ICS in each area.

It is imperative that there is communication between PCTs and continence services and that the networks currently lobbying for ICS are supported and maintained. Lobbying has been crucial and this should continue until full integration has been achieved.

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