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Continence services in a changing NHS

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VOL: 98, ISSUE: 17, PAGE NO: 58

Wendy Colley, OBE, RGN, DNCert, FETC, is clinical nurse specialist, continence care, West Cumbria Primary Care Trust, Whitehaven, Cumbria, and a freelance continence consultant

This article will consider the continence issues contained in the National Service Framework (NSF) for Older People (Department of Health, 2001a), and the Free Nursing Care in Nursing Homes (Department of Health, 2001b) documents. A second article outlines some of the strategies we are implementing in West Cumbria to address the requirements of the NSF for older people and Free Nursing Care in Nursing Homes regarding continence. This involves bringing professionals together and working closer on continence-related issues, so attempting to ensure the best use of resources while improving the quality of life for older people, wherever they live.

This article will consider the continence issues contained in the National Service Framework (NSF) for Older People (Department of Health, 2001a), and the Free Nursing Care in Nursing Homes (Department of Health, 2001b) documents. A second article outlines some of the strategies we are implementing in West Cumbria to address the requirements of the NSF for older people and Free Nursing Care in Nursing Homes regarding continence. This involves bringing professionals together and working closer on continence-related issues, so attempting to ensure the best use of resources while improving the quality of life for older people, wherever they live.

Focus on continence services
There has been an unprecedented focus on continence services by the Department of Health in recent years. At last continence issues are included as an integral part of major health initiatives.

Continence services welcome this raised profile. However, there is rising pressure to cope with an increase in demand for services already operating at maximum capacity. Many continence services still consist of the equivalent of one full time adviser with perhaps some clerical support.

The major impact on continence services is the increased volume of work. Services are coping with an ever-growing clinical caseload, teaching commitments to deal with current policy initiatives, managing integral parts of the system - such as a home delivery service - and various audit projects, as well as the day-to-day work of a specialist service and resource for professionals and patients.

How do we arrange our service to cope with the additional demand when there does not seem any spare capacity in the system? How can we present the case for an increase in resources when resources are finite? Is there another way to provide an improved service to more people within the same resources?

Since 2001 the focus has been placed on older people at home and in residential and nursing homes. It must be remembered, however, that continence services provide advice for people of all ages, and therefore resources cannot be concentrated solely on the older population. Another NSF is expected shortly, this time for children, which may also contain references to continence services for children and, if so, will no doubt also impact on current service provision.

Guidance on good practice
Before looking forward, we must first however, look back to April 2000 and the publication of Good Practice in Continence Services (Department of Health, 2000). This was a turning point for continence services. At the time of publication there was disappointment among some continence advisers and continence organisations that the document had been downgraded to 'best practice' and was not the binding policy document many had hoped for. The Continence Foundation was scathing in its comments, stating 'the government fails vulnerable patients with advisory 'policy'' (Continence Foundation, 2000a).

In fairness, Good Practice in Continence Services is proving to be a very useful document, pulling together and recommending best practice - combined with research evidence where it was available - and has far-reaching implications for the way continence problems are identified, assessed and treated. This document is regularly quoted in government papers when referring to continence topics. After many years in the wilderness, continence issues are now seen as important at the highest level and included on many government agendas for implementation by primary care groups and primary care trusts as well as acute and other NHS trusts.

Yet another publication that considers continence one of eight fundamental aspects of care and worthy of its own section is The Essence of Care (Department of Health, 2001c). This is a resource pack and a tool to help build on good practice and improve the quality of care. It explores benchmarking and provides a tool to advance the clinical governance agenda.

Developing integrated continence services
The executive summary of Good Practice in Continence Services states that 'health authorities, primary care groups, primary care trusts and NHS trusts should work together, through their health improvement programmes and long-term service agreements to ensure that people with continence problems are identified, assessed and get the treatment they need'.

The NSF for older people states that, by April 2003, 'health improvement programmes and other relevant local plans should have included the development of an integrated continence service' and by April 2004 'all local health and social care systems should have established an integrated continence service'.

The Continence Foundation suggested a model for action at PCG level in Making the Case for Investment in an Integrated Continence Service (Continence Foundation, 2000b) [Fig 1]. Those services, where this or a similar model was implemented, will be in a strong position to fulfil many of the requirements of the current agenda.

For others it is not too late. Your trust will be well aware of the implications of the NSF for older people and free nursing care requirements. Continence managers should ensure that trusts are aware at executive committee level of the current service and the service development required to meet the NSF milestones by April 2003 and April 2004.

The NSF for older people states that integrated continence services should be in line with published guidance on good practice and link identification, assessment and treatment across primary, acute and specialist care.

Continence services should include the following:
- Primary and community staff giving general advice to older people and their carers about healthy living (in particular diet and drinking appropriate fluids);

- Primary and community staff involved in the identification, initial assessment and care of older people;

- Staff in nursing and residential care homes to identify, assess, treat and review the needs of residents within agreed protocols;

- Hospital nurses to identify people with incontinence, to ensure that treatment is provided and that continence needs are assessed and a plan agreed before discharge from hospital;

- Specialist continence services to provide expert advice and be available to people whose condition does not respond to initial treatment and care;

- Links to designated medical specialties, such as urology and care of older people;

- Links to regional and national units for specialist surgery to form part of the care pathway for continence services;

- Availability and provision of continence aids/equipment;

- Access to bathing and laundry services;

- Patients and carers involved in developing local services;

This comprehensive list has implications for all members of the primary health care team, community managers, hospital staff, those working in residential and nursing homes, patients and carers and continence services. Following the publication of Good Practice in Continence Services most continence services will have planned and perhaps implemented additional training programmes, and trusts will already be achieving some of the listed requirements. However, most continence services will have work to do to achieve the requirements of all 10 points.

Free nursing care in nursing homes
The Free Care in Nursing Homes document has a greater impact on continence services than other services. Since October 1, 2001, trusts have been obliged to supply continence products free to current self-funders. On May 3, 2001, health minister Philip Hunt announced that 'from October this year continence pads and other continence supplies will be available free to residents of nursing homes. The change will benefit nursing home residents who pay their own care costs and need continence supplies - an estimated 24,000 people' (Department of Health, 2001d).

Six million pounds has been made available to support the introduction of free continence products and is distributed by health authorities. There will also be additional costs, such as nursing time for continence assessment, initial and ongoing training to nursing home staff, clerical staff time to process additional product requests and continence specialists to offer advice and treatment in difficult cases. Some patients may need physiotherapy or consultant referral. All of these interventions potentially increase costs.

The latest circular, Guidance on Free Nursing Care in Nursing Homes (Department of Health, 2001e), states that the NHS will be expected to fund the cost of continence products for all those in nursing homes from April 1, 2003. It is suggested that continence advisers, nurses and PCTs should use the period until then to establish processes for assessment of continence needs in readiness for this.

Perhaps this is the greatest opportunity for continence services since 1981, when there were only 19 nurses working in this specialty. Over the past 20 years continence services have developed, some embracing a multiprofessional team, and access to a continence service is available in most trusts. There are highly specialised centres for treatment and research, and perhaps at last a shift towards public understanding and acceptance of bladder and bowel leakage as a symptom of an underlying dysfunction.

Now is the time to move forward and build rapidly on the foundations so meticulously laid by those working in continence services and to look at a service which fits into the 21st century. This is a service which is in line with government policy and ensures that patients are involved in planning services that deliver prompt, high quality, comprehensive care.

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