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Developing continence services through partnership

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VOL: 98, ISSUE: 17, PAGE NO: 63

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

Since April 2001 there has been a reconfiguration of trusts in West Cumbria. Previously we were a combined trust, which included the acute sector, community and mental health and learning disabilities, serving a mostly rural area with a population of some 135,800 people. The community-based continence service, which consists of two part-time continence advisers, (one whole-time equivalent) had access in this combined trust to all disciplines.

Since April 2001 there has been a reconfiguration of trusts in West Cumbria. Previously we were a combined trust, which included the acute sector, community and mental health and learning disabilities, serving a mostly rural area with a population of some 135,800 people. The community-based continence service, which consists of two part-time continence advisers, (one whole-time equivalent) had access in this combined trust to all disciplines.

In April 2001 the combined trust was divided into three separate trusts: the acute trust and the mental health and learning disabilities trust are North Cumbria-wide and the West Cumbria Primary Care Trust (PCT) commissions and provides health care for residents in West Cumbria. This area is one of the most geographically isolated communities in England, stretching across some 685 square miles.

The continence service is now under the management of the PCT but still has the same input to the recently formed new trusts in this area, which uses approximately one day a week, or 20% of the whole-time equivalent.There is potential for change for the continence service, with perhaps the development of a service in the acute trust, but for the present the status quo is maintained.

Continence forum
In the light of the impending changes in the trust it was decided to review our continence forum, the small special interest group which was itself a development from the link nurse group.

An evening meeting was arranged, inviting a small number of those working in or with an interest in continence. Consultants, a GP, a manager, a physiotherapist, continence adviser and a nurse, along with agreed corporate support, attended this meeting. The consensus of the meeting was that the West Cumbria Continence Forum should be formalised and act as a resource and reference group on matters relating to continence for the trusts in West Cumbria. The main body of the forum should be expanded to include all those involved in continence issues to ensure representation from patients, carers, residential and nursing homes, social services and voluntary organisations. In addition, current membership of the group also includes consultants in urology, gynaecology, surgery (related to faecal incontinence problems), paediatrics and elderly care, the regional director of nursing, three GPs, a pharmacist, a midwife, an occupational therapist and nurses from all disciplines. In total there are about 30 active members.

How the forum works
A steering group was elected at the first meeting, consisting of a consultant gynaecologist (with a special interest in urogynaecology), a specialist physiotherapist for continence, a community and primary care manager whose main role is in commissioning, and the two continence advisers. The steering group meets every eight weeks to move current issues forward. Other forum members are asked to join the steering group for specific items where their skills are required - for example, one of the GPs on the forum also has a special interest in clinical governance.

Members of the forum are invited to submit items between full meetings to the steering group for action, where appropriate. Current projects of the steering group include delivering the requirements of the National Service Framework for Older People (Department of Health, 2001) and training issues. The community and primary care manager provides clerical support for all the meetings.

The forum meets twice a year, in June and December. The format of the meeting is to have a short business meeting to discuss current issues, including new government initiatives, and to report the progress of the steering group, followed by a speaker. Given the geographical challenges of the area, there are some logistical problems bringing people together. However, we attempt to find a central venue for the meeting. A buffet supper is served after the speaker, allowing valuable time for networking between colleagues. This is proving to be a valuable group and a cost-effective way to tackle some of the current issues facing the continence service in West Cumbria.

The continence service has produced a newsletter since August 1999. Initially this was produced every three months, but since June 2001 it is published every two months. This enables a cascade of information from the forum to others in the individual trusts.

The newsletter is a double-sided A4 information sheet and contains information from the forum, along with new products, product updates, safety notices, audit reports, product evaluation, relevant article references and other interesting snippets.

Preparing the newsletter is a fairly simple process, with a short time commitment for production. The consultant gynaecologist on the steering group has given secretarial time from his department for mailing out the newsletter. Once the original is produced, this is sent to the secretary for photocopying on special headed paper, along with a set of mailing labels. A database is held by the continence advisers. The current circulation is in excess of 250, which includes all GP practices, hospital wards and residential and nursing homes.

The continence service operates its own website, not only as a means of further communication between professionals but also as a resource for patients. This will be further developed in response to requests from users. This may be viewed at

As far as continence services are concerned, the main areas for training currently include the primary health care team (PHCT), hospital staff and staff working in residential and nursing homes.

The training issue is vital, time-consuming and ongoing. Pressure from every specialist area, demanding additional training, descends relentlessly on PHCT members every day. Asthma, diabetes, and coronary heart disease are three current popular and important topics. Yet among the plethora of training issues is that of continence - not a life-threatening symptom but one that drastically diminishes the quality of life for the sufferer. It is a common, hidden problem that often makes the sufferer feel ashamed and reluctant to seek help. It is essential, therefore, that this topic is included in education programmes and the time allowed for continence training is used effectively.

In the PCT in West Cumbria continence training is included in the regular monthly half-day education sessions, arranged by GP practices. Workshops will be included to enable PHCTs, with guidance from the continence service, to identify their own models, for identifying and treating continence problems within primary care. Using an agreed framework, it is expected that models will be similar, so offering a consistent service across the trust.

Training requirements for residential and nursing homes presents a different problem - how to coordinate a training programme across a wide geographical area, when staff can be released only one or two at a time, for an hour at best. As part of an audit carried out in west Cumbria in 2000, it was identified that training was requested by all residential homes. Staff wanted to cover several aspects of continence problems and managers would prefer this to be 'in house'. The main problem facing the continence service is a lack of resources to deliver this type of training commitment, so what alternatives are there?

Support resources are available that can help to address the training issues in residential and nursing homes as well as greatly contributing to hospital staff training.

Some manufacturers are providing educational material. For example, the Continence Care Training Programme from Paul Hartmann is a comprehensive, eight-session training programme for care staff working in health and social care, which can be presented over eight one-hour sessions, two half-day sessions or one full day. It comprises a teaching plan, training notes, acetates and handouts ready for photocopying, for each session, and relevant exercises and a quiz. A certificate of attendance is also included for those who complete part of or the whole programme.

A continence service with limited resources has to explore different methods of delivering training, and we are investigating the possibility of training two senior members from each residential and nursing home so they can train their staff. Support will be given from the continence service, and a system for estimating the effectiveness of the training will be developed. The continence advisers would support the homes in their training and the implementation of programmes to reduce incontinence levels while liaising with the PHCT caseload holder to ensure the reinforcement of this positive approach.

A regular drop-in clinic for residents in the homes would be implemented, as this suggests a positive way forward to help residents and further train staff (Nazarko, 2001).

An attempt has been made to demonstrate some strategies used in West Cumbria that may be useful to others when planning the future for continence services and implementing government policies at little cost to the trust. Some of the lessons we have learnt are:

- Much can be achieved by working with corporate partners within agreed trust policies;

- A multiprofessional continence forum brings together all those involved in continence issues, but must include user representation;

- Communication is a two-way process, and channels for communication must be simple and effective;

- Support packages are available to help deliver varied training programmes and make the best use of resources.

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