Author Caroline White, BA, is freelance medical journalist
Bradford & Airedale Teaching PCT used NICE guidance to develop a pathway to improve the management of women with continence problems. Caroline White reports.
An estimated five million women over the age of 20 in England and Wales have urinary incontinence. Stress incontinence, caused by physical exertion, such as sneezing or exercise, accounts for around four out of 10 cases, while urge incontinence, in which a sudden strong urge to urinate cannot be stopped, accounts for around one in five. A further one in three women will have both, known as ‘mixed’ incontinence.
The toll on an individual’s personal and professional life can be considerable, while the annual cost to the NHS is estimated to be around £1.8bn. But the true cost may be more as many women suffer in silence. NICE reports that it may take affected women up to 10 years to seek help, possibly due to embarrassment, or because they believe little can be done to help them.
To encourage more women to come forward and improve the clinical care offered, NICE published clinical guidelines (NICE, 2006) on the management of incontinence, including overactive bladder syndrome (the frequent need to urinate with or without urge incontinence before the bladder is full, including during the night).
The guidance places great emphasis on thorough initial assessment to determine incontinence type and rule out infections or other causes, and the use of behavioural interventions including pelvic floor exercises and weight loss, if appropriate, as standard treatment.
Identifying the problem
The incidence of incontinence rises with age, and one in three women over 40 will be affected. A 2005 Royal College of Physicians’ national audit of incontinence care for older people, however, found that, at that time, only 53 of the 138 responding PCTs were providing an integrated care service.
‘There has been a tendency to believe that incontinence is a natural consequence of ageing,’ says nurse consultant Kath Wilkinson (pictured), who has had a key role in developing an incontinence care pathway at Bradford & Airedale Teaching PCT. The trust, which serves a population of over 511,000, was reconfigured from four PCTs. It includes 91 GP practices and two community hospitals, and covers some of the most deprived and wealthy areas in England. One in four people in the area is of South Asian origin.
‘When the NICE guidance was issued, I was asked to draw up an action plan as the continence lead. The guidance provided an ideal framework to support the case to build additional capacity in to the continence service,’ says Ms Wilkinson.
Many women with incontinence were being referred to urologists and gynaecologists when they could have been managed more appropriately in primary care by a specialist nurse or physiotherapist. This delayed treatment and added to costs. A local audit of nurse-led clinics in June 2006 showed that, of 80 patients seen in three months, symptoms either improved or were resolved in some three-quarters of them. Only one out of 10 patients needed to be referred to a consultant.
When the two continence services in Bradford and Airedale joined, it was clear that one pathway was needed in order to resolve the inequities that existed in service provision
across the trust and address unmet needs.
‘Incontinence is not just a problem of older women. We see plenty of people under 65, who develop a problem after childbirth or around the menopause,’ Ms Wilkinson explains. ‘The PCT was interested [in a redesign], not only because it would improve services for patients, but also because it recognised it could save money on the numbers of continence pads prescribed and referrals.’
In July 2006 a working group was set up to develop a single pathway, built around NICE guidance and best practice, and informed by national policy for patient-led services and care closer to home. Drawn from primary and secondary care, this included consultant urologists and gynaecologists, GPs with a special interest, nurse specialists, physiotherapists, technicians, managers and commissioners.
The aim was to create a service that would reduce unnecessary referrals while boosting choice and access for women, and which would be easy for busy health professionals to use. The service also needed to be culturally sensitive. As Ms Wilkinson explains: ‘It can be embarrassing for Asian women to see a male doctor and have such intimate investigations, which are taboo.’
The group began with a mapping exercise to find out what was happening and what it would like to happen in the future, such as having more staff and training. An assessment protocol and referral form were developed, and practice guidance, policy and prescribing guidelines drawn up.
The referral form was designed to fast-track patients needing urgent referral to secondary care, such as those with bleeding or suspected tumours, while preventing others from having to have unnecessary hospital appointments and investigations.
GPs refer patients, except those with bleeding, persistent infections or suspected cancerous growths, to a central point. They are triaged every week by a continence physiotherapist or specialist nurse, and offered an appointment within four weeks of referral at a physiotherapist or nurse-led clinic near their home.
The hour-long appointment includes urinalysis, a bladder scan, a vaginal examination and a bladder diary review. The nurse and physiotherapist can order further investigations or make direct referrals to secondary care if the assessment results warrant it or conservative treatment has been unsuccessful.
A full evaluation, including patient feedback on quality-of-life factors, is under way but 400 people were referred to the pathway in its first six months
– around double the previous figures. In Ms Wilkinson’s words: ‘The GPs are referring patients to us thick and fast’.
‘The gynaecologists tell us that referrals to secondary care have also fallen, and that these are now more appropriate,’ she says. ‘Because [the women] have been thoroughly assessed and treated conservatively first, all the groundwork has been done.
‘We can take an holistic approach. Sometimes consultants can’t do this because there just isn’t time. Patients usually only get 10 minutes with them.’
She puts high acceptance of the service down to the respect continence services already had in the trust, the commissioner, who is a former nurse and effective teamwork: ‘We all worked together and respected each other’s roles and contributions,’ she says. ‘We didn’t encounter any real barriers, because we had good arguments for meeting the 18-week target, complying with NICE guidance and saving money.
‘It was more a case of reminding them of our existence. We ran a couple of evenings for GPs, to tell them about the service and gave a talk about the nurse’s role.’ But she admits that it wasn’t all plain sailing.
‘You have got to sell yourself. Continence is not perceived as sexy and glamorous. You need to gift wrap it and hook people in,’ she says. ‘We ran lots of training and link days.
‘If you can’t do a presentation or put forward a business case, find someone who can help you. There is always someone else somewhere who is doing the same as you.’
The future looks bright. It is anticipated that the pathway will become part of practice-based commissioning next year, and the working group is looking at developing similar continence pathways for children and men as well as one for erectile dysfunction.
NICE (2006) Clinical Guideline 40: The Management of Urinary Incontinence in Women.
Key points for success
- Make sure there is a shared understanding of the needs of people with incontinence and a genuine desire to improve patient care;
- Identify key players in the trust to drum up support and get them together around a table;
- Base your plans on strong evidence and sound arguments;
- Use commercial sponsorship to run training;
- Take a multidisciplinary team approach;
- Hold regular meetings to update on progress and maintain momentum;
- Have an effective communications strategy, with practice visits and local media publicity so professionals and patients are aware of the service;
- Continue regular reviews after implementation to pick up teething problems;
- Audit progress and feed results back to all key stakeholders and attract further investment.