VOL: 99, ISSUE: 01, PAGE NO: 63
Linda Morrow, MSc, RGN, RM, Dip DN, continence adviser, Lothian Primary Care NHS TrustThe current challenge to continence services in England - to make equitable provision of absorbent products to patients regardless of where they live - was met by Scottish services 10 years ago.
The current challenge to continence services in England - to make equitable provision of absorbent products to patients regardless of where they live - was met by Scottish services 10 years ago.
The divergent paths of the health departments in England and Wales and Scotland was caused by different interpretations of the same paper, NHS Circular 1989 (GEN39). In England and Wales the interpretation of this circular was that patients in nursing homes pay for their nursing care, and this should include continence products. In Scotland SHHD/DGM(1991)(67) defined that NHS patients in nursing homes are registered with a GP and therefore should receive the same continence provision as other GP patients.
Continence products were to be provided in two ways. Where the most appropriate product was available on the Scottish drug tariff - for example, catheters and sheaths - the GP should raise a prescription for the nursing home resident. Where the recommended aid was not available on drug tariff - for example, absorbent continence garments - provision should be made by the community nursing services.
The Scottish Office Home and Health Department suggested that patients in nursing homes would be assessed for products by the district nursing service, or nursing home nurses could assess their own patients and submit this to the NHS continence service for product provision.
The view of Lothian Health was that it was not appropriate for NHS staff to assess patients already cared for by qualified nurses in the private sector. However, there was a difficulty in that the NHS was accountable for the expenditure on absorbent products.
Role of the continence adviser
To address this issue my post as continence adviser was established to work in partnership with the private sector, to raise standards of continence care and to encourage appropriate use of containment products. The initial focus of the service was to provide specifically tailored training to all nursing home staff, free of charge. The homes were also offered support with individual care plans, resident reviews and with more complex assessments, including bladder scanning. Products were provided to residents through the same service available to patients in the community.
Support for NHS and residential home staff
It became apparent that the nursing home sector was benefiting from continence support and training that was not available to NHS staff in the area. The appointment of two part-time continence nurses to take on the nursing home role enabled me to manage the service and support my NHS community colleagues.
The continence needs of residents in Scottish residential homes (known as part 4 accommodation) was also changing. In the early 1990s places were allocated according to set criteria, one of which was continence. Subsequent changes in legislation have ended this distinction and there are increasing numbers of patients in residential homes with continence problems. Residential homes do not have qualified nursing staff, and training and development did not reflect this legislation.
1.5 whole-time equivalent continence nurse posts were established to support the residential homes throughout Edinburgh city, East and Mid Lothian. These nurses undertake patient assessment and support the home staff in care planning.
Review of the supply of continence products
In 1997 the dual supply route for continence supplies was reviewed. In the light of modernisation of services it was considered inappropriate that a GP would undertake a continence assessment and chose between containment using prescription items or referral to the community nursing service/nursing home staff for pads. Conversely, nursing home and community nurses were being trained to perform a holistic assessment of urinary continence and implement a comprehensive care plan but had to approach a GP for an item on prescription.
To address this anomaly Lothian was used as a pilot site for the supply of drainage systems as well as absorbent garments through the continence service. Its aim was to ensure that patients benefited from a holistic assessment and care planning by an appropriate professional and that, where containment was required, all options would be available to the professional undertaking the assessment.
This change has enabled us to offer innovative solutions to patients' continence problems, as there is one budget encompassing all provisions. The beauty of focussing on the patient as recipient of service, rather than the nurse and her employer as customers, is that the service is provided on an equitable basis throughout the region.
Opportunities to work in partnership with the private sector should be seized with both hands. The benefit of a patient-focussed service is that, rather than arguing about entitlements based on place of residence, we can talk about entitlements based on assessed need.