Changes in provision mean bladder and bowel problems are no longer the remit of school nurses. Is their involvement essential or a costly luxury?
Following strategic health policy changes – such as the transfer of school nursing from public to local authority funding and the designation of continence as a public health issue – children’s continence care has dropped down the healthcare agenda. This raises concerns about the gap in paediatric knowledge in primary care. Previously, school nurses would have assessed children and ensured timely intervention. This article discusses their role and the impact of policy changes.
Citation: Rogers J (2016) Changes in continence provision for children. Nursing Times; online issue 4, 8-9.
Author: June Rogers is PromoCon paediatric continence specialist.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here
Historically, school nurses have played a major role in supporting children with continence problems, providing expert advice and support. Some, for example, have run clinics for children with bedwetting problems, carrying out assessments and initiating first-line treatments.
Services for children currently have a lower priority than those of adults. The Nuffield Trust (Kossarova et al, 2016) identified that NHS England’s strategic plan has few explicit priorities for children and, other than mental health, child health is not explicitly incorporated in the latest NHS Business Plan priorities.
A number of recent changes have led to huge gaps in service provision:
- Transfer of school nursing from public health to local authority funding;
- Designation of continence issues, such as wetting problems in school, as a ‘clinical need’, rather than a ‘public health’ issue, which means that continence problems are no longer the remit of school nurses;
- Cuts in local authority funding.
The Paediatric Continence Forum (PCF), via a freedom of information request, identified the low priority given to commissioning community-based services for children and young people with bladder and bowel (continence) problems (PCF, 2015). Of the primary care trusts and clinical commissioning groups (CCGs) that responded, only 40% reported commissioning comprehensive paediatric continence services.
An estimated 900,000 children and young people (5-19 years) in the UK have bladder or bowel problems (Box 1), but this is likely to be an underestimate because problems are often under-reported, as families struggle to self-manage due to a lack of awareness about available services or because services simply do not exist.
Bedwetting among schoolchildren aged 6-13 is estimated at about 10% (Sarici et al, 2015), with constipation affecting up to 30% (Tabbers and Benninga, 2015) and daytime wetting 5-15% (Swithinbank et al, 2010). These figures are not insignificant, yet across the country the provision of integrated community-based services for children with continence problems is patchy, with isolated areas of excellent provision alongside areas providing little more than a free nappy service.
Box 1. Bladder and bowel problems
- Delayed toilet training
- Daytime bladder problems
- Faecal soiling
The Nuffield Trust (Kossarova et al, 2016) expresses concerns about the gap in paediatric knowledge and expertise in the community, specifically the appropriate paediatric training of providers in primary care (Kennedy, 2010). Only 30-40% of GPs have specialist paediatric training (NHS Confederation, 2012), some of which may not be relevant to dealing with children in primary care, yet children aged under 15 represent 10-25% of GP workload nationally (Gill et al, 2014; Kennedy, 2010). This is of particular concern now that many school nurses have been decommissioned from seeing children with problems, such as bedwetting. This role now falls within the remit of GPs, who may not have the capacity or experience to manage these issues.
Further concerns about the workforce for children and young people in the community have been raised in the 2015 QualityWatch Annual Statement (Health Foundation and Nuffield Trust, 2015), such as the decline in the number of paediatric doctors working exclusively in the community, alongside no increase in numbers of school nurses.
The Nuffield Trust (Kossarova et al, 2016) recommends placing greater emphasis on health promotion and disease prevention. It says that proactive early intervention, where every contact with a child and family is used as an opportunity, is essential. However, schools are only weakly connected to health and wellbeing services in the NHS and, as school nurses find themselves being limited to addressing mainly so-called public health issues, such as obesity and immunisation, rather than a child’s holistic needs, this connection is likely to come under further strain.
It is clear that many opportunities are being lost for collaborative innovation in prevention, health and wellbeing promotion. In the long term, early intervention and investment in the broader determinants of child health would lead to a reduction in the disease burden, with consequent benefits for adult health and social care services. Through early intervention, school nurses can identify and manage problems before they become serious and refer children with complex conditions to specialist provision.
Impact on the child and family
Wetting and soiling problems can have a significant emotional impact on children and young people, increasing the risk of bullying and behavioural problems (Joinson et al, 2006). Parents and carers also come under stress. There is evidence of a link between wetting and soiling accidents, and child punishment, including physical abuse by some parents or carers (National Institute for Health and Care Excellence, 2010a/2010b).
Continence problems in children and young people may take many months or years to resolve, so early diagnosis and management is vital. Failure to intervene early often results in the condition becoming chronic, requiring referral and treatment in hospital (PCF, 2015).
Many school nurses are highly competent in providing advice and information on nocturnal enuresis, constipation or soiling and toilet-training problems. This often includes first-line (level 1) treatment, including toileting, and fluid and diet advice, treatments for bedwetting (enuresis alarm or medication), and treatments for constipation, such as the use of stimulant laxatives or macrogols (via the GP or nurse prescriber) (PCF, 2015).
The use of hospital emergency care in managing acute problems is growing, such as for idiopathic constipation, which could potentially be resolved outside hospital (Gill et al, 2014). As well as being clinically inappropriate, high use of A&E and hospital admissions are expensive; diverting some patients to primary care, where clinically appropriate, could be a cheaper option for commissioners.
The NHS is under pressure to make savings but service cuts lead to a lack of capacity, paediatric expertise and communication between primary and secondary care. This, alongside, perceived or real difficulties in accessing GP appointments, may be why parents seek care from A&E or why care is often entirely offered in hospital (Kossarova et al, 2016).
The National Child and Maternal Health Intelligence Network maps out a range of issues around child health, including hospital admissions for constipation and length of stay, comparing the figures across regions and local authorities in England. If an area provides a well-resourced community paediatric continence service, the number of children presenting for hospital admission for constipation, for example, should be close to zero, yet most show a significant number of admissions, reflecting not only a poorly resourced community-based service, but poor compliance with NICE guidelines and standards.
Early intervention benefits
There are clear benefits of having school nurses in the continence team. They are in a prime position to pick up bladder and bowel problems early, thereby reducing inappropriate and expensive referrals by GPs to secondary and tertiary care. Early intervention by the school nurse (level 1) potentially ensures the problem is dealt with effectively in the community, with referral to community paediatric continence services, if necessary (level 2) (PCF, 2015).
Early interventions bring cost savings, as they reduce the need to make outpatient referrals to secondary and tertiary services. These can cost between £160 and £220 for first appointments and £94 to £123 for follow-ups; A&E attendances cost on average £108 and day-case treatment £693. This compares with an average figure of £17.66 an hour for a band 6/7 nurse in primary care (National Child and Maternal Health Intelligence Network, 2015).
Maintaining a level 1 school nurse intervention, as part of a community-based paediatric continence service, must continue to be a priority Many CCGs cite lack of funding or having no allocated budgets as a reason for services not being commissioned, yet the development of a community-based paediatric bladder and bowel (continence) service is something they cannot afford not to have. It is also vital for school nurses to play a pivotal role.
- Although school nurses are best placed for early identification of continence problems, changes in provision mean it is no longer within their remit
- Continence problems may be a symptom of an unrecognised issue and can have emotional consequences
- Early identification can prevent complications such as faecal impaction and urinary tract infections
- School nurses can provide advice on nocturnal enuresis, constipation and other continence problems
- Intervention by school nurses is cost-effective because it reduces the need to make referral
Gill PJ et al (2014) Primary care quality indicators for children: measuring quality in UK general practice. British Journal of General Practice; 64: 629, e752–757.
Health Foundation and Nuffield Trust (2015) Closer to Critical? QualityWatch Annual Statement 2015.
Joinson C et al (2006) Psychological differences between children with and without soiling problems. Pediatrics; 117: 5, 1575-1584.
Kossarova L et al (2016) The Future of Child Health Services: New Models of Care.
National Child and Maternal Health National Network (2015) Continence Needs Assessment: Continence in Children for Local Authorities and CCGs.
NHS Confederation (2012) Children and Young People’s Health and Wellbeing in Changing Times.
National Institute for Health and Care Excellence (2010a) Bedwetting in Under 19s. NICE Guidelines [GCG111]. Bit.ly/28QzXqQ
National Institute for Health and Care Excellence (2010b) Constipation in Children and Young People: Diagnosis and Management. NICE Guidelines [CG99].
Paediatric Continence Forum (2015) Paediatric Continence Commissioning Guide.
Sarici H et al (2015) Prevalence of nocturnal enuresis and its influence on quality of life in school-aged children. Journal of Pediatric Urology; doi: 10.1016/j.jpurol.2015.11.011
Swithinbank LV et al (2010) The natural history of daytime urinary incontinence in children: a large British cohort. Acta Paediatrica; 99: 7, 1031-1036.
Tabbers MM, Benninga MA (2015) Constipation in children: fibre and probiotics. BMJ Clinical Evidence. Mar 10. pii: 0303.