Commissioning a faecal continence service for the management of faecal incontinence in adults

Faecal incontinence (FI) is a stigmatising condition that is likely to affect over half a million men and women in the UK. Current epidemiological information shows that between 1% and 10% of adults are affected. It is likely that 0.5-1.0% of adults experience regular FI that affects their quality of life. FI is closely associated with age (prevalence is about 15% in adults aged 85 years living at home) and is even more common in residential and nursing homes (prevalence ranges from 10% to 60%)^[1].

Because of fear and embarrassment, FI remains a largely hidden problem, particularly for people where there are associated cultural/religious issues. People with FI often experience social exclusion, and frequently suffer from stress, anxiety and depression, which can cause them to delay seeking help. A proactive approach to case-finding is needed because people with FI and their carers may not be aware that there are treatment options available that often result in the alleviation of symptoms and/or a cure.

Faecal continence services should be provided as part of an integrated continence service and people with FI should be offered care by healthcare professionals who have the relevant skills, training and experience. The management of FI usually starts with addressing reversible factors using a conservative approach that includes advice about diet, bowel habit and/or medication. Only if this fails to restore continence does it progress to specialised options and investigations.

The specialised management of FI includes non-surgical interventions such as pelvic floor muscle training, bowel retraining, specialist dietary advice, biofeedback, electrical stimulation and rectal irrigation. Frequently, specialised continence services are provided by specialist continence nurses and/or physiotherapists.

Nearly two thirds of people with FI are also expected to have urinary incontinence (known as double incontinence). The Good practice in continence services and the National service framework for older people have called for integrated continence services to be established to address the needs of people with urinary incontinence and/or FI. However, in 2005 and 2006 the National audit of continence care for older people, sponsored by the Healthcare Commission, reported that a basic infrastructure is currently in place to deliver improved continence services, but that there has been little progress in the pursuit of truly integrated continence services as envisaged. There is a suggestion from hospital trusts that there is a reduced availability of continence specialist nurses. This is a cause for concern because continued inadequate assessment of incontinence, with an emphasis on containment rather than cure, does not indicate high-quality care. Also, it is expensive from a financial and a health perspective. In the face of the great daily cost of containing continence, the audit indicates a missed opportunity to assess, treat and reduce the numbers of incontinent people and the associated financial costs.

Benefits

The potential benefits of robustly commissioning an effective faecal continence service for the management of FI in adults include:

• providing the best possible outcomes for people and their carers through identification and intervention, resulting in alleviation of FI symptoms and/or cure
• improving perceived quality of life, preservation of dignity and, where possible, independence and mobility
• providing long-term management for people who do not wish to continue with active treatment or who have intractable FI
• reducing the risk of urinary tract infections, falls, social isolation and depression in older people suffering from FI^[1]
• reducing inappropriate reliance on disposable pads and other products for the containment of FI in older people^[1]
• reducing inappropriate referrals to specialised services
• reducing inequalities and improving access to services that are culturally sensitive and meet the needs of people with physical, sensory, mental or learning disabilities.
• better value for money, through helping commissioners to manage their commissioning budgets more effectively - this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways.

Key clinical issues

Key clinical issues in providing an effective faecal continence service for the management of FI in adults are:

• actively identifying people with FI
• conducting a clinical baseline assessment identifying any contributory factors before any treatment for FI is considered
• offering a combination of initial management interventions and condition-specific interventions before any specialised treatment
• providing effective and efficient clinical care to high-risk and specific groups and those requiring specialised and long-term management in line with NICE clinical guideline CG49 on faecal incontinence
• providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning a faecal continence service for the management of FI in adults include:

• National service framework for older people.
• Good practice in continence services.
• Referral guidelines for suspected cancer.
• Delivering the 18 week patient treatment pathway.
• The Care closer to home' initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say.
• Commissioning framework for health and well-being.
• World Class Commissioning.
• The NHS in England: The operating framework for 2009/10.
• Considering the impact of patient choice.
• A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with Standards for better health.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.

References

1. Royal College of Physicians (2006) National audit of continence care for older people 2006. London: Royal College of Physicians.