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

Service components

The key components of a faecal continence service for the management of faecal incontinence (FI) in adults are:

• identifying, assessing and initial management of FI
• developing a high-quality integrated continence service for the management of FI.

Identifying, assessing and initial management

Because FI is a stigmatising condition, NICE clinical guideline CG49 on faecal incontinence states that active case-finding will often be needed. It recommends that healthcare professionals should actively yet sensitively enquire about symptoms in high-risk groups including, for example, frail older people and people with urinary incontinence. The clinical guideline also recommends a proactive approach to bowel management for specific groups including people with limited mobility, faecal loading and constipation. Therefore, it is important that clinical teams work with local and national organisations to raise public awareness of the causes, prevalence and symptoms of FI and encourage people with FI to seek appropriate help.

Continence problems usually present in primary care; however, some people will present or be identified for the first time during a hospital admission. Commissioners will need to be confident that primary care staff, community teams and hospital staff are trained to identify people with FI and carry out a clinical baseline assessment to identify contributory factors. They should be able to offer initial management tailored to individual circumstances and adjusted to personal response and preference.

The recommended interventions include information about diet, bowel habit, toilet access, medication and coping strategies. In addition, advice should be offered on the use of continence products such as disposable body-worn pads and toilet access cards, and a RADAR key to allow access to ‘disabled' toilets in the National Key Scheme.

There will be some symptomatic people who do not wish to continue with active treatment or who have intractable FI. These people will require long-term management and NICE clinical guideline CG49 on faecal incontinence recommends that their symptoms should be reviewed at least every 6 months. Commissioners will wish to be assured that healthcare professionals are competent to offer this advice and support.

Developing a high-quality integrated continence service for the management of FI

NICE clinical guideline CG49 on faecal incontinence recommends that people who continue to have episodes of FI after initial management should be considered for specialised management. This may involve referral to a specialist continence service, which may include:

• pelvic floor muscle training
• bowel retraining
• specialist dietary assessment and management
• biofeedback
• electrical stimulation
• rectal irrigations.

People with continuing FI after specialised conservative management should be considered for specialist assessment, including:

• anorectal physiology studies
• endoanal ultrasound; if this is not available, magnetic resonance imaging, endovaginal ultrasound and perineal ultrasound should be considered
• other tests, including proctography, as indicated.

Therefore, commissioners will need to ensure that there is appropriate local access to, and capacity for, the investigations required, and that people who report or are reported to have FI are offered the appropriate care. This care should be managed by healthcare professionals who have the relevant training and experience and who work within an integrated continence service. These healthcare professionals, who are usually specialist continence nurses and specialist physiotherapists, may have a number of responsibilities, including the specialised assessment and management of FI, awareness raising activities, and the training and education of other healthcare workers across primary, secondary and residential care. Commissioners will wish to assure themselves that all healthcare professionals involved in the management of FI have the required skills and access to relevant training and education. See the implementation advice for NICE clinical guideline CG49 on faecal incontinence for information on initiating awareness raising activities and on training and education.

The Good practice in continence services sets out a model of good practice to help healthcare professionals achieve more responsive, equitable and effective continence services, including principles for commissioning a properly integrated continence service. It suggests that, locally, a strategic lead or director may be responsible for coordinating the development and implementation of common policies and procedures across relevant healthcare sectors and with local authorities. It also suggests that commissioners will need to consider a cohesive and comprehensive service that enables treatment, based on assessment, to be delivered in the most appropriate setting. This is usually primary care in the first instance, which then allows easy access to specialist care when needed. Therefore mixed models of provision may be appropriate across a local health economy. Appendix 3 of the 2007 Royal College of Nursing publication Is policy translated into action? provides an example of a model for an integrated continence service.

Local stakeholders, including service users and carers, should be involved in determining what is needed from a faecal continence service in order to meet local needs. The service should be patient-centred and integrated in line with the recommendations set out in Good practice in continence services.

The service specification needs to consider:

• the required competencies of, and training for, staff responsible for providing the service
• the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place)
• ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally
• care and referral pathways
• information and audit requirements, including IT support and infrastructure
• planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks
• service monitoring criteria.

Useful sources of information may include:

• Delivering the 18 week patient pathway: 18 week commissioning pathways: Rectal bleeding commissioning pathway 2008 and Change in bowel habit commissioning pathway 2008
• The NHS networks: learning from practice database offers examples of innovative commissioning across the NHS and its partners.
• The Map of medicine provides an information resource that visually organises the latest evidence and best practice guidelines.
• The NICE shared learning database offers examples of how organisations have implemented NICE guidance locally.
• NICE implementation advice for NICE clinical guideline CG49 on faecal incontinence.