Commissioning a paediatric continence service
Nocturnal enuresis, or bedwetting, is involuntary wetting during sleep in a person with no physical disease at an age when they could be expected to be dry, generally considered to be a developmental age of 5 years or over. Children and young people who experience bedwetting may also have daytime urinary tract symptoms, such as daytime wetting or frequent or urgent urination[1,2].
Idiopathic constipation is difficulty, pain or straining when passing stools, and/or passing stools less often than normal. Constipation is referred to as ‘idiopathic' if it cannot be explained by anatomical or physiological abnormalities.
Continence problems in children and young people are common, yet there is evidence that the need and demand for continence services in some areas is significantly under-resourced when compared with services for other conditions with a comparable prevalence, such as asthma and otitis media (ear inflammation)[5,6]. Continence problems are more common in younger children, with constipation having a peak prevalence in toddlers. However, prevalence remains high in older age ranges, with 1 in 50 teenagers experiencing bedwetting and 1 in 100 children and young people aged between 11 and 18 years having idiopathic constipation[2,7,8].
Continence problems are more prevalent among children and young people who have some physical disabilities, such as spina bifida or cerebral palsy. Children and young people with learning difficulties such as Down's syndrome or autistic spectrum disorders may take longer to achieve continence[2,4,9].There is also a higher prevalence of continence problems among children and young people in local authority care.
Continence problems can have a significant emotional impact, and can increase the risk of bullying and of behavioural problems in children and young people. Managing the problem can be stressful for parents and carers and can strain family relationships. While most parents do not get angry with their child as a result of bedwetting, there is evidence of a link with child punishment, including physical abuse by parents or carers[1,2,4].
Continence problems in children and young people may take many months or years to resolve, so it is important that they are diagnosed and managed early. If the conditions are not managed and become chronic they may result in referral, treatment and/or surgery in secondary care[2,4]. Toilet training and evidence-based treatment for continence problems can be effective using a variety of interventions, from drug treatments and bedwetting alarms to more complex and comprehensive treatment plans. It is important that treatment is adapted to the needs and circumstances of the child or young person and their family.
It is estimated that establishing a paediatric continence service for children and young people aged 19 years and under could lead to a significant reduction in the number of admissions to secondary care for idiopathic constipation, by providing assessment and management of continence problems in primary and community settings. There is also the potential to reduce costs further by reducing the demand for continence products such as nappies or pads.
The 2010 National audit of continence care for adults found that most continence services are poorly integrated across acute, primary and community settings, that training of healthcare professionals is inadequate and that there is no-one specifically responsible for commissioning and improving continence services. Good practice in paediatric continence services recommends that commissioners of health and social care services commission an integrated paediatric continence service.
The potential benefits of robustly commissioning an effective paediatric continence service include:
- greater awareness of continence problems resulting in improved identification, early intervention and faster referral-to-treatment times
- reducing costs resulting from inappropriate referrals to paediatricians and preventing unplanned hospital admissions for children and young people with abdominal pain caused by chronic constipation
- improving clinical outcomes and quality of life for children and young people and their families through evidence-based treatment that promotes continence, preventing unnecessary long-term reliance on nappies and pads and the need for surgery
- increasing clinical and cost effectiveness: by making commissioning decisions based on NICE guidance and accredited information from NHS Evidence, commissioners can ensure that they are using their resources more effectively.
Key clinical issues
Key clinical issues in providing an effective paediatric continence service are:
- increasing awareness of continence problems so that children and young people with continence problems are identified and assessed, and where appropriate those with ‘red flag' symptoms or safeguarding concerns are referred promptly to the appropriate service (see service components section)
- improving assessment and reducing unnecessary invasive examinations and procedures, leading to improved clinical outcomes, by providing evidence-based treatment for continence problems in line with NICE guidance
- providing a ‘whole child' approach so that complex and comorbid problems can be treated appropriately, leading to better outcomes for children and young people and their parents or carers
- providing a quality assured service.
National priorities and initiatives relevant to commissioning a paediatric continence service include:
- Equity and excellence: liberating the NHS: Transparency in outcomes - a framework for the NHS (draft for consultation).
- Revision to the operating framework for the NHS in England 2010/11
- Procurement guide for commissioners of NHS-funded services 2010.
- Quality, innovation, productivity and prevention.
- Commissioning for quality and innovation (CQUIN): makes a proportion of providers' income conditional on quality and innovation.
- The Care closer to home initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
- 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.
- National service framework for children, young people and maternity services.
- Good practice in continence services.
- Every child matters: change for children and Sure Start Children's Centres.
- Healthy child programme: pregnancy and the first five years of life and the Healthy child programme: from 5 to 19 years old.
- Healthy lives, brighter futures - the strategy for children and young people's health.
- Aiming high for disabled children.
- Essence of care 2010: benchmarks for bladder, bowel and continence care.
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.
1. NHS Modernisation Agency (2003) Good practice in paediatric continence services - benchmarking in action. London: Department of Health
2. National Clinical Guideline Centre (2010) Nocturnal enuresis: the management of bedwetting in children and young people. London: Royal College of Physicians
3. Patient UK (2008) Constipation in children. Available from www.patient.co.uk/health/Constipation-in-Children.htm
4. National Collaborating Centre for Women‘s and Children‘s Health (2010) Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care. London: Royal College of Obstetricians and Gynaecology Press
5. National Institute for Health and Care Excellence (2010) Surgical management of OME: costing template.
6. National Institute for Health and Care Excellence (2010) Guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma.
7. Prynn P (2008) Practical advice for managing constipation in infants. Continence UK 2(3)
8. Butler RJ (1998) Night wetting in children: psychological aspects. Journal of Child Psychology and Psychiatry 39: 453-63
9. Thomas S (2005) Commissioning continence services for children and young people. Nursing Times.net
10. Mooney A, Statham J, Monck E et al. (2009) Promoting the health of looked after children: A study to inform revision of the 2002 guidance. Institute of Education: University of London
This page was last updated: 02 March 2012