Commissioning a urinary continence service

Urinary incontinence (UI) is a common condition that can affect women of all ages. It is defined by the International Continence Society as ‘the complaint of any involuntary leakage of urine' and is wide ranging in its severity and features. Urinary incontinence may occur as a result of abnormalities of function of the lower urinary tract or as a result of other illnesses that tend to cause leakage in different situations.

The conservative management of UI refers to treatment therapies that do not involve surgery. Conservative management is recommended in NICE clinical guideline CG40 Urinary incontinence: the management of urinary incontinence in women as a first-line, cost effective option for women with UI. It includes lifestyle interventions, physical, behavioural and drug therapies, and may also include preventive strategies such as pelvic floor muscle training for women in their first pregnancy.

Although rarely life-threatening, UI can seriously influence the physical, psychological and social well-being of affected individuals. The impact of the condition on the families and carers of women with UI may be profound, and the resource implications for the health service can be considerable. The Department of Health publication Good practice in continence services published in 2000 reported that incontinence is often a major reason for the breakdown of the relationship between the carer and the person they are caring for, and this can lead to the affected person being admitted to residential or nursing home care; incontinence is second only to dementia as an initiating factor for such moves.

Where data exist, most estimates of prevalence of UI in the adult female population (15 years and older) vary between 25% and 45%^[1]. However, UI may be significantly underreported because of the associated embarrassment.

Although UI affects predominantly women, commissioners may wish to consider the needs of their whole population, especially older people (including those living in nursing homes), when commissioning urinary continence services. These services should be organised in an integrated way, with various professionals often employed by health and social care agencies, providing a service that has agreed clinical governance principles.

The 2001 National service framework for older people called for the establishment of integrated continence services for older people by 2004. However, evidence suggests that there has been limited action towards fulfilling this aim, and that the provision of services remains extremely variable^[2].

Benefits

The potential benefits of robustly commissioning an effective urinary continence service for the conservative management of UI include:

• reducing unnecessary treatment and inappropriate reliance on products for the containment of UI - for example, pads and other equipment^[3]
• providing the best possible outcomes for women and their carers through identification and intervention, resulting in alleviation of UI symptoms and/or cure
• reducing the risk of urinary tract infections, falls, social isolation and depression and improving the quality of life for older people suffering from UI^[3]
• reducing inequalities and improving access, enabling older women, women with physical, sensory or learning disabilities and women who do not speak or read English to have equal access to information and urinary continence services
• improving performance and person-centred clinical care through implementing the recommendations for the conservative management of UI as outlined in NICE clinical guideline CG40 on urinary incontinence
• better use of resources, through helping commissioners to commission 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 urinary continence service for the conservative management of UI are:

• actively identifying women with UI through the provision of education and training for healthcare workers across primary and secondary care
• initiating appropriate treatment following assessment and symptomatic categorisation of the cause of UI by appropriately trained staff
• ensuring that women requiring urgent referrals for suspected cancer are seen within the 2-week national target for urgent referrals and that appropriate referral pathways are in place for specialist referral for more complex cases
• providing effective and efficient clinical care for the conservative management of UI in line with NICE clinical guideline CG40 on urinary incontinence
• providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning a urinary continence service for the conservative management of UI include:

• World class commissioning.
• The NHS in England: The operating framework for 2009/10.
• 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.
• The Expert patients programme.
• 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. National Collaborating Centre for Women's and Children's Health (2006) Urinary incontinence. Full national clinical guideline on the management of urinary incontinence in women. London: RCOG Press.
2. Thomas S (2003) Is policy translated into action? London: The Continence Foundation and Royal College of Nursing.
3. Royal College of Physicians (2006) National audit of continence care for older people 2006. London: Royal College of Physicians.