Specifying a urinary continence service

Service components

The key components of a urinary continence service for the conservative management of urinary incontinence (UI) are:

• identification and appropriate referral of women with UI
• initial assessment and conservative management of UI by trained and competent staff
• developing a high-quality integrated continence service.

Identification and appropriate referral of women with UI

The Department of Health publication Good practice in continence services describes a number of problems across England that affect access to, and delivery of, services. It suggests that:

• systematic effort is required to identify cases of incontinence, regardless of where a person may be residing
• public education and awareness of incontinence is a critical factor in the delivery of good services
• staff trained in the identification and management of incontinence should ensure a proactive approach during clinical consultations and should assist in the identification of women experiencing symptoms associated with UI in nursing/residential homes and across primary and secondary care.

Continence problems will usually present and be identified in primary care. However, older people living in long-stay accommodation should have the same access to services as those living in their own home. Primary care and community teams should have professionals who are trained to carry out initial assessment and conservative management, and/or a referral pathway to a specialist continence service.

All people with UI and symptoms indicating a more complex condition should have access to a specialist continence service that employs, among others, specialist continence nurses and specialist physiotherapists. These health professionals have a number of responsibilities, including the initial assessment and conservative management of UI, awareness raising activities, and the training and education of other healthcare workers across primary and secondary care.

NICE clinical guideline CG40 on urinary incontinence recommends that women with UI who have symptoms indicative of suspected cancer should receive an urgent referral in accordance with the national target for urgent referrals for suspected cancer.

For further information on referral pathways see Delivering the 18 week patient pathway: urology pathway, which includes ‘blood in urine pathway version 2.1' and ‘female incontinence pathway version 2.1'.

Initial assessment and conservative management of UI by trained and competent staff

NICE clinical guideline CG40 on urinary incontinence recommends the following.

• At the initial clinical assessment, the woman's UI should be categorised as stress UI, mixed UI or urge UI/overactive bladder syndrome (OAB). Initial treatment should be started on this basis. In mixed UI, treatment should be directed towards the predominant symptom.
• The use of multi-channel cystometry, ambulatory urodynamics or videourodynamics is not recommended before starting conservative treatment.
• Absorbent products, hand held urinals and toileting aids should not be considered as a treatment for UI. They should be used only as a coping strategy pending definitive treatment, as an adjunct to ongoing therapy or for long-term management of UI only after other treatment options have been explored.

The conservative management of UI in women includes:

• Lifestyle interventions.
• Pelvic floor muscle training.
• Bladder training.
• Drug treatment if bladder training is ineffective.
• Bladder catheterisation for women in whom persistent urinary retention is causing incontinence.
• Electrical stimulation and/or biofeedback for women who cannot actively contract their pelvic floor muscles. However, current availability is limited in some areas, so commissioners may wish to consider commissioning services from specialist regional teams.

Commissioners will wish to assure themselves that all health professionals involved in the conservative management of UI have the required skills and access to relevant training and education. See the implementation advice for NICE clinical guideline CG40 on urinary incontinence for information on initiating awareness raising activities and on training and education.

Developing a high-quality integrated continence service

The Department of Health publication Good practice in continence services sets out a model of good practice to help health professionals achieve more responsive, equitable and effective continence services. 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. Appendix 3 of the 2004 Royal College of Nursing publication Is policy translated into action? provides an example of a model for an integrated continence service.

Commissioners will need to consider commissioning a service that enables treatment, based on assessment, to be delivered in the most appropriate setting, which is usually primary care in the first instance; and allows easy access to specialist care when it is needed. Mixed models of provision may be appropriate across a local health economy.

The NICE shared learning database offers an example of a nurse/physiotherapist-led urinary continence service based in primary care for women in the Bradford and Airedale Teaching Primary Care Trust, which has a large multi-ethnic minority population and areas of wealth and deprivation. Before the introduction of the initiative, many inappropriate referrals were made to urology and gynaecology consultants in secondary care. A single primary care pathway was developed to facilitate referral to the continence service and promote conservative management in accordance with NICE clinical guideline CG40 on urinary incontinence and best practice guidelines. An audit of the service is in progress; however, local GPs and health professionals working in primary care have engaged in the pathway and the number of referrals to the continence service has increased.

More general examples can be found at the Shifting care closer to home demonstration sites - report of the specialty subgroups for urology and gynaecology. These examples identify innovative ways of delivering urology and gynaecology services that include continence services, and suggest that outpatient treatment can be carried out in community settings, closer to home, by any combination of the following staff: specialist nurses, GPs with a special interest in the condition, ultrasonographers, and consultant urologists and physiotherapists, provided that they have had appropriate training and demonstrate the required competencies. These examples are offered in order to share local practice, but NICE makes no judgement on the compliance of these services with its guidance.

Local stakeholders, including service users and their carers, should be involved in determining what is needed from a continence service in order to meet local needs. Commissioners may wish to consider the needs of men, children, and specific groups who are likely to encounter continence problems and/or have service access difficulties. These include ethnic minority groups; people with long-term physical disabilities, neurological conditions or learning disabilities; and homeless people and those living in hostels or residential care.

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; ensuring services are accessible to all residents in the area served
• 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.

Further useful sources of information may include:

• Delivering the 18 week patient pathway: 18 week commissioning pathways Female incontinence.
• 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.
• Implementation advice for NICE clinical guideline CG40 on urinary incontinence.