Quality statement 5: Specialised management

Quality statement

Adults who continue to experience episodes of faecal incontinence after initial management are offered referral for specialised management.

Rationale

Some people will continue to have episodes of faecal incontinence after initial management and may benefit from specialised assessment and management, which can both identify the cause of symptoms and indicate further treatment options. These people should have the opportunity to discuss the possibility of referral and agree a course of action that meets their needs and preferences; some people will choose not to pursue active treatment. There are a number of specialist conservative, medical and surgical interventions that can help, and these are likely to be provided by different specialists. Access to the most appropriate specialist management will improve the quality of life for some people with faecal incontinence.

Quality measures

Structure

Evidence of local referral pathways for all options for specialised management of faecal incontinence.

Data source: Local data collection. The National Audit of Continence Care (NACC) collects data on whether services have clear pathways for referral between providers. The APPG Continence Care survey includes a question on what pathways are available for people with incontinence within the organisation.

Process

Proportion of adults continuing to experience episodes of faecal incontinence after initial management who are offered referral for specialised management.

Numerator – the number of people in the denominator who are offered referral for specialised management.

Denominator – the number of adults continuing to experience episodes of faecal incontinence after initial management.

Data source: Local data collection. Also contained in NICE audit support for Faecal incontinence (NICE clinical guideline 49), criterion 5. The National Audit of Continence Care (NACC) collects data on further investigations and referrals to a specialist or another service for people with a treatment plan.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers have local referral pathways for all options for specialised management of faecal incontinence and ensure that staff providing initial management are aware of them.

Healthcare professionals ensure that they are aware of local referral pathways for all options for specialised management of faecal incontinence and offer referrals in accordance with these to adults who continue to experience episodes of faecal incontinence after initial management.

Commissioners ensure that they commission services with expertise and capacity for specialised management of faecal incontinence.

What the quality statement means for patients, service users and carers

Adults who still have symptoms after the first steps in managing faecal incontinence are offered a referral for specialist advice and possible further treatment.

Source guidance

  • Faecal incontinence (NICE clinical guideline 49), recommendations 1.4.1 (key priority for implementation) and 1.4.2.

Definitions of terms used in this quality statement

Faecal incontinence

This is any involuntary loss of faeces that is a social or hygiene problem [NICE clinical guideline 49, scope].

Initial management

This involves adjusting the person's fluid intake, diet and medication separately and ensuring that they complement each other (see statement 4). [NICE clinical guideline 49, full guideline].

Specialised management

This consists of conservative, medical or surgical interventions provided by a specialist continence service or secondary care specialists and may include:

  • pelvic floor muscle training

  • bowel retraining

  • specialist dietary assessment and management (this is a detailed specialist intervention, separate to the basic dietary advice offered as part of initial management)

  • biofeedback

  • rectal irrigation

  • electrical stimulation

  • 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

  • surgery (for example, sphincter repair, sacral nerve stimulation, stoma).

[Adapted from NICE clinical guideline 49, recommendations 1.4.1 and 1.5.1].

Equality and diversity considerations

Faecal incontinence is associated with many protected characteristics that are covered by the Equality Act 2010, including age, disability, sex, and pregnancy and maternity. The consequences may also impact on others, including religion and belief. Not all interventions offered by specialist services will be suited to all people with faecal incontinence. For example, some treatments may not be suitable for people who are unable to understand or adhere to treatment instructions, and interventions such as pelvic floor muscle training may not be suitable for people with neurological or spinal conditions. The key consideration is to ensure that people with protected characteristics covered by the Act can access specialised management if it is appropriate for them, and that assumptions are not made about suitability of the intervention. Adjustment should be made to both specialist assessment and treatment options when possible. This may mean giving extra support and time, especially to disabled people. Improving access to specialist services for all people with faecal incontinence is an important step in removing any unequal access to the most effective care. Effective management is likely to promote equality of opportunity by allowing increased participation in society and public life.