An enterprising project is aiming to define standards of care and service expected in the neglected area of continence

An enterprising project is aiming to define standards of care and service expected in the neglected area of continence

Despite much work in producing national guidelines and policies, continence care remains a neglected area. For elderly people, it means the provision of pads and products at great cost to the NHS, often to the detriment of clinical assessment and management.

Inadequate assessment of incontinence, with an emphasis on containment rather than cure, is expensive from both a financial and health perspective.

Because of the great costs involved in containing continence, a national audit of continence care for older people indicated a missed opportunity to assess, treat and reduce numbers of incontinent people.

One of the audit's main findings was that relatively few primary or secondary care services had produced a written policy which addresses patient management, education and training, and quality assurance.

This led to a range of clinical and management problems. For example, where nearly all sites asked a screening question relating to bladder and bowel care, only 64 per cent of primary and 44 per cent of secondary sites had a protocol for providing basic assessment to patients.

Only half of acute trusts offered structured training on continence management to staff. Despite the fact that 80 per cent of services had a written policy that pads should be available on the basis of clinical need, 81 per cent of primary care and 76 per cent of care home services limited the maximum number of daily pads for patients.

Healthcare staff wanted to improve quality of the care, but felt this was difficult without a clear steer on direction of travel. Feedback from the audit showed that they would value a free downloadable template policy that they could use to define standards of care.

There is clearly a need for a central store for the collection of this material, in addition to a forum for distribution of information which allows staff caring for people with continence problems to save time and costs. The confusion caused by the proliferation of recommendations and management guidelines prompted the Royal College of Physicians' clinical effectiveness unit to host a new resource.

The working party for the national audit felt that they could provide a template by examining the many policies submitted, giving each a 'quality mark' and then putting these on the internet site for people to mix and match for their own purposes.

We were also determined to ensure that the final policy should be practical, recommending evidence-based treatment pathways, which were reported to be used by only 40 per cent of primary care and 24 per cent of secondary care services.

The nursing members of the working party have now analysed all of the policies applicable to secondary and primary care to draw up the template. During this process they have identified a lack of good-quality policies applicable to care homes, which include statements about what should be expected from local district nursing and specialist continence services. The working party is building a template to fill this gap.

While there is not yet any evidence that having a policy can influence quality of care, a set of agreed standards can only aid delivery, supply useful focus to the disease area and provide a benchmark by which quality of care can be judged.

The template will cover: case finding; assessment; referrals; management plans and care pathways; service-level agreements; education and training; audit and governance; and patient and carer involvement.

It will be using examples of best practice from all over the country. These include the use of care pathways at Bristol South and West primary care trust and the management guidelines from West Lincolnshire PCT, which have been recognised by the working party as outstanding examples.

Adrian Wagg is clinical director of the healthcare of older people programme at the Royal College of Physicians. Get the report here