PREFACE
Two key developments make this publication timely: the NHS is re-organising its primary care services into Primary Care Groups (and soon into Primary Care Trusts); and the Department of Health has issued guidance on best practice for the delivery of continence services. This guidance, prepared by an expert working party, results from concern at Ministerial level about weaknesses in the current service.

But it is unlikely that many PCGs or PCTS will give high priority to continence services unless the arguments for investing in them are powerfully deployed.

This booklet brings together relevant facts and figures from which continence specialists can make a compelling case. It relates primarily to England but can readily be adapted to use elsewhere in the UK.

In producing this booklet we have had much valuable help from Veronica Haggar (Association for Continence Advice), Sue Thomas (Royal College of Nursing Continence Care Forum) and Mandy Wells (representing Incontact); and their organisations together with the Association of Chartered Physiotherapists in Women's Health lend the publication their support.

David Pollock
Director
The Continence Foundation
March 2000

identification at primary practice level of all patients with incontinence;

full assessment leading to first-line treatment in the primary care setting, with treatment/ management plans agreed with individual patients;

integrated continence services, run by a Director of Continence Services who would usually be a specialist continence nurse or physiotherapist, bringing together under agreed protocols and procedures primary, secondary and tertiary care, including specialist diagnostic and treatment services;

continence services to be comprehensive, embracing urinary and faecal incontinence, children and adults, at home and in homes, and bringing together all relevant health disciplines, social, educational and psychological services, users and carers ( see also section 13. )

2. THE ORIGIN OF THE GUIDANCE

The new guidance was drafted by an expert group chaired by Professor Paul Abrams of the Bristol Urological Institute. This group was appointed by Paul Boateng, then Under Secretary at the Department of Health, in the wake of considerable public and Parliamentary concern over the inadequacies of some local services (Patients Association, 1998; Anthony, 1998). This was exacerbated when the Government without notice closed a loophole, previously countenanced by the Treasury, whereby VAT could be avoided on NHS purchases of continence pads for home delivery (Continence Foundation, 1998). Protests were successfully coordinated from national level and the Department of Health was led to setup the review group with a remit to draft the guidance.

References:
Continence Foundation (1998): The Politics of Continence. Continence Foundation, London

Anthony B (1997): The Provision of Continence Supplies by NHS Trusts. Middlesex University School of Health, Biological and Environmental Sciences, for Incontact.

Patients Association (1998): The Priority Given to Commissioning Health Services for Elderly People and those with Incontinence Problems by Health Authorities. Patients Association, Harrow, Middlesex.

1.   The New NHS Guidance
2.   The Origin of NHS Guidance
3.   Prevalence of Incontinence
4.   Calculating the Local Numbers Affected
5.   The Natural History of Incontinence
6.   The Iceberg Effect
7.   Special Local Considerations
8.   Comparing Numbers with other Diseases
9.   Linking Incontinence with NHS Priorities
10. Quality of Life
11. Clinical Governance
12. The Cost of Incontinence to the NHS
13. The Need for an Integrated Service
14. Getting Incontinence on the Agenda
     RETURN TO TOP OF PAGE

NB: 3.8% wanting help is 3,800 per 100,000 population aged over 40.

4. CALCULATING THE LOCAL NUMBERS AFFECTED

You can apply the percentages quoted above to the national population and to your local population. Alternatively, use the figures from the Royal College of Physicians study (1995). These are for people living in their own homes (see section 7(a) below for those in residential and nursing homes and long-stay hospitals) and are set out in the table below.

If you do not know your local population figures by age and sex, your Health Authority Public Health Department or your NHS Trust will have them.

Alternatively:

in England and Wales, for health authority populations by sex and age, consult "1991 Census: Key Statistics for New Health Areas - England and Wales" (ISBN 011 691 6990) and for local authority populations telephone the Population Estimates Unit (01329 813318) or check the Office of National Statistics website (http://www.statistics.gov.uk);

in Scotland consult the General Register Office website http://www.gro-scotland.gov.uk and in the Data Library click Population Estimates - 1998 mid-year and download table 4 or else obtain "Mid-1998 Population Estimates - Scotland" (ISBN 1-874451-55-9) (the same estimates) from Customer Services, GRO for Scotland, Ladywell House, Ladywell Road, Edinburgh EH12 7TF;

in Northern Ireland consult the website http://www.nisra.gov.uk (look under Statistics/Demography) or contact the General Register Office (tel 028 9025 2032, fax 028 9025 2044, Oxford House, 49-55 Chichester Street, Belfast BT1 4HL) for mid-year population estimates for local authorities; for health board figures, write to the Census Office, Macauley House, 2-12 Castle Street, Belfast BT1 1SA.

* Royal College of Physicians (1995)

** Office of National Statistics - figures for 1997.

§ e.g., if you have 50,000 women locally aged 45-64, then the minimum number who are likely to be incontinent is 50,000 x 8 / 100 = 4,000 and the maximum number 50,000 x 15 / 100 = 7,500. (Then, if only 2,000 women in this age group are on your local records as having continence problems, you can deduce that at least 2,000 and maybe up to 5,500 have not presented, indicating the need for local awareness campaigns.)

Reference:

Royal College of Physicians of London (1995): Incontinence: causes, management and provision of services. Royal College of Physicians, London. ISBN 1 873240 97 X

1.   The New NHS Guidance
2.   The Origin of NHS Guidance
3.   Prevalence of Incontinence
4.   Calculating the Local Numbers Affected
5.   The Natural History of Incontinence
6.   The Iceberg Effect
7.   Special Local Considerations
8.   Comparing Numbers with other Diseases
9.   Linking Incontinence with NHS Priorities
10. Quality of Life
11. Clinical Governance
12. The Cost of Incontinence to the NHS
13. The Need for an Integrated Service
14. Getting Incontinence on the Agenda
     RETURN TO TOP OF PAGE

References:

Chiozza M et al (1998): An Italian epidemiological multicentre study of nocturnal enuresis: British Journal of Urology 81:suppl 3: 86-89

Diokno A (1998): Post prostatectomy urinary incontinence: Ostomy Wound Management 44:54-8, 60

Foldspang A et al (1999): Prevalent urinary incontinence as a correlate of pregnancy, vaginal childbirth and obstetric techniques: American Journal of Public Health 89:209-12

Hamper C et al (1997): Prevalence and natural history of female incontinence: European Urology 32:suppl 2: 3-12

Jay J et al (1998): Urinary incontinence in women: Advanced Nurse Practitioner 6:32-7

Johnson M (1998): Nocturnal enuresis: Urological Nursing 18:259-73

Kamm M (1994): Obstetric damage and faecal incontinence: Lancet 344: 730-733

Keller S (1999): Urinary incontinence: occurrence, knowledge, and attitudes among women aged 55 and older in a rural Midwestern setting: Journal of Wound Ostomy and Continence Nursing 26:30-38

Malmsten U et al (1997): Urinary incontinence and lower urinary tract symptoms: an epidemiological study of men aged 45-99: Journal of Urology 158:1733-7

Moilanen I et al (1998): A follow up of enuresis from childhood to adolescence: British Journal of Urology 81:suppl 3:94-97

Norton C (1996): Faecal incontinence in adults: prevalence and causes: British Journal of Nursing 5: 1366-1373

Payne C (1998): Epidemiology, pathophysiology and evaluation of urinary incontinence and overactive bladder: Urology 51:(2A suppl):3-10

Samuelson E et al (1997): A population study of urinary incontinence and nocturia among women aged 20-59 years: prevalence, well-being and wish for treatment: Acta Obstetrica et gynaecologica Scandinavica 76:74-80

Swithenbank L et al (1998): The natural history of urinary symptoms during adolescence: British Journal of Urology 81:90-3 Thom D (1998): Variation in estimates of urinary prevalence in the community: effects of differences in definition, population characteristics and study type: Journal of the American Geriatric Society 466:473-480

Thom D, Brown J (1998): Reproductive and hormonal risk factors for urinary incontinence in later life: a review of the clinical and epidemiological literature: Journal of the American Geriatric Society 46:1411-1417

Wishaw M (1998): Urinary incontinence in the elderly: establishing a cause may allow a cure: Australian Family Physician 27:1087-1090

1.   The New NHS Guidance
2.   The Origin of NHS Guidance
3.   Prevalence of Incontinence
4.   Calculating the Local Numbers Affected
5.   The Natural History of Incontinence
6.   The Iceberg Effect
7.   Special Local Considerations
8.   Comparing Numbers with other Diseases
9.   Linking Incontinence with NHS Priorities
10. Quality of Life
11. Clinical Governance
12. The Cost of Incontinence to the NHS
13. The Need for an Integrated Service
14. Getting Incontinence on the Agenda
     RETURN TO TOP OF PAGE

References:
Brocklehurst JC (1993): Urinary incontinence in the community - analysis of a MORI poll: British Medical Journal 306: 832-4

Keller S (1999): Urinary incontinence: occurrence, knowledge, and attitudes among women aged 55 and older in a rural Midwestern setting: Journal of Wound Ostomy and Continence Nursing 26:30-38

Norton PA et al (1988): Distress and delay associated with urinary incontinence, frequency and urgency in women: British Medical Journal 297: 1187-9

1.   The New NHS Guidance
2.   The Origin of NHS Guidance
3.   Prevalence of Incontinence
4.   Calculating the Local Numbers Affected
5.   The Natural History of Incontinence
6.   The Iceberg Effect
7.   Special Local Considerations
8.   Comparing Numbers with other Diseases
9.   Linking Incontinence with NHS Priorities
10. Quality of Life
11. Clinical Governance
12. The Cost of Incontinence to the NHS
13. The Need for an Integrated Service
14. Getting Incontinence on the Agenda
     RETURN TO TOP OF PAGE

7. SPECIAL LOCAL CONSIDERATIONS

(a) Does your area have a higher than average number of people in nursing/residential homes?

The Royal College of Physicians (1995) gave the following incontinence prevalence figures for both sexes (but note that since the time of the studies on which it is based the number of long-term hospital places has been severely reduced so that the incidence of incontinence in nursing and residential homes has probably risen noticeably):

8. COMPARING NUMBERS WITH OTHER DISEASES

Incontinence affects large numbers of people but remains a neglected and to some extent hidden condition. Compare the numbers affected by incontinence (based on sections 3 and 4 above) with those affected by various other conditions (all figures are for UK):

(a) Urinary incontinence

Applying Royal College of Physicians (1995):                             2.5 - 4.0 million (see section 5)

Applying MORI (Brocklehurst, 1993) to the population figures from the Office of National Statistics:

Applying the MRC percentages for "incontinent several times a month" to the population aged 40+:

(i) Stroke: Of the 85% of stroke patients who survive for a week, 42% are incontinent. More importantly, 18% of stroke patients are still incontinent on discharge from hospital (Rudd et al, 1999). Good continence services can not only mitigate the effects of the stroke: they can thereby restore self-esteem and promote efforts at recovery.

(ii) Accidents: Incontinence can cause falls as people with urge incontinence hurry to get to the WC: the risk of falls is increased with urge incontinence by 30% and the risk of fractures 3% (Brown, 2000; Stevenson et al, 1998). The same must be true for those with nocturia who have to find their way to the toilet at night perhaps half awake and in the dark.

(i) In a sample of several thousand people aged 65+, over a period of nine years "the risk of hospitalization was 30% higher in women following a diagnosis of incontinence . . . and 50% higher in men . . . after adjustment for age, cohort and co-morbid conditions. The adjusted risk of admission to a nursing facility was 2.0 times greater for incontinent women . . . and 3.2 times greater for incontinent men . . . Urinary incontinence increases the risk of hospitalization and substantially increases the risk of admission to a nursing home, independently of age, gender and the presence of other disease conditions, but has little effect on total mortality." (Thom et al, 1997)

(ii) In a sample of 9008 community residents aged 65+, those with urinary incontinence but without cognitive impairment or significant physical disability were 70% more likely to be admitted to an institution (and 20% more likely to die) within five years than those who were continent: see reference for detailed definitions (Rockwood et al, 1999)

(i) Only 21% of those with profound learning disabilities are always dry day and night (and the rates for "never wet by day" are 94% for those with mild, 89% with moderate, 82% with severe and 42% with profound learning difficulties) (von Wendt et al, 1990; Smith & Smith, 1998)

(ii) Diabetes leads to peripheral neuropathy which can involve incontinence (Appel & Baum, 1990)

(i) "Stress can harm people's physical health" (para 3.11) - the stress imposed on carers looking after people with incontinence is mentioned above (section 7(e)). People with incontinence - especially those who have not sought help or are unaware that help is available - undoubtedly also suffer from stress.

(ii) "The Healthy Citizens Programme . . . aimed at ensuring people have the knowledge and expertise they need to deal with illnesses and health problems" (para 3.29) - the ignorance of many people about incontinence and the treatments available needs to be dispelled by public awareness campaigns such as are urged as "critical" in the Guidance. The White Paper then identifies three strands for the programme: NHS Direct, health skills and expert patients:

- The NHS is providing the NHS Direct telephone service and website, both of which deal with incontinence.

- Health skills which could well be seen as covering preventive exercising of pelvic floor muscles, especially before or during pregnancy. The White Paper cites skills related to asthma and arthritis - you can note that coughing caused by asthma may exacerbate or precipitate stress continence, while arthritis can cause functional incontinence.

- The expert patients programme is to help people deal with chronic illness. There are many skills related to coping with chronic incontinence: for example, pelvic floor exercises and intermittent self-catheterisation.

References:

Appell RA and Baum N (1990): Neurogenic Bladder in Diabetes: Pract Diabetol 9(4): 1-4. Audit Commission (1999): First Assessment: a review of district nursing services in England and Wales. Audit Commission, London

Brown J (in press): Urinary incontinence: does it increase risk for falls and fractures? Journal of the American Geriatric Society 48(7)

Department of Health (1998 a): The New NHS: Modern and Dependable: A National Framework for Assessing Performance: consultation document. Department of Health, January 1998

Department of Health (1998 b): Modernising Social Services: Promoting Independence, Improving Protection, Raising Standards. Department of Health, November 1998

Department of Health (1999 a): Saving Lives: Our Healthier Nation (Cm 4386). The Stationery Office, London, July 1999.

Department of Health (1999 b): Making a Difference: strengthening the nursing, midwifery and health visiting contribution to health and healthcare. Department of Health, London, July 1999. ( See http://www.doh.gov.uk/nurstrat.htm  )

Department of Health (1999 c): Modernising Health and Social Services: National Priorities Guidance 2000/01-2002/03. Department of Health, London, December 1999 (See http://www.doh.gov.uk/npg/ )

Rockwood et al (1999): A brief clinical instrument to classify frailty in elderly people: The Lancet 353: 205-206.

Rudd AG et al (1999): The National Sentinel Audit for Stroke: a tool for raising standards of care: Journal of the Royal College of Physicians 33: 460-464.

Smith PS and Smith LJ (1998): Promoting continence training for people with learning difficulties: Journal of Community Nursing 12: 18-25

Stevenson B et al (1998): Falls risk factors in an acute-care setting: a retrospective study: Can J Nurs Res 30(1): 97-111.

Thom et al (1997): Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality: Age and Ageing 26: 367-374

Tinetti ME, Williams CS (1997): Falls, Injuries due to Falls, and the Risk of Admission to a Nursing Home: New England Journal of Medicine 337(18): 1279-84

von Wendt L et al (1990): Development of bowel and bladder control in the mentally retarded: Developmental Medicine and Child Neurology 32: 515-518

1.   The New NHS Guidance
2.   The Origin of NHS Guidance
3.   Prevalence of Incontinence
4.   Calculating the Local Numbers Affected
5.   The Natural History of Incontinence
6.   The Iceberg Effect
7.   Special Local Considerations
8.   Comparing Numbers with other Diseases
9.   Linking Incontinence with NHS Priorities
10. Quality of Life
11. Clinical Governance
12. The Cost of Incontinence to the NHS
13. The Need for an Integrated Service
14. Getting Incontinence on the Agenda
     RETURN TO TOP OF PAGE

seek help early
openly discuss the problem
identify some positive aspect of incontinence.

provide explicit pro-active documented care plans to the consumer
involve the consumer in the choice of management or treatment
consider the consumer's views

References

Button D, Roe B, Webb C, Frith T, Colin-Thomé D, Gardner L (1998): Continence: Promotion and Management by the Primary Health Care Team.: Consensus Guidelines. Whurr Publishers, London.

Department of Health (1994): Incontinence. Department of Health, London

Johnson TM 2nd, Kincade JE, Bernard SL, Busby-Whitehead J, Hertz-Picciotto I, DeFriese GH (1998): The association of urinary incontinence with poor self-rated health: Journal of the American Geriatric Society 46(6): 693-9

Mitteness LS (1987): The management of urinary incontinence by community-living elderly: Gerontologist 27(2) 185-193

NHS Executive (1994): Incontinence: Citizens' Charter booklet. Department of Health, London.

Roe B, Wilson K, Doll H, Brooks P (1996): An Evaluation of Health Interventions by Primary Health Care Teams and Continence Advisory Services on Patient Outcomes related to Incontinence. Health Services Research Unit, Department of Public Health and Primary Care, University of Oxford.

Skoner MM (1994): Self management of urinary incontinence among women 31 to 50 years of age. Rehabilitation Nursing 19(6) 339-347

White H (1997): Incontinence in Perspective. Chapter in Getliffe K, Dolman M (1997): Promoting Continence. Baillière Tindall, London

1.   The New NHS Guidance
2.   The Origin of NHS Guidance
3.   Prevalence of Incontinence
4.   Calculating the Local Numbers Affected
5.   The Natural History of Incontinence
6.   The Iceberg Effect
7.   Special Local Considerations
8.   Comparing Numbers with other Diseases
9.   Linking Incontinence with NHS Priorities
10. Quality of Life
11. Clinical Governance
12. The Cost of Incontinence to the NHS
13. The Need for an Integrated Service
14. Getting Incontinence on the Agenda
     RETURN TO TOP OF PAGE

a) Estimating the Overall Cost to the NHS

Although information about NHS costs is difficult to obtain, the following conservative estimate of the total cost to the NHS of treating incontinence can be put forward with some confidence. The great majority of this cost is incurred at primary care level. Note that the estimate does not include any allowance for residential, nursing home or long-term hospital care due solely to incontinence.

The estimate is for England only, but can reasonably be grossed up for the United Kingdom (the population of England is 83.5% of the total UK population). Pro rata estimates for Scotland (8.7%), Wales (5.0%) and Northern Ireland (2.8%) are subject to a greater margin of error.

* Multiply this figure by your local population in thousands to get an approximate minimum local cost.

** See commentary below.

*** The estimate makes no allowance for overheads beyond direct employment costs - e.g., for appropriate shares of the cost of premises and of ancillary staff.

**** There is a small degree of overlap (surgeons' salaries) between staff and surgery costs.

The total for England of £353,595,000 suggests a total for the UK as a whole of about £423,467,000 - roughly 0.85% or 1/120th of the total cost of the NHS.

(i)    DRUGS

The 1998 edition of Prescription Cost Analysis - England (Department of Health) reveals the following:

[NB: 1999 figures are now available]

* 50% only to exclude surgical use.
** 10% only as main use is for diabetes insipidus.
*** 16% oncost advised by NHSE Pharmacy & Prescribing Branch

These totals do not include drugs used in hospitals and NHS nursing homes, but it is thought unlikely that these would add significantly to the overall total.

(ii)   PRESCRIPTION APPLIANCES

The 1998 edition of Prescription Cost Analysis - England (Department of Health) reports:

[NB: 1999 figures are now available]

* 16% oncost advised by NHSE Pharmacy & Prescribing Branch

These totals do not include appliances used in hospitals and NHS nursing homes, but it is again thought unlikely that this omission would add considerably to the total cost, not only because the volume used in hospitals is relatively small but also because they typically obtain their supplies at a considerable discount or even entirely free.

(iii)   CONTAINMENT PRODUCTS

The consumption and cost of absorbent products is not collected nationally and the only reliable figures are for central purchases by the NHS Supplies Authority.

A Parliamentary Question on 10 November 1999 produced the following information for the financial year 1998/99 for England only:

In the same Parliamentary Answer, the Department of Health estimated that NHS Supplies accounts for "around 50 per cent" of the total purchases by the NHS, suggesting that the overall total spend on these items in England is perhaps £55 million a year. This would suggest a UK spend, pro rata to population, of £66 million.

Discussions with the Department of Health show that the estimate of 50% is "soft" and certainly the NHS's purchases are so organised that it is impossible for anyone to speak with certainty of the total. Informal indications suggest that, with local budgets for these products often overspent, many purchases are made under other budget heads; and contacts with manufacturers suggest that the total market may be greater than the Parliamentary Answer indicated.

A much higher figure is suggested by the market research company Euromonitor (1997), who estimated the total UK market in 1995/96 at US$229 mn (about £140 million), of which about 7% was retail sales and the rest institutional - largely NHS. This would set the NHS purchases at around £125 million in 1995/96. Moreover, Euromonitor reported that the total had grown by 81% in previous five years and forecast that the total would grow by 2001 to about $385 mn (about £255 mn).

A more recent report from Euromonitor (1999) estimates that the retail (private purchases) market for incontinence pads in 1998 was worth £11.3 million at retail sales prices, having risen from £7.7 mn in 1996, but includes no estimate of the size of the overall market.

On the basis, therefore, that NHS Supplies' share of the total may be closer to 40%, the value of the total NHS purchases of absorbent products would be about £69 million in England and £82.5 million in the UK as a whole.

(iv) STAFF

The following estimates cover only the staff most directly involved and are for England only:

* Staff numbers, in w.t.e., are based for nurses, GPs and obstetricians and gynaecologists on statistics on the Department of Health website, for continence advisors on the Continence Foundation's database, and for other categories on estimates from relevant professional associations. Gradings for nursing posts are intended as broad averages and are based on point 2 of grades D and E, point 3 of grades F, G and H. The calculation for physiotherapists is based on point 3 of grade Senior I. The salary taken for consultants is £63,640, for registrars £29,200. The cost of GPs is based on superannuable fees of £52,600 and expenses of £24,700. The percentages of time spent on continence-related work are intended as conservative estimates of the time spent by the category of staff as a whole and are based on discussion with senior representative members of each category of staff.

** Includes only salaries, superannuation and National Insurance. Salaries are at 1999/2000 rates. National insurance is calculated at 12.2% of net salary after deduction of £4,335. In April 2000, NHS superannuation goes up from 4% to 5% and salaries rise by about 3%. This will add approximately £7,500,000 to the total. (A further rise in superannuation to 6% is planned for April 2001.)

*** The Audit Commission (1999) produced survey evidence that the proportion of District Nurses' referrals relating to continence management was 3% and bowel management 2%, but in addition 20% were for assessments of all kinds, and 6% for advising carers and patients: both categories will include a substantial proportion of referrals related to continence. More important, many of their other referrals (e.g., 20% on dressings) would take much less time than the typical incontinence case.

(v) SURGERY

The Department of Health's annual National Schedule of Reference Costs reports the number and average cost of surgery by broad "HRG" categories and is published on the Department's website www.doh.gov.uk/nhsexec/refcosts.htm Each HRG code includes a number of procedures as classified by the Office of National Statistics (previously OPCS). Figures for the number of cases for each OPCS code were provided by the Department of Health Statistics Division. The estimate below, using figures for 1998/99, is based on (a) a conservative assessment of the OPCS procedures relevant to incontinence (no prostate operations are included) and hence the relevant proportion of the total of cases under each HRG code; (b) applying this proportion to the numbers of FCEs and average costs per HRG. This assumes (for want of better information) that the average costs for an HRG category are broadly applicable to the individual OPCS procedures it contains. A very small number of day-cases is included and is separately calculated.

(b) Estimating Local Costs

The simplest way to calculate local costs is by applying to the local population the costs per 1,000 population in the summary table at the start of this section.

Alternatively you may wish to try to calculate local costs directly. Some cost elements are available locally. Local prescription costs, for example, should be available from your Health Authority's prescribing advisor. You will know your own budget for containment products. You should be able to make some calculation of staff costs using the formulae in the table above (section (a)(iv)) and applying local staff numbers: these should be available from your local personnel office. Information about surgery should be available from the head of the surgical directorate at your local acute NHS Trust - or from its Finance Department.

(c) Comparative costs

(i) Care at home as against residential care:    Many older people move into residential or nursing home care as a result of their incontinence. The additional cost is considerable and could in many cases be avoided (usually much to the advantage of their quality of life). Average costs for people placed in residential care at public expense in 1995 were:

      Residential Home care:        £  9,317
      Nursing Home care:             £13,000
      Hospital (long-term care):     £41,912

By comparison, the average cost of services for those in their own homes was:

     Home care:                        £1,590
     Community nursing:            £1,274
     Day care [i.e., day centres] £1,385
     "Meals on wheels":               £396

(Source: calculated from Tables 2.1, 2.2, Royal Commission on Long Term Care (1999) and based on Personal Social Services Research Unit estimates)

(ii) Conservative treatment and cure as against continued use of absorbent products: Providing a patient with incontinence pads costs between £100 and £600 a year in the cost of the pads alone: a percentage has to be added for administration and for repeated re-assessments and for treating any complications (sores etc). By contrast, for a specialist nurse or physiotherapist to spend even as much as ten hours helping the same person to overcome their incontinence by pelvic floor exercises or bladder retraining would cost under £150.

(iii) Conservative treatment and cure as against too early resort to surgery: In some places opportunities for cure by conservative means are not exhausted before patients are referred for possible surgery. The cost for the former in (ii) can be contrasted with the average costs for surgical procedures given in the table above (section 12(a)(v)).

(iv) Treatment by nurses as against urogynaecologists: Prasher et al (1996) reported on an Australian randomised controlled trial comparing treatment of mild and moderate incontinence by nurse continence advisors with treatment by urogynaecologists. Overall results were better with nurse continence advisors, dropout rates were lower and their costs were 30% lower.

(v) Savings from delaying onset of urinary incontinence: The American Federation for Aging Research (1995) has analysed the potential benefits of postponing the onset of the diseases of aging and reported to a White House conference that $8 billion a year could be saved by delaying the onset of urinary incontinence - or, it may be surmised, therefore, by curing it at an early stage.

The scope for higher rates of cure or remission can be surmised from the report by the Royal College of Physicians (1995) that "several studies have shown 70-80% cure or improvement rate of suitable cases in primary care" (quoting O'Brien et al (1991) and Langro-Jansenn et al (1991)) coupled with the findings of the Audit Commission (1999) that the standard of assessments of incontinent patients by district nurses left much to be desired. (In a sample of seven NHS Trusts the scope of actual assessments was compared with a list of key items derived from guidelines on recommended practice. The best Trust completed only 70%, the worst only 31% of the items. Urine tests were carried out for only half the assessments, and only one assessment in six used a frequency volume chart, with two Trusts never using them.)

References:

American Federation for Aging Research and the Alliance for Aging Research (1995): Putting Aging on Hold: Delaying the Diseases of Old Age: an official report to the White House Conference on Aging. American Federation for Aging Research, New York

Audit Commission (1999): First Assessment: a review of district nursing services in England and Wales. ISBN 1 86240 149 7

Department of Health: Prescription Cost Analysis- England - 1998. Department of Health, 1999 (ISBN 1 84182 0458)

Euromonitor (1997): World Survey of Incontinence Products. Euromonitor, London

Euromonitor (1999): Disposable Paper Products: the International Market. Euromonitor, London

Langro-Janssen T et al: Controlled trial of pelvic floor exercises in the treatment of urinary stress incontinence in general practice: British Journal of General Practice 41: 445-9

O'Brien J et al (1991): Urinary incontinence: prevalence, need for treatment and effectiveness of intervention by a nurse: British Medical Journal 303: 1308-12

Prasher S, Moore K et al (1996): The role of the nurse practitioner in a urology service: Br J Urol 77: 502-505

Royal Commission on Long Term Care for the Elderly (1999): With Respect to Age - Long Term Care: Rights and Responsibilities: The Stationery Office, London. ( Also at www.open.gov.uk/royal-commission-elderly/ )

Wagner TH and Hu T (1998): Economic Costs of Urinary Incontinence in 1995: Urology 51(3): 356-361

1.   The New NHS Guidance
2.   The Origin of NHS Guidance
3.   Prevalence of Incontinence
4.   Calculating the Local Numbers Affected
5.   The Natural History of Incontinence
6.   The Iceberg Effect
7.   Special Local Considerations
8.   Comparing Numbers with other Diseases
9.   Linking Incontinence with NHS Priorities
10. Quality of Life
11. Clinical Governance
12. The Cost of Incontinence to the NHS
13. The Need for an Integrated Service
14. Getting Incontinence on the Agenda
     RETURN TO TOP OF PAGE

- embracing the range of primary care and community settings, the local specialist continence service, local hospital services and access to regional or national specialist surgical centres;

- taking in awareness work, identification of people affected, assessment, treatment, review of treatment and long-term management for those needing it;

- requiring involvement of service users both in service planning and delivery and as individual patients in the agreement of plans for their management and treatment;

- covering work on faecal as well as urinary incontinence, for children as well as adults, and for people living in homes as well as at home;

- bringing together people in very many disciplines, including GPs, practice and district nurses, health visitors, midwives, specialist continence nurses and physiotherapists, paediatricians and physicians for the elderly, urologists and (uro-)gynaecologists, gastroenterologists and coloproctologists, and the social, educational and psychology services, etc.

- run by a Director of Continence Services who will usually be a specialist continence nurse or physiotherapist.

reduce the average cost of dealing with individual patients - better value for money;

usually bring about cures or improvements in the condition - better clinical outcomes; and

produce happier, healthier, more satisfied patients - and carers. - better quality of life - and good public relations!

MODEL FOR ACTION AT PCG LEVEL

Prepared by the Continence Foundation in collaboration with:

Association for Continence Advice 020 8692 4680
Royal College of Nursing Continence Care Forum 020 7647 3743
Association of Chartered Physiotherapists in Women's Health 020 7242 1941
Incontact 020 7700 7035

The Continence Foundation is grateful to these companies for grants to help with this project and publication:

    Bard Ltd               Pharmacia Ltd               SCA Hygiene Products Ltd

Published by

The Continence Foundation
A company limited by guarantee (registered in England, no. 2662838) and a registered charity (no. 1014429)

307 Hatton Square, 16 Baldwins Gardens, London EC1N 7RJ Tel: 020 7404 6875 Fax: 020 7404 6876
Helpline: 020 7831 9831 E-mail: continence.foundation@sdial.pipex.com
URL: http://www.continence-foundation.org.uk

April 2000