Inadequate and incomplete - continence care in the UK
The first national audit of incontinence care for older people in the UK shows widespread failure to diagnose and manage continence problems. The audit, undertaken by the Royal College of Physician’s Clinical Effectiveness and Evaluation Unit and commissioned by the Healthcare Commission, examined the quality of care for older people with urinary and faecal incontinence in primary care, secondary care and care homes in England, Wales and Northern Ireland.

The audit was based on the standards set in the National Service Framework for Older People [2001] and the Department of Health guidance “Good practice in continence services”[2000] and recorded the care of over 9,000 patients and 700 care home residents. Data were returned by 159 Trusts covering 195 hospitals, 141 Primary Care Trusts and 29 care homes.

Urinary incontinence affects some 24% of older people and 30-60% of people in institutional care. Faecal incontinence occurs in approximately 1-4% of adults and up to 25% of people in institutional care. Both cause much distress and loss of dignity for the older person.

Effective management of continence depends on a thorough assessment of the patient leading to a diagnosis. The audit found that although specialist NHS staff had good continence knowledge, patients were often not examined thoroughly or given routine assessments. Even where this had been carried out effectively, there was no guarantee that the underlying diagnosis would be found and treated – for most patients only the symptoms are managed, when in some cases there could be a cure. In addition, the audit found a lack of written policies, missing documentation, limited provision of staff training, high use of indwelling catheters in hospital settings and widespread rationing of continence pads.

The National Service Framework for Older People set the requirement that service providers should establish integrated continence services by April 2004. However, the audit indicates that there has been only limited action toward this and that provision of services remains extremely variable. The findings of the audit include:

Only 59% of primary and 32% of secondary care sites have a written policy which covers continence care for older people
Nearly all sites ask a screening question relating to bladder and bowel care, but only 64% of primary and 44% of secondary sites have a protocol for providing basic assessment to patients
Integrated continence services are only present in 53/138 of primary care and 50/195 secondary care sites, and in 10 out of 27 care homes taking part in the audit. On further inspection, many of the services said to be integrated were missing vital elements
Only 49% of secondary care trusts offer structured training on the management of continence to their staff
Despite about 80% of services having a written policy that pads should be available on the basis of clinical need, 81% of primary care and 76% of care home services limit the maximum number of daily pads for patients
60% of primary and 70% of secondary care patients with bladder or bowel problems received pads as a way of managing their condition, rather than treating the underlying problem
Less than half of patients, where it was appropriate to do so, had a documented explanation of their condition and treatment
Inadequate assessment of incontinence with an emphasis on containment rather than cure is expensive, from both a financial and health perspective. In the face of the great daily cost of containing continence, the audit indicates a missed opportunity to assess, treat and reduce the numbers of incontinent people. We feel that this audit represents a significant step in raising the profile of continence and contributing to the improvement in the quality of care for older people with bladder and bowel problems.

Dr Adrian Wagg, Chairman of the Continence Working Party, said:

“This is probably the largest audit on continence care world wide and we are extremely grateful to everyone who has participated. It shows that care for people with continence problems is patchy at best, that a cure is seldom attempted and that the single mandatory target for continence in the NSF has not been met. There is a wealth of opportunity for improvement, something that we will be attempting to encourage over the coming months”

National Audit of Continence Care for Older People