In October 2006, NICE published its guideline on The management of urinary incontinence in women.1 In a previous article, Drs Roesner and Wagg examined the guideline with relevance to primary care and highlighted some of the implications contained within it.2 This paper examines what evidence there is of implementation of the guideline since publication and discusses barriers that might be in place or that may have arisen.
Implications of urinary incontinence
Although more common in later life, urinary incontinence (UI) is by no means confined to the elderly. Bothersome lower urinary tract symptoms (LUTS) affect approximately 59% of adult women.3 Although not fatal, and often perceived as a minor problem, women experience considerable loss of quality of life and social functioning as a result and are at risk of significant associated co-morbidity, which may include:4,5
- skin and urinary tract infection
- risk of institutionalisation.
Urinary incontinence constitutes a considerable financial burden on the NHS. The associated annual costs based on 2004–2005 figures are estimated at £743 million, or approximately £244 per year for each woman with UI symptoms, with much of that expenditure on pads, and £207 million to the affected individuals. Additional hidden costs as a result of personal expenditure and loss of economic activity are estimated as being almost equivalent to these.6,7 Certainly, as far as containment products are concerned, it is known that NHS provision only equates to approximately one-third of pad usage, the rest being paid for privately.8
Urinary incontinence is associated with a social taboo and is talked about reluctantly. Many women suffer with the condition for years before seeking help, or mention the problem to their doctor as an aside at the end of a consultation for another matter. This situation may have been exacerbated by the recent adoption of ‘one appointment, one problem’ practices in primary care, where the problem deemed less important may not be mentioned.9
Treatment may not be actively pursued by clinicians, either through ignorance about what can be done, a belief that what can be done is ineffective, or because the condition is not thought of as serious enough to warrant attention; and, of course, management of UI may be seen as costly in terms of time or not worth the bother when compared to more financially rewarding items of service.
Progress and disadvantages
The NICE guideline put into place recommendations covering assessment, lifestyle, and behavioural and pharmacological management of UI, and suggested relevant red flag symptoms and findings that mandated either departing from the incontinence care algorithm or that necessitated urgent referral for a specialist opinion. Hopefully, recommendations in the NICE guideline have led to an overall improvement in the standard of care for women with incontinence. What evidence is there of change?
All GPs are now organised into practice-based commissioning (PBC) groups, with extended purchasing powers and indicative budgets to commission healthcare from providers of NHS services, regardless of origin. Practices within some groups may develop specialist expertise in specific therapy areas to deliver continence services to their population, or form an independent organisation to provide these. At the same time, practices are being given key performance indicators, which are used to measure their performance against other practices, with increasing use of financial penalties for poor performers.
Referrals to secondary care are increasingly being monitored for ‘appropriateness’ by panels of clinicians in a bid to reduce the number and the associated cost. In certain circumstances incontinence may not be perceived as being important enough to warrant referral and may therefore be managed inappropriately by those with little interest in the condition other than cost maintenance. Likewise, rules preventing internal hospital referrals, which require consultants to request onward referral via GPs, may also result in no referral being made where continence is concerned. The cost of maintenance products too may come under increasing scrutiny by commissioners of continence services, regardless of any underlying assessment or management.
To aid the process of commissioning in continence care, NICE has produced a service specification and toolkit for commissioning continence services for women, and this is available from the NICE website (see Box 1).10 This should aid primary care commissioners in specifying the required quality of care for the population for which they have duty of care, although anecdotal evidence is that there is little attention paid to continence services, even with the advent of the 18-week pathway in secondary care.11 There is no waiting ‘limit’ before treatment is received in primary care.
Box 1: The NICE urinary continence service commissioning tool can be used
to assess local service requirements and work out costs of commissioning
Assessment and conservative management
The National audit of continence care for older people was published in 2006,12 but since publication of the NICE guideline later that year there has been no structured attempt to assess the degree to which it has been implemented. However, given that compliance with the guideline had considerable implications for training, education, and delivery of services, a recent Royal College of Nursing (RCN) publication shows there has been little action to divert resources specifically for the purpose. The RCN survey suggests that many specialist nurses still fear vacancy freezes and redundancy and that they are being asked to perform non-specialist duties.13
Excellent work has been carried out, however, in collaboration with Skills for Health to define the requisite competencies for continence care,14 and the framework for integrated continence services is certainly available.
There has been some change in the pharmacological management of UI, and in February 2008, NICE published an uptake report.15 The guideline recommended offering first-line treatment with immediate-release non-proprietary oxybutynin to women with overactive bladder (OAB) or mixed UI if bladder training has been ineffective. In case of intolerance to immediate-release oxybutynin, alternatives should be considered, such as:1
- extended-release or transdermal formulation of oxybutynin.
The uptake report uses data from the electronic Prescribing Analysis Cost Tool system, which covers use of these drugs for all those with LUTS, not just women, (for example: 35.1% of prescriptions for oxybutynin were for men) so these data should be interpreted with caution.
A gradual increase was found in the number of prescriptions for drugs to treat OAB of around 10% per annum, meaning that more people are receiving treatment. There is, of course, a greater number of these drugs available. In the period covered by the uptake survey, the first year after the issue of the guideline, there were 2.85 million prescriptions for anti-muscarinic drugs. The monthly trend data after publication of the guideline showed an upturn in the number of oxybutynin prescriptions, reversing a slow downward trend in its use. These data are supportive of the supposition that the guideline has had some impact. Whether this continues, remains to be seen.
Assistance with implementation
The success of any guideline depends upon its implementation; the uptake of NICE guidelines is variable and there are few formal mechanisms to monitor this, although each PCT Chief Executive Officer is responsible for implementation and reporting on progress with it. A number of publications have been produced that should make commissioning of a NICE-compliant service easier and all relevant documents are available on its website. However, centrally dictated guidelines are never well received and it is clear that there needs to be local ownership of the guideline to evoke change.
Factors that do appear to be important for implementation include:
- motivation to achieve the target for change
- resources available for change
- motivators outside the service, healthcare, and government
- opportunities for change—that is, how people understand the required change.
There is no doubt that local ownership is an essential prerequisite for the promotion of any change. An example of this was revealed by a survey of GPs in Sydney, Australia, before guidelines on the management of LUTS in men were launched. They were asked what they felt would be most helpful for local implementation.16 Respondents placed high value on endorsement by eminent individuals and organisations other than those developing the guidelines, and they favoured small-group continuing education with facilitators, lectures and videos, and patient education materials to aid implementation.
Although there is general agreement on the need to adapt international and national guidance to local needs, there is also evidence that considerable time and money can be spent on such initiatives with little apparent benefit. Care needs to be taken so that time is not wasted ‘reinventing the wheel’ simply for the sake of giving the guidance a local flavour.
The NICE guideline on The management of urinary incontinence in women has now been available for some twenty months. Since then there has been no structured attempt at monitoring the implementation of the guideline, and continence probably lies at the bottom of a commissioner’s pile of ‘must dos’. There was some evidence of improvement in care for older people from the National Audit in 2006,12 which may well have persisted. The NICE guideline itself also made audit recommendations (available on the NICE website) and encouraged those in secondary care to take part in the ongoing audits from both the British Society of Urogynaecologists and British Association of Urological Surgeons, and it is to be hoped this has had some impact.
What is really needed in this area when mandatory ‘targets’ are less fashionable? Would a QOF entry for continence have an impact and any associated financial incentive instigate action to implement guideline recommendations? A national audit of continence care for all adults is currently being planned for 2010–2012 and a NICE guideline on LUTS in men will be published by 2010, which might enable us to examine to what extent there has been uptake of NICE recommendations in this area.
- 59% of adult women have troublesome lower urinary tract symptoms
- Annual cost to the NHS is approximately £244 per woman with symptoms of urinary incontinence per year—much of it on pads
- Local female continence assessment and treatment services could easily be commissioned through PBC in the community
- Effective pharmacotherapy could be cost neutral or cost saving—reducing expenditure on pads
- Monthly cost of oxybutynin = £7.24 (2.5 mg b.d.)a
- National Institute for Health and Care Excellence. Urinary incontinence: the management of urinary incontinence in women. Clinical Guideline No 40. London: NICE, 2006.
- Roesner M, Wagg A. New NICE guideline highlights challenges of urinary incontinence. Guidelines in Practice 2007; 10 (1): 15–21.
- Irwin D, Milsom I, Hunskaar S et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006; 50 (6): 1306–1314.
- Ko Y, Lin S, Salmon J, Bron M. The impact of urinary incontinence on quality of life of the elderly. Am J Manag Care 2005; 11 (4 Suppl): S103–111.
- Wagg A. Urinary incontinence—older women: where are we now? BJOG 2004; 111 (Suppl 1): 15–19.
- Turner D, Shaw C, McGrother C et al. The cost of clinically significant urinary storage symptoms for community dwelling adults in the UK. BJU Int 2004; 93 (9): 1246–1252.
- Papanicolaou S, Pons M, Hampel C et al. Medical resource utilisation and cost of care for women seeking treatment for urinary incontinence in an outpatient setting. Examples from three countries participating in the PURE study. Maturitas 2005; 52 (Suppl 2): S35–47.
- Desai N, Keane T, Wardle J, Wagg A. Continence pad provision in England and Wales: Fair all round? J WOCN 2008. (In press.)
- www.timesonline.co.uk/tol/news/uk/health/article3736238.ece (accessed 14 June 2008)
- National Institute for Health and Care Excellence. Urinary continence service commissioning guide. London: NICE, 2008. www.nice.org.uk/usingguidance/commissioningguides/uiwomen/UrinaryContinenceService.jsp (accessed 14.06.08)
- Wagg A, Peel P, Lowe D, Potter J. National Audit of Continence: programme report of the national audit of continence care for older people (65 years and above). London: RCP, 2006. Round 2 generic report at http://continenceaudit2006.rcplondon.ac.uk/
- Skills for Health. Competence application tools. CCO1. Assess bladder and bowel dysfunction. tools.skillsforhealth.org.uk/competence/show/id/416 (accessed 13 June 2008)
- National Institute for Health and Care Excellence. NICE implementation uptake report: drugs used in the management of urinary incontinence. London: NICE, 2008.
- Puech M, Ward J, Hirst G, Hughes A. Local implementation of national guidelines on lower urinary tract symptoms: what do general practitioners in Sydney, Australia suggest will work? Int J Qual Health Care 1998; 10 (4): 339–343.G