Who’s counting? The case for urgent action to improve NHS continence care
Executive summary
Our healthcare system needs to adapt to meet the needs of an ageing society. 80% of the increase in major illness over the next twenty years will come from an older population.1
14 million people in England currently have some degree of urinary incontinence.2As our population ages, these conditions, such as Overactive Bladder (OAB), where patients get a sudden or compelling need to pass urine and where risks of urinary tract infections, falls and fractures are higher, will increase sharply. Our research – which uses published studies on the age based prevalence of OAB and applies them to the current population of England – estimates that there are 5 million people in England with OAB today and that this is expected to rise to over 7 million by 2035. Most of this increase will be the result of an ageing population – the proportion of those with OAB who are aged 65 and over is expected to rise from 60% to 70% in this period.
Such increases will have knock on impacts on healthcare systems, with more primary care appointments, hospital admissions and demand in social care. We estimate that OAB currently costs the healthcare system in England an estimated £3.7 billion and that this will rise to over £5 billion by 2035.
Urological conditions and continence services are not a healthcare system priority. While some selective and welcome action is being taken through the Women’s Health Strategy, these conditions are largely absent from the main national policy documents such as the Government Mandate, NHS Long Term Plan and various other post pandemic recovery service plans.
Despite 400,000 people being on the urology waiting list there is no National Clinical Director in NHS England. There is work on service transformation led by the Getting It Right First Time (GIRFT) team and the National Bowel and Bladder Health project. A new commissioning guide for continence services was published in 2018.3 However, and understandably, progress on implementing actions on these initiatives has been impacted by the pandemic and health system restructuring. Indeed hospital activity levels for urology have not yet returned to 2012/13 levels and the last ten years can be viewed as a lost decade for delivering service improvements.
‘What gets measured, gets managed’ is traced back to Peter Drucker’s 1954 book on the ‘practice of management’.4 Whilst there is some data on the performance of urology services such as waiting times data, the lack of up to date integrated data on the demand, quality and provision of such services is a major barrier to progress. Without this knowledge, the ability of the system to improve is greatly reduced. The last national clinical audit was completed in 2009/10.5 Urology is not included within the list of 28 clinical audits commissioned by NHS England and the Health Quality Improvement Partnership (HQIP).6 This is despite it being the 11th largest secondary care specialty for hospital admissions.
The commissioning and publication of a new clinical audit can form a baseline from which action to develop and deliver improved services can be taken. NHS England can use the audit to create a urology service dashboard to monitor performance and outcomes more closely on an ongoing basis. A National Clinical Director should be appointed to provide national leadership and roll-out good practice care pathways and ‘level-up’ urology services. Within Integrated Care Boards (ICBs) and Primary Care Networks (PCNs) a new national audit, leading to a service dashboard can be used to galvanise new action, pioneer innovative community led service models and improve accountability of service delivery.
Urological conditions and continence care are set to be an increasingly important area of health system delivery and management. Policy action in the last decade has been too slow and new and urgent action is now needed to improve services. To do so effectively requires better data on population health needs and service capability. A new clinical audit accompanied by a digital service dashboard would be a good place to start.
Summary of recommendations
This report makes recommendations in four areas for improving NHS continence services and the identification, management, support and treatment available for patients.
Improving NHS continence service data
- NHS England should commission a new national clinical audit for continence care through the Healthcare Quality Improvement Partnership (HQIP). Conducting the audit should be used to improve clinical coding in relation to continence care and support the development of a urology service dashboard that monitors and tracks health systems against important service performance standards
Prioritising continence services
- The Major Conditions Strategy should include commitments on delivering more holistic assessments of older people’s needs. Continence care should be a central part of such assessments and embedded within relevant care pathways
- Any future Government healthcare prevention strategy should include the better management of continence care as a priority. This should have a leadership role for primary care in delivering an enhanced continence care prevention pathway
- NHS England should appoint a National Clinical Director (NCD) for urological conditions to oversee the improvement of services resulting from a refreshed clinical audit. The NCD should work through a refreshed National Bladder and Bowel Health project to deliver it. Targets for recovering and improving urology services should be included within annual NHS planning guidance
- The National Bladder and Bowel Health Project should use the proposed clinical audit to identify gaps in service provision and work with ICBs and clinical networks to ‘level-up’ the provision of continence care across the country. ICBs identified as high performing should be paired with areas that are more challenged to share good practice and ways of working. Best practice service delivery case studies should be written-up and highlighted on the FutureNHS portal.9 Locally ICBs and Trusts should look to identify ‘Continence care champions’ who can help them in raising the quality and delivery of continence care
- Aligned to the Major Conditions Strategy, the Department of Health and Social Care, NHS England and NICE should use upcoming reforms to the Quality and Outcomes Framework (QOF) to deliver more holistic patient centred assessments. For older patients, the person centred assessment should include an evaluation of continence care issues
Engaging effectively with patients to tackle stigma and improve selfmanagement
- NHS England should ensure that the NHS App signposts and links to relevant information on symptoms, treatment and care for continence issues for relevant population groups. This should provide a relatively low cost way for engaging with those with or at heightened risk of such conditions. The App should signpost patients to existing effective tools and resources such as the bladder and bowel CONfidence app10
- Government should work with healthcare professionals and charities to coordinate a new campaign to tackle stigma and raise awareness relating to continence care issues. This could be done to coincide with World Continence Week in June.11 ICBs should ensure dedicated helplines for continence care within their localities, so that patients can confidently seek appropriate assistance and support when required
Improving the education and training of healthcare professionals
- The General Medical Council (GMC) should ensure that all medical school student curriculums integrate continence care training more extensively into the undergraduate syllabus. The Nursing and Midwifery Council (NMC) and the Health & Care Professions Council (HCPC) could do similar for nursing, physiotherapy and allied healthcare professional degrees. This should include at least a full day’s worth of training on both basic bladder and bowel health and ideally one full day on each area.
- Professional Urology Associations, covering the spectrum of the urology workforce, should consider how greater emphasis can be placed on increasing the attractiveness of working in urology and continence care specifically for new graduates
- NHS providers should mandate basic continence training modules to be taken as part of onboarding processes for all clinical staff and as part of ongoing competency assessment processes
- The Health and Care Professions Council (HCPC) – responsible for standards in social work – and Care Quality Commission (CQC) should explore appropriate mechanisms to ensure that those working in social care and nursing home settings get sufficient training in the basics of continence care as part of onboarding processes12
1 Health Foundation. Health in 2040. July 2023. p7 (Accessed on 3 August 2023)
2 House of Commons Library. Bladder and bowel continence care. June 2023. (Accessed on 3 August 2023) A methodology setting out the methods for the calculations in the report is available on p60
3 NHS England. Excellence in Continence Care. June 2018. (Accessed on 3 August 2023)
4 P Barnett. If what gets measured gets managed, measuring the wring thing matters. Corporate Finance Review. January/February 2015. (Accessed on 3 August 2023)
5 Royal College of Physicians. National audit of continence care. 2010. (Accessed on 3 August 2023)
6 Health Quality Improvement Partnership (HQIP).The National Clinical Audit Programme. (Accessed on3 August 2023)
9 Future NHS portal. Available at https://future.nhs.uk/
10 Expert Self Care. CONfidence App. (Accessed on 3 August 2023)
11 Awareness Days. World Continence Week. (Accessed on 3 August 2023)
12 Astellas and Bladder Health UK. Ensuring high quality OAB and continence care in the UK. April 2023
This independent report was commissioned by Astellas Pharma Ltd. Full editorial control rests with Future Health.