Leading change

The nurse lead at Bedfordshire Continence Service undertook a comprehensive service review, developing new systems, processes and pathways in order to address unwarranted variation in their service’s practices, to improve the outcomes and experience of people using their service.

Where to look

The Continence Service provides advice, support and treatment for people with continence needs across Bedfordshire and Luton, with a current caseload of >7,500 patients (June 2018). Continence advisors are nurses who have undertaken specialist training in continence management so they can effectively assess individual continence needs and develop a treatment programme tailored to the needs of the person. The continence team see patients either at home, or in an out-patient clinic with an aim of managing symptoms of incontinence where possible, and providing continence aids.

A long-term strategic approach for people using the service was needed as a result of growing complexity, increased caseload numbers and a need for a more systematic approach to the assessment and review process for patients. This new approach has been led by the nursing team, as requested and supported by the Director of Community Services.

The nurse leaders completed a comprehensive review of the Bedfordshire Continence Service as an internal audit had highlighted unwarranted variation when compared to national recommendations and other comparable services. The review highlighted that there were patients on the caseload that had not had a recent treatment review, that processes weren’t supporting effective use of resources and that this was having an impact upon the experiences for staff and patients using the service. The continence service was overspent against its budget and costs were continuing to increase, in a bid to meet patient need. The review further showed:

• The caseload was increasing;
• The formulary in use had no gatekeeping controls in place (any resources could be used freely without sign-off);
• Patients were staying on the same prescription for extended periods without review of their personalised needs;

The nursing leaders recognised that current practice may not be the most effective approach and that there was an opportunity to develop the service to achieve better patient outcomes.

What to change

In addition to the comprehensive review the nursing leaders completed, in November 2015 the document ‘‘Excellence in Continence Care” was published by NHS England. The document states the aims of commissioning and delivering continence care as:

• Better quality of life and more independence through finding solutions appropriate to individual needs
• Less reliance on pad and products by using alternative treatments
• A reduction in admissions to hospitals and care homes
• Fewer complications, such as UTI and skin breakdown
• A reduction in costs

Identifying their unwarranted variations in resource use, patient experience and case load management, the Bedfordshire Continence Service committed to make changes in order to meet and support all of these areas. The review clearly demonstrated that the nursing team was fundamental in changing current practice to minimise waiting lists for treatment and they had purposeful relationships with local hospitals which were key to patient pathways.

How to change

The nursing team developed and led a programme of quality improvement using a service-wide approach to care improvements, with the support of their management team. The nursing team reviewed the service’s caseload ensuring people who required the service were prioritised and those people who no longer needed the service were appropriately discharged.

With the refreshed caseload list, the team then set to increase the number of patient contacts they had daily, to reduce waiting lists further and boost the number of patients reviewed and treated using prescriptions personalised to meet their individual needs. The team also increased the number of outpatient clinics offered. Additional training was offered to nursing homes so that staff in the homes were empowered to care for patients closer to home wherever possible.

Adding value

Nursing staff have led changes in the community practice which have added value to the patient experience and outcomes, but have also reflected a reduction in costs and improvements in use of resources.

• Better outcomes – Improvements were made through a focus on appropriate medication and treatment options being routinely reviewed (patient safety). This has become more systematic as an approach, as well as remaining reactive as patient’s situations change. With regard to clinical effectiveness, the nurses have been able to treat patients closer to home through increasing the number of outpatient clinics. There has also been a stepped change to tailor treatment to individual need with routine review – this has led to a trend towards increasing successful patient discharge.
• Better experience – Feedback has shown improvements in patient experience. A recent survey highlighted that 100% (of 54 patients surveyed) would recommend the Bedfordshire Continence Service. From the Friends and Family Test, patients reported:

I was seen by Nurse M. At no stage did I feel that my problem was too minor for her to discuss, support or help me to overcome. She examined me with so much dignity that any fears or embarrassment were allayed immediately. Thank you.

I was a bit anxious about the appointment but the nurse put me at ease, explained things in detail and gave me the confidence to go forward with assessment and treatment.

• Better use of resources – Resources were used more effectively, through gatekeeping of product prescribing, reviewed operational service delivery and reaffirming of patient pathways. The service is now spending within its allocated budget, even with rising patient caseload. The table below shows the total spend on continence products each financial year for the past 6 years:

Financial year	Total continence product spend	Patients on the caseload
2010-2011	£1,219,646	Unknown
2011-2012	£1,344,144	6108
2012-2013	£1,475,436	6324
2013-2014 (Review began)	£1,500,478	6545
2014-2015	£1,399,253	6797
2015-2016	£1,079,635	7300

There have been some instrumental changes to the service provision:

• Reduction in over prescriptions (from 5 products to 3 products per 24 hours). There have been no clinical implications and as a result patients are aware they can request reviews more frequently.
• Increase in the number of out-patient clinics run from half-day sessions to full-day sessions, resulting in a reduction of waiting times and enabling patients to have their assessments sooner.
• A review of the continence training provided by the team to other community staff to ensure it was effective. Current attendance is 20 to 25 delegates per session which is a vast improvement from 8 to10 delegates previously.
• Strengthened links and relationships with local hospitals ensuring they have access to the correct assessment paperwork for patients that are assessed, prior to discharge. This ensures that these patients are reviewed by the Continence Service swiftly following discharge to ensure the correct products are ordered and still required by patients.
• Improved management of the patient caseload, with the appropriate discharge of patients who are not on active treatments or who have not ordered products in the last 6 months.
• An increase in the number of patients that have been seen per day by each clinician. This is now being routinely monitored to ensure it is appropriate for both staff and patients. The service has seen an increase from 4.2 contacts to 6.5 contacts per day. This has meant that more patients have been reviewed and their prescription amended appropriately and has led to less over prescribing.

Challenges and lessons learnt for implementation

The nursing leadership team have relayed that they have learnt that their review of practice and steps to make changes benefited their patients, the staff as well as improved use of resources. As a result, the advice they have offered to others is not to be afraid to make changes and to challenge practice, even if long-standing, as it may be resulting in unwarranted variation in care provision.

Changes need to be ongoing and the continence service continues to aspire to delivering a cost effective service that meets the needs of patients as this changes over time.

Staff engagement is key as supporting them to be part of this has resulted in clear objectives for quality improvements needed.

Find out more

For more information contact:

Lindsay McMillan, Senior Continence Nurse Advisor, Bedfordshire Continence Service, Lindsay.McMillan@eput.nhs.uk