Bladder and Bowel Continence Care

Andrew Selous Excerpts

Thursday 29th June 2023 Westminster Hall

[Andrew Selous (South West Bedfordshire) (Con)]

I beg to move,

That this House has considered bladder and bowel continence care.

It is a pleasure to serve under your chairmanship, Sir Graham. This week is World Continence Week, so I am grateful to the Backbench Business Committee for allocating this debate on what is often a taboo subject, and therefore something of a neglected area of healthcare. Continence issues affect millions of people in England and across our whole country.

In 2018, the NHS England “Excellence in Continence Care” guidance was published. It estimated that there are 14 million people of all ages in England with bladder problems, and a further 6.5 million—again, of all ages—with bowel problems. Those are huge numbers, which is why this debate matters. Continence problems can take away people’s freedom and mobility, in some cases leading to people becoming housebound. Those problems can also lead to depression and wellbeing issues.

The Paediatric Continence Forum has informed me that continence difficulties, including bedwetting, daytime wetting, constipation, soiling and difficulties with toilet training are predicted to affect approximately one in 10 children. Unless treated, those problems can perpetuate into adolescence and adulthood. They have significant cost implications for the NHS in unplanned admissions, A&E attendance, costly consultant appointments and so on. Children need a community-based and nurse-led service.

I was honoured to take over as the chair of the all-party parliamentary group for bladder and bowel continence care, following the excellent work of my predecessors, the late Baroness Greengross and Rosie Cooper. It was the APPG that lobbied NHS England to produce the guidance that I have spoken about. I am also grateful for the many clinicians, royal colleges, charities, patient advocates and patients themselves who have given freely of their time and expertise to assist the APPG in bringing forward the debate today.

I am concerned that there has been little monitoring or review of the implementation of the “Excellence in Continence Care” guidance produced by NHS England. I hope the Minister will tell us what he is doing to address that. The last full published audit of continence care was carried out by the Royal College of Physicians in 2010. Dr Adrian Wagg, then the clinical director of the national audit of continence care, painted a stark picture when he said:

“Bladder and bowel incontinence affects 1 in 5 people causing ill health, depression, social isolation, and costing the NHS millions of pounds. Although these are treatable conditions, people of all ages, and vulnerable groups in particular (frail older people and younger people with learning disability) continue to suffer unnecessarily and often in silence, with a ‘life sentence’ of bladder and/or bowel incontinence”.

An up-to-date audit would provide a complete list of services and show regional gaps in provision. It could benchmark improvements. We could look at the number of services and specialists, identify areas for training programmes, recruitment and commissioning, as well as identifying the causes of incontinence and looking at the impact on the quality of life and comorbidities. Such an audit would also need to look at the costs involved and where savings might be made. I hope the Minister will commit to an updated audit.

Many people are too embarrassed even to talk to their GP about these issues. People suffer in silence and can become depressed and isolated, before eventually seeking help. That can affect employment, education and socialising. There is some evidence that half of people with those conditions will wait five years or more before seeking medical advice. The lack of awareness and promotion of pelvic floor health leads to acceptance of bladder weakness, particularly as part of ageing or as a result of childbirth; by the way, pelvic health is every bit as important for men as for women.

I note that NHS England’s maternity and women’s health team has an excellent initiative on perinatal pelvic health, which is very encouraging to see. I also commend NHS England for launching a programme in 2021 for pregnant women and new mothers to prevent and treat incontinence and other pelvic floor issues. It has 14 pilot sites around the country, and I would like to know what learning has come from these and what the next steps for the NHS are.

One of the most important things I can do in this debate is to promote the bladder and bowel CONfidence app, which is packed with helpful pelvic floor health advice. It was commissioned by the Florence Nightingale Foundation to celebrate the year of the nurse and midwife in 2020. The project was led by Dr Nikki Cotterill, professor in continence care at the University of the West of England. The app aims to provide quality-assured health and wellbeing information, promote safe self-care and aims to reduce avoidable demand on services. It signposts services and other sources of support and makes it easier for people to get help. I would like to know from the Minister what the NHS can do to promote the app and ensure that the information on it is widely known.

I understand that the NHS workforce plan is imminent. I very much hope that there is a plan to increase the number of specialist continence nurses, as many of them are retiring. I ask the Minister if NHS England is working with the General Medical Council to mandate that the medical, nursing and physiotherapy curriculums include bladder and bowel continence training more extensively in their syllabuses in all these areas. I would also like to know if Health Education England will be providing more specialist education courses for both stoma and urology continence nurses to enter the profession.

The APPG has worked with the Nursing and Midwifery Council to get basic training for bladder and bowel continence in their standards for nurses and midwives. We would like to see this mandated in their curriculum and be applied to general practitioner education standards as well. I would also like to know if the Minister has had any conversations with the Royal College of General Practitioners and the Royal College of Nursing about continuing professional development, including one-day training courses on continence care. This has huge potential to upskill the existing workforce to deal with this problem.

For many people, incontinence should not be accepted as a normal part of life. A high proportion of cases are curable, particularly bladder weakness. Consulting a medical professional may flag indications of underlying causes such as bladder, bowel or prostate cancer, which is why the five-year waits for a first consultation are so concerning. There is variability of access to specialist support across the country.

One of the clinicians who advises the APPG, Professor Charles Knowles, wrote the excellent report on pelvic floor services in 2021. I hope the Government took careful note of it, because it was a combination of work by 30 experts and made recommendations in six areas: awareness and education, technology-enabled care, integration of expertise, surgery procedures and premises, utilising human resources and novel approaches to freeing up resources.

As parliamentary co-conspirator with my friend and constituent Tim Briggs CBE, the originator of the Getting It Right First Time programme, I would like to know whether there is a GIRFT programme for continence care. If there is not, there certainly should be, because it has had amazing results in all the other specialisms. Are the royal colleges and the Department of Health and Social Care able to give greater direction on the need for so-called benign surgery for bladder and bowel conditions, which people are currently waiting longer for and can badly affect quality of life and wellbeing? I understand that clinicians who work with the APPG have highlighted that they believe there is racial inequality in the provision of continence care. Can we start investigating this by publishing ethnicity data on NHS treatment rates in continence care?

The APPG has led the Boys Need Bins campaign, given that men’s toilets very rarely have sanitary disposal provision. Around 11% of men in the 60-to-64 age group have urinary incontinence—that would include quite a few Members of the House—and the percentage rises with age. That figure does not include other continence issues, such as the need to use stoma bags. Men who need to use pads, catheters, stoma bags and other related items need to be able to dispose of their used products hygienically, discreetly and correctly.

One in eight men diagnosed with prostate cancer is likely to experience some degree of incontinence as a side effect, and men often say that this poses a greater problem to them than the cancer diagnosis itself. Prostate Cancer UK alerted me to the following comment in its survey regarding men having to use disabled toilets:

“Consequently, men are often forced to use disabled toilets in order to dispose of their pad or associated stoma bag products in the provided sanitary bin. It is important to note that nearly 1 in 4 men stated that they are not disabled so find it ‘embarrassing’ to use this toilet to access a sanitary bin whilst 42% stated feeling embarrassed, stressed, and anxious about using a disabled toilet, as they had experienced or felt that people will judge them. Indeed, one man told us that: ‘Whilst at a football ground, I had to ask a (male) steward if I could have access to an accessible toilet…(and) he commented, “You don’t look very disabled”’. This experience…felt inappropriate, degrading, humiliating and embarrassing.”

What do the Government expect these men to do when there is no disposal provision where they work or are being educated?

In June 2022, the BBC Radio 4 “PM” programme had a discussion about this issue that led Prostate Cancer UK and a number of other organisations to support the Boys Need Bins campaign. The campaign targets employers, hospitality venues, sports venues, retail outlets and local authorities—Winchester Council, for example, has successfully implemented such as scheme.

We have had reports of a postcode lottery in the supply of products needed. Getting the right products could lead to a reduction in urinary tract infection and skin problems such as dermatitis and pressure ulcers, and reduce costly hospital admissions. I would like reassurance that the NHS will look at the total costs in the patient pathway and not just at the unit cost per product, which could be a false economy, leading to higher costs for the taxpayer and less good outcomes for patients.

One of the most upsetting facts I discovered while preparing for the debate is that of hospital-acquired incontinence. A National Institute for Health and Care Research-funded study was published in June 2022 by the Geller Institute of Ageing and Memory, which is based at the University of West London. The research revealed that among patients with dementia admitted to hospital, over a third developed hospital-acquired incontinence, having previously been continent. There were some very upsetting accounts of patients who were not allowed to leave their bedside to reach the toilet, and even patients who were able to get to the toilet unaided were required to ask permission. Should there not be a right to self-toilet if someone can get to the loo on their own? The Spinal Injuries Association has contacted me to say that some of its members’ carers were not allowed to accompany them to hospital, leading to deep distress when people were not able to get to a toilet.

This is a very sensitive and delicate issue that does not get enough attention, and let me say straight away that I have all the sympathy in the world for nurses and healthcare assistants, who are rushed off their feet. We will not find the right way forward in this debate, but I implore the Minister to take this issue back to the Department so that we can preserve the continence, and therefore the dignity, of as many hospital patients as possible. If we get these issues right, we can save the NHS money that is currently spent on pads and appliances, reduce comorbidities and hospital admissions, and improve the lives and wellbeing of so many people.

A large number of people are admitted to hospital with urinary tract infections caused by catheter-associated urinary tract infection, and that greatly increases A&E attendance and unplanned admissions. Clinicians who advise the all-party group say that improving catheter care in the community would significantly reduce A&E attendance and hospital admissions.

I draw Members’ attention to a new service in Cornwall that has been piloting a continence car service run by NHS Cornwall 111. The cars are staffed by specialist paramedics who have additional skills, including catheter/continence management. The service reports that this has meant fewer patients being transferred to hospital and has taken the pressure off the local ambulance service. That seems to be yet another shining example of best practice in the NHS, so my question to the Minister is: what is NHS England doing to urgently evaluate it? If it is as good as it appears to be, we should mainstream it across all integrated care boards.

I want to give the last word to a young person in their 20s who has lived with chronic issues of bowel and bladder continence all through their life. This person wrote to me this week after seeing the debate advertised to say that they had never been referred to a specialist unit outside of paediatrics. It was only through a friend that they found out about the world-leading continence facilities at Northwick Park Hospital.

The pads that this person used suddenly stopped at one point because they had not been graduated from the paediatric to the adult system. They were discharged from the paediatric system and were no longer on anyone else’s system even though they have a lifelong condition. Despite the issues, this young adult works in an office and shares a flat with friends, ostensibly having a normal life even though since infancy they have needed to change pads three times a day to maintain cleanliness.

This person has three requests: first, they want the whole issue to be destigmatised in the public’s mind. Secondly, they want schools, colleges and universities and employers to care for students and workers experiencing these conditions sensitively and in an informed way. Lastly, they want proactive support for people living with bladder and bowel incontinence to explain the range of possible treatments available and the offer of mental health support for patients living with these conditions.

I salute the courage of this outstanding young adult for not being defeated by these issues and for working and leading a normal life. I want the Minister to take their comments to heart and back to the Department for action.

--- Later in debate ---

[The Minister for Health and Secondary Care (Will Quince)]

It is a pleasure to serve under your chairmanship, Sir Graham. It is unusual to have almost an hour to respond to a Westminster Hall debate. I assure you that I do not intend to use all that time, but I will endeavour to answer as many questions as possible.

I congratulate my hon. Friend the Member for South West Bedfordshire (Andrew Selous) on securing this important debate, and on his appointment as chair of the all-party parliamentary group for bladder and bowl continence care. I join him in paying tribute to campaigners such as the Urology Foundation for their incredible work during Continence Week and throughout the year.

I thank my hon. Friend for sharing the experience of the young adult who contacted him. That is what this debate, and this place, is all about. It is about destigmatising the issue, which was the No. 1 ask of that young adult. It is also about trying to bring about positive change not just for him but for patients up and down the country, especially given how many people we know are affected by continence issues.

We know—my hon. Friend set this out very articulately and eloquently—that incontinence is an issue with which too many suffer in silence. We must all learn to speak more openly about it. As the hon. Member for Bristol South (Karin Smyth) rightly set out, it is estimated that around 14 million men, women, young people and children, of all ages, are living with bladder problems. As has also been pointed out, all continence problems can be debilitating and life-changing. As we have heard, they can affect a wide range of care groups and can be of particular concern to the ageing population.

As my hon. Friend the Member for South West Bedfordshire rightly set out, this also creates pressures for our healthcare system. Complications and treatments for continence problems—for example, pressure ulcers, urinary tract infections, catheterisation, which my he pointed to, or faecal impaction—can all lead to admission and extended stays in hospital, which we should try to avoid wherever possible. The need to do what is right for patients and healthcare professionals alike means that care pathways should be commissioned to ensure the early assessment and effective management of incontinence.

To improve continence care across the whole public health and care system, NHS England has established the national bladder and bowel health project to improve continence care. As my hon. Friend rightly pointed out, it has also published “Excellence in Continence Care”, which is a practical guide for leaders and commissioners. That includes guidance for commissioners—so ICBs—and leaders in healthcare systems to ensure that people who are diagnosed with UTIs receive high-quality treatment.

I have heard my hon. Friend’s concerns about the implementation of the continence care guidelines. I will, as he asked, take this back to the Department and raise it with the Minister for Social Care, my hon. Friend the Member for Faversham and Mid Kent (Helen Whately), to discuss what more we can do alongside NHS England.

On 9 May, NHS England published its delivery plan for recovering access to primary care. It is an ambitious plan that includes proposals to improve options for community-based services to treat urinary tract infections. As part of that, appropriately trained community pharmacists will be commissioned to provide a clinical service to care for patients with urinary symptoms, providing timely access to assessment, information and advice.

In addition—this does fall within my direct remit in the Department—the National Institute for Health and Care Excellence has produced guidance on the management of faecal incontinence in adults, which healthcare professionals and commissioners are expected to take fully into account as part of the delivery of services. That guidance outlines that management strategies should consider diet, bowel habit, toilet access, medication and, importantly, coping strategies. Those management strategies will be required to account for the sensitive and socially stigmatising nature of incontinence, as my hon. Friend the Member for South West Bedfordshire set out. We know how important that is to patients, their families and—as the hon. Member for Strangford (Jim Shannon) pointed out—their carers.

I want to touch on another area, which my hon. Friend the Member for South West Bedfordshire touched on also, which is antimicrobial resistance, because we have updated the 2019 to 2024 national action plan on tackling antimicrobial resistance. The plan is core to this debate because it outlines that the UK will enhance the prevention of UTIs by providing early, accurate diagnosis and treatment of suspected and confirmed UTIs. That includes the prescription and use of antibiotics and therapeutics for older people, both in their own homes, which is critical, and in care homes, so that patients get the care they need, when and where they need it, and are less likely to suffer from the discomfort of urinary tract infections, or indeed secondary infections, which we know can follow.

To improve bowel care for people with spinal cord injury, NHS England has also published a service specification, with specialist multidisciplinary teams that provide advice and care in bowel management, including promoting and managing continence. My hon. Friend also referred to medtech, and I am really passionate—

[Andrew Selous]

The Minister might not be able to respond to this now, but before he moves on to the tech, the Spinal Injuries Association made the very good point that a lot of people with spinal injuries have carers—trained people—who are willing to come in and assist the very hard-pressed hospital staff, but are unable to. Can that be looked at? I get the complications, and I am not asking the Minister for an answer now, but one of my children spent some time in healthcare in hospitals in Africa, and in many parts of the world, if a patient’s family and friends do not go into the hospital, they will not survive. If we completely keep carers out and bar the door, have we not gone a little too far? There have to be standards, of course—it would have to be done in agreement with the staff and there would have to a be risk assessment. I absolutely get all that, but the current position seems bizarre, when there are hard-pressed staff and carers who are willing to come into hospital with their patients, so I wonder whether that could be looked at.

[Will Quince]

My hon. Friend makes a very good point. Instinctively, I totally agree with him, and I would be very happy to meet him to discuss, alongside NHS England, what more we would need to do to enable that to happen. I suspect that, in this kind of area, an individual with incontinence would often much rather have a family member, a carer or another trusted loved one support them through that process, alongside trained medical professions than anything else. So it is a good point, a fair challenge and one I will take away and consider in more detail.

Let me turn to medtech, which is a real passion of mine. We want to make sure that patients in our NHS get access to the most cutting-edge technological advances. We talk a lot about pharmaceuticals, but medtech is something that we should take very seriously, too. Earlier this year, we published our first ever medtech strategy, which says that the lowest price does not always translate to the best value. That is an important point, because the Government believe that the value of a product should be considered across the whole patient pathway, not in terms of the individual cost.

The application and adoption of value-based procurement in the NHS is a key priority in the medtech strategy, in order to realise, as I have set out, the potential of that technology to improve patient outcomes and, importantly and alongside that, to support the NHS workforce. Without getting too technical, the strategy includes a commitment to modernise part IX of the drug tariff, which lists devices that can be prescribed in the NHS.

The reason I am labouring this point is that the Government and I recognise how important patient choice is, and that a range of continence products is really important to living well with this condition. That is why there is a focus on making changes to part IX. By re-categorising part IX into groups of clinically comparable products that are interchangeable by their nature, cost-effectiveness can be compared fairly, and ICBs and clinicians will be more informed and more likely to use part IX. Doing so will also enable companies that are making innovative products to enter the market and encourage further innovation in this space, which will ultimately only benefit patients. We will continue to support the provision of a range of continence products in part IX of the drug tariff, to ensure equitable access for all patients.

The reason I labour the point about patient choice is that we must ensure that patients have a voice in the product range available in the drug tariff, so that patients’ interests are at the heart of how the tariff operates. We are currently engaging with patient groups, which is really important, and a targeted consultation will be launched later this summer to ensure that the tariff continues to be able to provide effective products to patients.

My hon. Friend and others also referred to the long-term workforce plan and the need for specialist continence nurses. I have spent the last few months saying that the plan will be published “soon”, then “very soon” and now “imminently”. I do not know if I can say “very imminently” —I am not sure there is such a thing—although I have spent most of today talking about the NHS long-term workforce plan. I anticipate spending most of tomorrow, and indeed Monday, talking about the NHS long-term plan. My hon. Friend and others will not have to wait very long before they will be able to read the plan in full. I am sure that he and others will understand why it would not be right for me to share details of it ahead of publication, but I mean it when I say that he will not have to wait very long at all.

On the points about public toilets and accessible toilets, I am conscious that I am straying into the territory of the Department for Levelling Up, Housing and Communities, which has responsibility for building regulations. It approves documents for the provision of toilets in publicly accessible buildings, which falls under the Building Act 1984 and the Building Regulations 2010. That legislation does not currently require sanitary bins in men’s toilets, but I understand the points made by my hon. Friends the Members for South West Bedfordshire and for Don Valley (Nick Fletcher), as well as the hon. Member for Strangford, about the anxiety that men feel. They make a compelling argument, and I would encourage them to raise it with the relevant Minister at DLUHC—I will do that too.

I understand that Colostomy UK has a stoma-friendly toilet campaign that is aimed at organisations, businesses and individuals. The campaign focuses specifically on accessible toilet facilities and the needs of people living with a stoma. The hon. Member for Strangford makes a fair challenge to the civil service and Government Departments to lead by example on that point. I will raise the issue with the Cabinet Office to see whether it is something we should explore further.

I thank my hon. Friend the Member for South West Bedfordshire for alerting me to the bladder and bowel CONfidence app, which was something that I was not aware of before my research ahead of the debate. I now know that a number of NHS trusts and medical centres are aware of the app and promote its use. Following this debate, I will look into whether NHS England could reference the app on its health webpages, which would be really helpful. I will also look into what more we can do to promote the app, as it sounds like a great tool.

My hon. Friend the Member for Don Valley raised the possibility of a men’s health strategy, and specifically a Minister with responsibility for men’s health. I know it is an issue that he is hugely passionate about and has campaigned long and hard on. I can give him the assurance that the major conditions strategy will take into account the needs of both men and women. Of course, we recognise that different approaches need to be taken for men and women in the provision of treatment of major conditions, especially over the whole course of life.

The Secretary of State for Health and Social Care, in Men’s Health—which is not a magazine I have read, but I have seen the cover—explicitly invited men to respond to the call for evidence to help us to ensure that the strategy takes into account the needs of men. I know that my hon. Friend the Member for Don Valley wants the Government to go further on this issue. He has already raised the issue with the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Lewes (Maria Caulfield), and I would also be happy to meet with him to discuss it.

[Andrew Selous]

I ask the Minister to forgive me if he was coming to this, but before he concludes, will he say a little bit about the third of dementia patients who go into hospital continent and come out incontinent? Many of them are actually trying to get to the toilet but have had difficulty. I find that very upsetting. As I said, it is not an easy issue, and I 100% get the pressures on the staff, but I think the issue is something that has not been spoken about. It has just happened under the radar. I am not expecting an answer today, but I would like a recognition that the Minister has clocked it, is concerned about it, and will take it back to the Department, because I was really upset when I learnt about that figure.

[Will Quince]

I entirely understand why my hon. Friend would be upset. In truth, I do not have an answer for him immediately. If he holds fire, however, I am going to make a broader offer to meet with him directly or alongside the APPG to discuss that and any other issues with NHS England and officials in the Department who are experts in the area. He raises a powerful point, and it is an issue that we need to explore further.

The hon. Member for Strangford raised prostate cancer statistics. I will write to him specifically, because I know he would like more detail on this issue. He is absolutely right that there has been a considerable increase in diagnoses of prostate cancer. I think the statistics are that in 2020 we diagnosed something in the region of 36,000 cases, whereas in 2000 it was 25,000, which is something like a 45% increase. Diagnosis is generally a good thing, especially early diagnosis, because it means that we are catching the disease early. However, I understand that about 51% of prostate cancers were diagnosed at an early stage in 2021, which demonstrates that we have a lot more to do in that space. I will write to the hon. Gentleman on that point, and will raise it with my hon. Friend the Member for Faversham and Mid Kent.

I have not answered all the questions that my hon. Friend the Member for South West Bedfordshire asked. As tempting as it is to take up the remaining 35 minutes of the debate, I will commit to meeting with him personally, or indeed with the all-party parliamentary group and campaigners, alongside NHS England and the Department, to talk about some of the other issues in detail. I think they certainly warrant that, so I would be delighted to do that.

In summary, NHS England has published its delivery plan, which sets out our proposals to improve options for community-based services to treat urinary tract infections. In addition, NICE has produced guidance on the management of faecal incontinence in adults. The annual spend on incontinence products from part IX items alone is approximately £255 million. As I said, we know how important patient choice is and understand that having a range of continence products is important to living well with this condition. That is why I can promise that there will be a focus on making changes to part IX of the drug tariff.

To conclude, I know that many people who experience bladder and/or bowel problems experience stigma, a point made eloquently by my hon. Friend the Member for South West Bedfordshire. They can be embarrassed to talk about the symptoms with friends, family and even, to some extent, healthcare professionals. That is why I am particularly pleased that my hon. Friend secured today’s debate, which has provided me the opportunity to play a small part in tackling the stigma that surrounds this issue. I think all hon. Members that have taken part in this debate have helped to defeat the stigma that surrounds the issue. I am not so naive as to think that there will be thousands watching this debate at home, but the debates are kept online and I hope people will watch. They will realise that it is vital to talk to medical professionals about their health issues and problems in this space and, wherever they feel it is necessary, to seek out professional care.

[Andrew Selous]

Thank you, Sir Graham, for looking after us this afternoon; I thank all my colleagues who came along. The hon. Member for Strangford (Jim Shannon), who is such a stalwart of these debates, was so right to say that this has traditionally been seen as a women’s issue. He pointed out that it is not and talked about the impact on intimate relationships, which is vital to highlight as well. He talked about the importance of the Dispose with Dignity campaign and the needs around it, which we have heard good commitments on from the Minister on today.

My hon. Friend the Member for Don Valley (Nick Fletcher) also supported the Boys Need Bins campaign and talked about the negative impact on men’s mental health. He called on us to listen and act, and asked how this issue could fit within the men’s health strategy. I am extremely grateful to him for coming along. I completely agree with the shadow Minister, the hon. Member for Bristol South (Karin Smyth), that this is an issue we need to prevent, cure and manage. She is 100% right about that. I am grateful for her support for the app, which comes from her part of the world.

I am hugely grateful to the Minister for his commitments. I will take him up on that meeting. I will also put him down as a Boys Need Bins champion in Government. I know it is not his departmental responsibility, but if he can be there with us to try to make progress, I will take that as a win this afternoon. I look forward to the meeting.

Question put and agreed to.

Resolved,

That this House has considered bladder and bowel continence care.