Continence Self-Assessment Framework (2014)
Clinical Commissioning Group (CCG)
About this document
The purpose of the NHS England self-assessment framework for continence is to:
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Establish baseline data on continence commissioning by CCGs in England
Support CCGs to begin to establish a dialogue with providers in relation to local continence pathways and services
Identify priority areas for action to strengthen commissioning and improve patient outcomes
Background
It is estimated that between three and six million people in the UK are living with symptoms of urinary incontinence. Evidence collated through the most recent National Audit of Continence Care (2010) and
through patient group and clinician feedback suggests that the quality of care for people with incontinence is highly variable and symptoms are underdiagnosed and poorly managed1, 2, 3, 4. Of particular
concern, evidence heard through the Francis Inquiry found that 22 out of the 33 cases presented as oral evidence included “significant concerns” about continence care 5.
Poor continence care has a negative impact on patient outcomes and experiences and can also lead to unnecessary morbidity and service use by raising the risk of infection, pressure sores and falls6, 7.
Given that the prevalence of incontinence increases with age, population changes are likely to lead to the intensification of these issues over time8.
The NHS has estimated annual spending for treating urinary and faecal incontinence in adults at £500 million 9 but at present there is very little information about the commissioning of continence services
within the NHS. A number of assessments of service provision have been undertaken in the past10, 11, 12, but the extent to which CCGs understand local needs and take steps to plan and commission
services to support people with incontinence is unknown. This means that there is no up to date assessment of current service levels and the quality and impact of services on individual outcomes.
The evidence, reporting requirements and outcome frameworks information is included at pages 7 and 8.
Self-assessment framework questions
Introductory
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How many people are there in your CCG area with continence needs (request by age group)?
How many people with a long term condition have incontinence as a comorbidity?
How many people were admitted to hospital as an emergency for an incontinence-related condition (such as a UTI or fall)?
How many people in residential, nursing care and domiciliary care in your area have an identified continence need?
Have many complaints have been received in relation to continence and toileting care?
The SAF questions should be answered with reference to the measures and scoring guide. For each question, CCGs should report:
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A score (red, amber or green);
An explanation for the score;
A link to substantiating information and evidence
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Measure
Red
Amber
Green
Part A: Data and service design
1. Data on local needs
CCG holds local data on the number of people with
continence needs in primary care, acute, nursing, residential
and domiciliary settings.
The number of people with
continence needs across
settings is not known.
Data exists on the number
of people with continence
needs in some but not all
settings (eg primary care)
There is comprehensive
local data on the
number of people with
continence needs
across care boundaries.
There is a record of the continence needs of high risk
patients such as:
 people with a long term condition (eg cardiovascular
disease, respiratory disease, stroke, dementia, learning
disability, cancer13)
 the over 65s
 pregnant women
2. Evidence-based commissioning
CCG can demonstrate that they use a range of collated
evidence/information/data including the needs of high risk
populations to ensure evidence-based commissioning. Data
should inform a range of person-centred and cost effective
options across the care pathway.
3. Continence service specification
A local continence service is in place. The service
specification covers recording and reporting of the number of
patients with incontinence, and the assessment, diagnosis,
treatment of incontinence, as well as ongoing treatment, care
and support. This should detail levels of management
available:
 Level 1: a nurse or physiotherapist
 Level 2: a specialist nurse (continence, urogynaecology,
urology) or specialist physiotherapist
 Level 3: secondary care consultant
 Level 4: tertiary care
4. Cost of services
CCG has up to date information on the cost of managing
incontinence and is able to evaluate the cost effectiveness of
local services, to include:
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Incontinence is not
routinely recorded among
high risk groups.
Local data does not inform
commissioning along a
care pathway and there is a
lack of person-centred
options available to people
with incontinence and
family carers.
There is no local
continence service in place.
Incontinence is partially
recorded (X%) of at risk
groups.
Local data informs the
range of options and care
pathways available to some
people with incontinence,
their family and carers in a
range of settings.
The CCG can
demonstrate the use of
evidence-based quality
assurance frameworks
to improve patient
outcomes.
Local care pathways are
being developed and there
is some evidence of
community teams to avoid
hospital admissions.
The CCG can
demonstrate the use of
contractual levers to
improve quality of
continence care.
A continence service is in
place based on a
specification that covers
part of the pathway.
Service specification is
in place and covers all
levels.
There is a designated
local continence lead
responsible for the
whole service.
Cost data is not held or is
held at the level of urology
block contract.
Cost data is held and is
partially disaggregated to
help inform cost
effectiveness.
CCG actively uses
disaggregated cost data
to plan cost effective
service models in
partnership with
providers.
CCG can provide
assurance for 25% of
contracts, or if single
contract is in place, no
CCG can provide
assurance for 50% of
contracts, or if a single
contract is in place,
CCG can demonstrate
use of contractual levers
for improving safety,
quality and outcomes for
 basic and specialist assessment
conservative management
therapeutic treatment
containment products
surgical treatment
unplanned admissions and hospital stays (UTIs, falls,
pressure ulcers)
care home admissions
Part B: Quality assurance
1. Outcomes and quality assurance
CCG is assured through commissioning, procurement and
contract monitoring with providers that quality, safety and
outcomes for people with incontinence are being improved in
line with statutory duties and agreed quality metrics.
There are full records of
the continence needs of
high risk patients.
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Self-assessment
Readiness (R/A/G)
Comments
Process measures:
 Initial assessment (including appropriate diagnostic tests)
 Lifestyle, physical and behavioural interventions
 Choice of temporary containment products
 Pharmacological treatments and timely medication
review
 Information and support
 Specialist assessment and investigation
 Surgical and invasive treatment
Outcome measures:
 Symptom reduction
 Quality of life
 Ability to self-care
 Reduction in emergency admissions associated with
poor management (UTIs, urinary retention, pressure
ulcers, falls and fractures)
 Patient experience (see separate measure below)
2. Contractual incentives
The CCG uses payment and incentive schemes, such as
CQUINS, to incentivise providers to deliver quantified quality
improvement goals, such as:
 Improving the identification, assessment, diagnosis
and treatment of urinary incontinence
 Achieving a reduction in urinary tract infections
 Achieving a reduction in unnecessary catheterisation
3. Identification and assessment of needs
CCG is working in partnership with providers to ensure that
people with continence needs have access to a full range of
healthcare assessments in line with policy and best practice.
Staff working across different settings are trained in order to
be able to refer or signpost people with continence needs to
an appropriate healthcare professional.
4. Personalised care plans
CCG has evidence that patients are offered a personalised
care plan (or their continence needs are included in an
existing care plan and/or a personal health budget) which
documents patient-defined goals, is based on shared
decision-making and is reviewed at regular interviews in line
with NICE guidance. As part of this process, patients should
be given appropriate information to help them make
decisions.
5. Patient experience
CCG can demonstrate that there is evidence of patient
experience, review and analysis of complaints and use of the
whistle blowing policy affecting people with continence
leading to improved practice.
assurance is provided that
a full scheduled annual
contract and service review
took place.
assurance is provided that
a full scheduled annual
contract and service review
took place.
all contracts and that a
full scheduled annual
contract and service
review took place.
CCG cannot demonstrate a
range of process indicators
and outcomes supporting
quality assurance.
CCG can demonstrate
monitoring of a range of
process and outcomes
metrics.
CCG can demonstrate a
range of process and
outcomes metrics and
evidence of
improvement.
There are no CQUINS or
other payment schemes in
place.
There are CQUINS in place
but there is no
demonstrable improvement
against quality goals and
incentives have not been
awarded.
CQUIN/s are in place.
The provider has
satisfied quality goals
and incentives have
been awarded.
There is no systematic
process for assessing
people at risk of continence
problems within primary
care.
There is an agreed process
in place for identification
and assessment of
continence needs, but the
extent to which this is
followed is unknown.
Staff follow agreed
protocols for identifying
and assessing patients.
There is no basic
continence awareness
training for non-specialist
staff in different care
settings.
There is basic continence
awareness training
available for staff in
different care settings but
uptake of training is
unknown.
Staff who support high
risk individuals have
received basic
continence awareness
and promotion training
and are able to support
and signpost patients
appropriately.
Less than 50% of patients
have been offered a
personalised care plan
which documents patientdefined goals and is
reviewed at regular
intervals.
Evidence that at least 75%
of patients have been
offered a personalised care
plan which documents
patient-defined goals and is
reviewed at regular
intervals.
Evidence that more than
90% of patients have
been offered a
personalised care plan
which documents
patient-defined goals
and is reviewed at
regular intervals.
Patient feedback is not
collected or it is not
possible to identify the
experience of people with
continence needs.
Patient feedback and
complaint system in place
which provides data about
the experiences of patients
with continence needs. No
Patient feedback system
and complaints are in
place specifically
providing data about the
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6. Training and competencies
CCGs should be assured that healthcare professionals
involved in assessing, caring for and treating incontinence
have sufficient and appropriate training and competencies to
identify, assess, treat and manage patients with continence
needs as described in relevant NICE clinical guidance.
Part C: Involvement and integration
1. Patient and public involvement
CCG can demonstrate that patients, families and carers are
involved in service planning and decision-making in order to
ensure that their needs, choices and preferences are
understood and that services are patient-centred.
2. Health and wellbeing boards
CCG can demonstrate that the health and wellbeing board
has been informed of the continence services commissioned
and assured that the services will deliver in line with agreed
quality metrics.
evidence can be given of
specific service
improvement as a result of
the feedback.
experiences of patients
with continence needs.
There is no evidence of
appropriate training and
competence.
There is partial evidence of
appropriate training and
competence.
There is comprehensive
evidence of appropriate
training and
competence.
There is no evidence that
people with continence
needs and their carers
have been involved in
service planning and
decision-making.
There is evidence that
people with continence
needs and their carers
have been involved in coproduction but this is
limited.
There is clear evidence
of co-production and
CCGs use this to inform
commissioning practice.
Continence service is not
reported or known to the
health and wellbeing board.
Continence service is
known to the health and
wellbeing board but does
not play an active role in
continence planning and
scrutiny
Health and wellbeing
boards are aware of the
continence service and
play an active role in
integrated planning and
scrutiny
Commissioner can provide
evidence of integrated
governance structures.
Commissioning
arrangements are
integrated and provider
organisations share
information and work to
agreed protocols.
Health and wellbeing board
does not play an active role
in continence planning and
scrutiny.
There is evidence of
specific service
improvement as a result
of the feedback.
3. Integrated working
There are well functioning partnership agreements between
health and social care commissioners and providers of
continence care.
There is no evidence of
integrated governance
structures such as Section
75 agreements.
There are no joint
commissioning functions in
place.
There is no evidence of
joint working across health
and social care providers.
Monitoring is undertaken
jointly and key partners are
involved at Partnership
Board level.
There are some joint
commissioning functions in
place and joint working
between health and social
care provider organisations.
There is a local
continence lead
responsible for service
integration.
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References
1
Royal College of Physicians, National Audit of Continence Care, 2010
2
All Party Parliamentary Group for Continence Care, Continence care services: survey report, 2013
3
Expert group on lower urinary tract symptoms, 2 in 3: Delivering world class services for people with continence, lower urinary tract and bowel symptoms, 2011
4
Robert Francis QC, The Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013
5
Robert Francis QC, The Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust, 2010
6
Health and Social Care Partnership South East, Prevention and early intervention continence services, 2011
7
Expert group on lower urinary tract symptoms, Commissioning for incontinence, lower urinary tract and bowel symptoms - an audit, 2012
8
Department of Health, Good practice in continence services, 2000
9
National Institute for Health and Clinical Excellence, The management of faecal incontinence in adults – Draft Scope, 2005
10
All Party Parliamentary Group for Continence Care, Cost effective commissioning for continence care, 2011
11
Expert group on lower urinary tract symptoms, Improving outcomes for people with lower urinary tract symptoms: commissioning guide, 2014
12
Expert group on lower urinary tract symptoms, Commissioning for incontinence, lower urinary tract and bowel symptoms - an audit, 2012
13
Macmillan Cancer Support, Throwing light on the Consequences of Cancer and its Treatment, 2013
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Evidence, reporting requirements and outcome frameworks
Joint strategic needs assessment
Risk profiling and care management scheme (enhanced service for 2013-14)
Patient records (including electronic) in general practice and for inpatients
National CQUINs (NHS Safety Thermometer, dementia and delirium)
NICE pathways: urinary incontinence in women, lower urinary tract symptoms in men, faecal incontinence in adults
Local enhanced service (eg nurse-led rapid access clinic)
Local incentive schemes
NHS Outcomes Framework 2014-15 and CCG Outcomes Indicator Set 2014-15 (2.1, 2.2, 2.3, 2.4, 2.6, 3a, 3.6i, 4a, 4b, 4c, 4.5, 4.9, 5a, 5.3)
Any qualified provider implementation pack specification
Local enhanced service
NICE clinical guidelines CG171 urinary incontinence in women, CG97 lower urinary tract symptoms in men (and QS45), faecal incontinence in adults (CG49)
NICE urinary incontinence in women and LUTS in men costing templates
CCG Assurance Framework 2014-15 (Better Care Fund indicators: avoidable admissions, bed days, residential care admissions; Financial indicators)
CCG quality premiums (avoidable emergency admissions, friends and family test)
Right care: commissioning for value
CCG Assurance Framework 2014-15 (NHS Constitution indicators, Outcomes and Quality indicators OF domains 2,3,4,5)
CCG Quality Premium 2014-15 (FFT)
A national response to Winterbourne View Hospital
DH response to Francis Inquiry Hard truths: the journey to putting patients first (volume 1 and volume 2)
CQC fundamental standards (dignity and respect; care and treatment)
NICE quality standards, clinical and technology appraisals and interventional procedure guidance: CG171, CG97, CG49, QS45, forthcoming female UI quality standard (NB this list is not exhaustive at present)
NHS Outcomes Framework and CCG Outcomes Indicator Set 2014-15
NICE UI and LUTS audit tools
NHS England CQUIN pick-list
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Skills for Care: Care Certificate for care assistants (NB pilots do not include incontinence and this needs to be addressed – action for group)
NICE baseline assessment tool for urinary incontinence in women, lower urinary tract symptoms in men and faecal incontinence in adults.
NHS Outcomes Framework (Domain 2)
NHS Mandate 2014-15
NICE quality standards, clinical and technology appraisals and interventional procedure guidance: CG171, CG97, CG49, QS45, forthcoming female UI quality standard (NB this list is not exhaustive at present)
NHS Constitution (involvement in decision-making)
Right care: Lower urinary tract symptoms decision aid
NHS guidance on the “right to have” a Personal Health Budget in Adult NHS Continuing Healthcare and Children and Young People’s Continuing Care
Francis Inquiry and DH response to Francis Inquiry Hard truths: the journey to putting patients first (volume 1 and volume 2)
National CQUIN (Friends and Family Test)
CCG quality premium (Friends and Family Test)
Whistle blowing policy
NHS Constitution (dignity, privacy, respect and feedback)
NICE quality standards, clinical and technology appraisals and interventional procedure guidance: CG171, CG97, CG49, QS45, forthcoming female UI quality standard (NB this list is not exhaustive at present)
NHS Constitution
Commitment to carers
NHS Outcomes Framework 2014-15 and CCG Outcomes Indicator Set 2014-15 (2.1, 2.2, 2.3, 2.4, 2.6, 3a, 3.6i, 4a, 4b, 4c, 4.5, 4.9, 5a, 5.3)
DH Review following Winterbourne View
A national response to Winterbourne View hospital
Better Care Fund planning
Joint health and wellbeing strategies
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