Background and introduction
The Urology Trade Association (UTA) is the leading urology industry membership organisation in the UK, representing the majority of urology product manufacturers and suppliers to the urology appliance market. We welcome the opportunity to respond to this inquiry into patient centred care in the 21st Century.
An estimated 6 million people in the UK are affected by continence problems and many rely on urology appliances on a daily basis. High quality urology appliances allow users to effectively manage their conditions, maintaining their quality of life and independence and avoiding repeated medical consultations. Access to appropriate products is also important as poor long-term urological care often has a profound negative impact on a patient’s dignity and wellbeing.
The UTA believes that any future models of NHS care must consider that as the number of people with one or more long term conditions will increase, so will the number of people with continence problems. According to the World Health Organisation, longer life expectancies and an ageing population is likely to lead to an increased prevalence of neurological conditions, of which many will result in continence problems. As such, NHS England must consider making continence care a higher priority and providing clinicians with the support they need to ensure that continence care is provided at an adequate level. The UTA also believes that patients with continence needs must be able to make informed choices about the management of these needs, and must have access to products that best suit their needs. These products can only be provided if NHS staff properly evaluate the long-term implications of procurement on health outcomes and NHS budgets, rather than simply looking to make short term savings.
- How do models of NHS care need to change to deliver better patient outcomes, as cost effectively as possible, for the growing number of people living with multiple long-term conditions?
Existing models of care often do not always adequately take account of the link between continence problems and long-term conditions such as cancer, strokes, spinal cord injury, MS, spina bifida, Parkinson’s disease, and other neurological conditions; this is despite continence being a common symptom of many neurological conditions. The consequence of this is that patients with these conditions are frequently left without the support they need to manage their condition as well as possible. Therefore, there is a need to consider both how effective care is provided to deal with continence problems, and how continence is managed as part of other long-term conditions which can mean that patients have very complex needs.
The quality of care received by patients with continence problems has not always been high; this has implications not only for patients but also for public spending. For example, in September 2010, the Royal College of Physicians published the National Audit of Continence Care, which examined the quality of continence services in England, Wales and Northern Ireland. It identified a number of significant weaknesses in the care offered to patients and found that there is unacceptable variation amongst NHS Trusts in the type, quality and quantity of continence supplies made available to patients.
The UTA believes that NHS England and Health Education England should provide support to staff involved in making decisions about which products patients should use – from procurement staff to GPs to community nurses. These staff could benefit from increased training on the kinds of products which are used, to improve their knowledge of how their decisions can impact on patient outcomes as well as budgets. Patients should also be given better access to specialist services or nurses, so that they can get better advice on which products will help them to meet their needs, from a healthcare professional who has a good knowledge of both the system and the products available.
Future models of NHS care must also consider the long-term impact of product procurement. We are increasingly concerned about “silo budgeting”, where procurement staff look at the impact in the own small area or budget, without fully considering what wider impacts this can have. As an example of silo budgeting, there is often a tendency in urology to steer patients towards cheaper products through the use of tenders or formularies, which fail to take into account the wider costs and implications that inappropriately short-term and narrow procurement will have.
When patients cannot access products which meet their own specific needs this impacts on quality of life, independence and dignity, reducing overall outcomes. It also leads to product wastage, an increased incidence of urinary tract infections, and an increased reliance of health and social care services – leading to increased costs. It is worth noting that the average cost for the admission of emergency urethral catheterisation resulting from urinary tract infection is estimated in the region of £1,500 per patient, per visit.
- What does this mean for the way in which NHS resources are deployed across health economies in a financially constrained environment?
The provision of the most appropriate products to people with continence problems would result in less product wastage and fewer emergency admissions to expensive acute care settings. More appropriate care would also lessen dependence on other healthcare services, and lead to greater patient experience.
It would also be useful if the Government use forums such as the Continence Care Working Group to engage with stakeholders and ensure the dissemination of materials which can improve the quality of continence care.
In terms of ensuring product availability, future models of care must make sure that procurement decisions have a greater deal of expert input than at present, and that they are not only focused on short-term cost saving. The vast majority of procurement staff do not have clinical training and do not fully appreciate the subtle differences between medical products such as catheters. Two different forms of catheter may appear to be very similar, and indeed substitutable, non-specialist staff but small differences can make a real difference to patients and their ability to use the product.
- How can the role of general practice best be developed to support the new models of care required and what policy levers and financial mechanisms should be put in place to deliver these at the scale and pace needed?
General practice is often the first port of call for patients requiring assistance with their continence problems. Whilst GPs in general have some understanding of continence issues, we have found that there are many who are unaware of the impact that different products can have on patients, and that patients often leave general practice unaware that they have a right to access any product on the Drug Tariff – a comprehensive list of products which have been assessed and approved at a national level as clinically effective and cost effective.
As such, the UTA believes that GPs must be better informed about the products available to patients, and must be able to make appropriate suggestions to patients who might need products. Although the UTA has determined that some guidance is already available for GPs, the fact that it is not properly utilised is indicative of the need for better dissemination.
As outlined in Question 2, training and advice could be provided to GPs through a combination of efforts by NHS England, Health Education England and LETBs to develop higher quality teaching, better signposted toolkits and guidance to improve practice. These organisations could also work together to develop a library of e-learning resources for GPs who do not have a good understanding of continence and product options available for patients. Local clinical commissioning groups (CCGs) could conduct surveys to identify where continence services are poor and raise continence care as a priority in that area.
Where patients are in need of more specialist care, for example from a dedicated continence services, CCGs should ensure that referral pathways are in place so that GPs know where to refer patients.