When most people, professionals or media, discuss the NHS it is more often NHS England that they think about. However, due to devolution, each country has its own form of NHS system. Whilst the goal of any NHS system is to provide an excellent service for health provision to their population, how it is delivered can vary greatly. This article will examine how the initial NHS was set up, how devolution in Wales has changed how services in Wales are commissioned, and how this has impacted on continence/bladder/bowel care in Wales.


The establishment of the National Health Service in 1948 was in response to the lack of social and welfare care after the second world war. It has seen many changes in its development, and still has many challenging times ahead. However, with developments, differences have now evolved with different structures of organisation between NHS England and NHS Wales. These differences within health service delivery systems have contributed to different approaches to continence/bladder and bowel services being developed and approaches to strategic care provided for individuals. This article will look at why the initial NHS developed, effects Welsh devolution has on service type and why this has led to certain developments within Welsh continence/bladder/bowel services.

Establishment of National Health Service and Welsh Devolution

The National Health Service (NHS) was established on the 5th of July 1948 after the dark days after the second world war (Shapiro, 2010) with the underlying principles of:
  • Meeting the needs of everyone
  • Free at point of delivery
  • Based on clinical need, not ability to pay.
The service was intended to be encompassing of all clinical conditions for the entire population based on two components. The establishment of district general hospitals, owned by the state and a network of independent providers for primary care (Shapiro, 2010). This developed into the health service we know today but with deviations within each of the four nations.

NHS England’s system has been based on a market – based approach but Wales no longer focuses on that system but has based its approach around 3 year integrated medium term plans (Doheny, 2015). Since 2009, the Minister for Health and Social Services has been directly responsible for the delivery of health services across Wales via the seven Local Health Boards (figure 1) and three NHS

Trusts, i.e. ambulance service, Velindre (specialist cancer services), and Public Health Wales. It is partly due to the geographical size that services have been able to achieve integrated working relationships.

Currently NHS England is now moving on to integrated care systems (ICSs) with the aim of playing a critical role in aligning action between partners to achieve their shared purpose; to improve outcomes and tackle inequalities, to enhance productivity and make best use of resources and to strengthen local communities (NHS England, 2021). Wales however has its annual planning framework 2021 – 2022 (NHS Wales, 2020), which outlines the ministerial priorities and how they expect Health Boards to achieve by enabling the workforce, technological advances, finance, research and development, etc. These complicated health care systems may seem to have no immediate impact on a professional’s day to day clinical work, however we will explore this further by examining the effects these systems have on continence/bladder/bowel services.

Figure 1.
The seven Local Health Boards in Wales.

Development of continence/bladder/bowel services

Prior to 1998 continence services existed, however they were very sparse throughout the UK. There was very little education on continence/bladder/bowel care, no set competency framework for specialists and most services existed as merely a pad product delivery service. This view was supported by an audit commission report (1999) that stated, ‘In practice district nurses implement a conservative care plan focused on managing the problem rather than treating the underlying cause’ (Department of Health [DH], 2000).

The DH (2000) Good Practice in Continence Services saw these services as a new concept and identified them as being an essential part of the NHS as incontinence is a treatable condition. The guidance outlined a model of good practice to help achieve more responsive, equitable, high quality and effective services that would benefit patients (DH, 2000). Its aims were identified to:
  • Raise awareness of professionals to the problems of continence
  • Provide practical guidance for the NHS on the organisation of continence services across primary, acute and tertiary care
  • Provide advice on the individual assessment and treatment of continence by primary care and community staff
  • Describe targets that can be developed locally.
Since the publication of this guidance there have been multiple guidance and reports on continence care which have mainly been associated with NHS England but have also been adopted in NHS Wales. These reports include the Cost Effective Commissioning for Continence Care (All Party Parliamentary Group for Continence Care Report, 2011) which identified the need for strategic planning (identifying population needs for continence care, capacity planning, reviewing current service provision and identifying gaps and priorities), procuring of services including contracts and managing demand and finally monitoring and evaluating (by looking at activity and quality of service provided, financial arrangement, and feedback from patients).

Development of continence services in Wales 

In 2006 the All Wales Continence Forum (AWCF) was established after the launch of the All Wales Bladder and Bowel Pathway (NHS Wales, 2006). The initial terms of reference for the group were to launch the pathway throughout Wales and update the pathway as clinically required. This group was recognised by the then Welsh Nursing and Midwifery Council and reported directly to the Welsh Government via the office of the Chief Nursing Officer for Wales. This is still the case but also it now has representation on the group from the office of the Chief Nurse for Wales. 

The report from the advisory group on a strategy for older people in Wales (Welsh Government, 2002) stated that urinary incontinence is considerably under-diagnosed or diagnosed late because of social stigma, embarrassment, lack of knowledge and an assumption that it is inevitable with ageing. In response to this report the AWCF launched a paper for the Welsh Government (2011a) The indignity of incontinence: local information pack for assembly members calling for action in development for continence services.  

The AWCF has now developed to become an influential participant in developing and advising on continence/bladder/bowel care for the Welsh Government in Wales. They have representation on all leading boards relating to continence care including Public Health Wales (PHW), Welsh Urology Board, and Women’s Health Implementation Group. This has allowed Welsh continence/bladder/ bowel services to develop numerous all Wales guidance and influence future continence care for patients. This will now be discussed in more detail. 

Current Guidance  

Contracts and Procurement 

Contracts for Welsh continence pad products and all Wales acute urology products are undertaken by NHS Wales Shared Services Partnership (NWSSP) (https://nwssp.nhs.wales/ourservices/). This is an established procurement service that assists Health Boards and Trusts in the delivery of patient centred services. It is an award winning service focusing on value, safety, excellence, innovation and quality. It has allowed Wales for both the continence pad product contract and acute urology contracts to identify an all Wales need. This means that there is greater purchasing power, less clinical variation across the country (while still providing for all clinical variations and needs), decreases post code variations and provides an equitable provision for the patients in Wales. This is soon to be supported by the publication of the updated All Wales Continence Forum Guidance for the provision of continence containment products for adults in Wales Consensus document 2022. This now indicates all Wales guidance on selection of pad products for in-patient care and a criteria for issuing pull up pants. 

Another service that NWSSP provide is the surgical materials testing laboratory (SMTL). Their core service is to provide testing and technical services regarding medical devices to the Welsh NHS, enabling procurement services for NHS Wales and others in the NHS to undertake evidence based purchasing. They also provide commercial testing services to international medical device agency, are accredited to ISO17025 international standing for testing laboratories. This means that if there is any doubt with regards to the efficacy of any medical device used in urology it can be independently tested prior to purchase or during a contract if there are any clinical incidents raised. 

Urinary Catheter care 

Like Public Health England (2021), PHW has a similar agenda to decrease the prevalence of urinary tract infections associated with the use of indwelling urinary catheters (CAUTIs). Identified as interventions that can reduce CAUTIs and prioritised by NHS England (2021) were: 
  • Closer collaboration between Health Care Professionals (HCP’s) working in different settings or wards at the point of patient transfer  
  • Promote working closely with patients and their families, by making sure that they are able to make an informed choice about catheter use  
  • Promote a standardised approach by ensuring that HCPs in different settings adhere to the same guidelines when managing patients with catheters  
  • Ensuring that information about catheter use is recorded in a similar way across settings, thus allowing documentation to be shared between HCPs working in different settings  
  • Addressing staff beliefs and knowledge about risks associated with use of catheters   
  • Provision of bladder scanners with staff training in use of scanners.   
Whilst PHW identified its UTI 9 Key Standards for urinary tract infection (UTI) prevention, treatment and management (Public Health Wales, 2018).  This identified nine standards which then were divided into subdivisions (table 1). 

Table 1. PHW UTI 9 Key Standards.

The AWCF has been instrumental is trying to achieve these outcomes. There is already an all Wales catheter eLearning programme (https://learning.wales.nhs.uk/), accessible to all professionals in acute, primary and nursing home settings. It has also been agreed for the instruction of nursing students. It is accessed either via electronic staff record (ESR) or e-Learning Wales. It has defined competencies agreed by the learning and development teams and updating is recommended every 5 years in line with current guidance. 

It has also developed an All Wales Catheter Passport (NHS Wales, 2016) for patient information and accurate recording of patient’s catheter history.  

Case study 1: Betsi Cadwaladr University Health Board by Kristy Ross, Project lead and Deputy Head of Community Nursing 

A campaign to combat avoidable urinary tract infections linked to inappropriate use and care of catheters has reduced use of the devices by almost 20%. Betsi Cadwaladr University Health Board said the number of patients using catheters in its hospitals and in the community across North Wales had fallen by around 400 over the last six months. 

It follows the launch of the health board’s new catheter passport, which provides important information for the user, their loved ones, healthcare staff and carers. Every catheter user is issued with one of the documents, which includes details of the purpose of the device and guidance to help care for it – plus a handy credit card-sized reminder of its scheduled change date. 

Hospital staff have been asked to consider removing catheters every few hours where inpatients no longer meet the HOUDINI (an acronym for haematuria, obstruction, urological surgery/intervention, decubitus ulcer, input/output monitoring, nursing care and immobility) criteria to use one, and users in the community have been encouraged to ask for the devices to be removed for a trial period where possible. 

Figure 2. HOUDINI acronym.  

The new approach ensures catheters are used safely and only by people who really need them. 

Project lead and Deputy Head of Community Nursing for the Betsi Cadwaladr’s East area Kristy Ross said a full-scale audit of catheter use and infections would be completed in the coming weeks, but early signs from the initiative had been very encouraging.  

‘Our records and routine reviews have shown that colleagues in our acute, community and district nursing teams have been empowered by this campaign, are challenging inappropriate catheter use, and are delivering better care’. ‘It is fantastic to see our staff developing greater catheter confidence and improving our patients’ quality of life. Our project is having a positive impact, and we hope to be able to share more results soon’. 

The initiative has been backed by health campaigner Anna Cooper, from Wrexham. The 28-year-old used an in-dwelling catheter for two years as a result of treatment linked to widespread endometriosis.  

Betsi Cadwaladr delivers health services to a population of around 700,000 people across the Isle of Anglesey, Gwynedd, Conwy County Borough, Denbighshire, Flintshire and Wrexham County Borough. 

Electronic Records

With regards to evidenced based pathways, the AWCF has clinical representation for devising All Wales electronic records for both acute and community under the guidance of the NHS Wales Informatics Services (NWIS) and Welsh Community Care Information System (WCCIS). The catheter bundle with regards to insertion, management and removal has already been trialled within acute and this bundle has identified that there needs to be standardised evidenced based practice and guidance within all areas of care and this should be reflected in patient records. Work has also been undertaken to standardise electronic continence/bladder/bowel assessments and incorporates all aspects of what good assessments should include. As records in the near future will be electronic this will give services valuable information with regards to population needs, staffing required, types of incontinence suffered and patient outcome and experience measures. In the authors opinion, this can only be seen as a positive move.


The NHS was set up after the second world war to help health and social care. Since then it has evolved but in more recent years due to devolution of the four countries it has evolved in different directions. Within each system of the NHS there are benefits and disadvantages with regards to service delivery however this article has tried to identify some of the positive aspects with regards to NHS Wales and continence/bladder/bowel care provision. Some of these aspects have only been achievable due to the smaller geographical size of Wales compared to England. This has allowed the AWCF to establish itself as an excellent resource for the WG and influence service provision which hopefully will shape the future of continence/bladder/bowel services for Wales.  


All Party Parliamentary Group for Continence Care Report (2011) Cost-effective Commissioning for Continence Care. Available online:  

Department of Health (DH) (2000) Good practice in continence services. Available online: https://www.nhs.uk/chq/documents/2015%20uploads/dh%20-%20good%20practice%20in%20continence%20services.pdf  

Doheny S (2015) The organisation of the NHS in the UK: comparing structures in the four countries. National Assembly for Wales. Available online: https://senedd.wales/research%20documents/15-020%20-%20the%20organisation%20of%20the%20nhs%20in%20the%20uk%20comparing%20structures%20in%20the%20four%20countries/15-020.pdf  

NHS England (2021) Integrated Care Systems: design framework. Available online: https://www.england.nhs.uk/wp-content/uploads/2021/06/B0642-ics-design-framework-june-2021.pdf  

NHS Wales (2006) All Wales Bladder and Bowel Care Pathway  

NHS Wales (2016) Patient urinary catheter passport: looking after your urinary catheter. Available online:  https://phw.nhs.wales/services-and-teams/harp/urinary-tract-infection-uti-resources-and-tools/uti-downloads/patient-catheter-passport-for-wales-english-version/ 

NHS Wales (2020) NHS Wales Annual Planning Framework 2021 – 2022. Available online:  https://gov.wales/sites/default/files/publications/2021-01/nhs-wales-annual-planning-framework-2021-2022.pdf 

Public Health Wales (2018) UTI 9 Key Standards for UTI Prevention, Treatment and Management. Available online: https://phw.nhs.wales/services-and-teams/harp/urinary-tract-infection-uti-resources-and-tools/uti-downloads/uti-9-key-standards-for-uti-prevention-treatment-and-management1/ 

Public Health Wales (2016) Water keeps you well. Available online: http://www.wales.nhs.uk/news/40453 

Public Health England (2021) Exploring the implementation of interventions to reduce catheter-associated urinary tract infections (ENACT). Available online: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1017534/ENACT_CAUTI_report.pdf    

Shapiro J. (2010) The NHS: the story so far (1948 – 2010). Clin Med 10(4): 336 – 338 
Welsh Government (2002) The Report from the Advisory Group on a Strategy for Older People in Wales, When I’m 64......and more. Available online: https://www.iwa.wales/agenda/2010/10/when-im-sixty-four/  

Welsh Government (2011a) The indignity of incontinence: local information pack for assembly members. Available online: https://business.senedd.wales/documents/s43157/Consultation%20response%20RC%2016%20-%20All%20Wales%20Continence%20Forum%20AWCF.pdf  

Welsh Government (2011b) All Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Inpatients. Available online: http://www.wales.nhs.uk/sitesplus/documents/862/FOI-077e-15.pdf