Background 

In 2019, the first author took over a clinical lead role for three related teams at Lewisham and Greenwich NHS Trust in South London. The teams were the pelvic health physiotherapists at Lewisham and Queen Elizabeth’s Hospital and the community continence team in Lewisham. All three teams are part of the same Trust and the vision was to form one larger, more connected team. The role also included management of the containment product service which was a completely new challenge.
 

Current guidelines and evidence 

The most robust guidelines that inform practice in this area are from the Association of Continence Professionals (2023) and NHS England (2018). The Excellence in Continence Care guidance (NHS England, 2018) still remains useful despite the changes that have happened to the NHS since it was published. There is considerable detail in this document that supports clinical reasoning and the provision of high standard care. 

The Continence Product Advisor website (https://www.continenceproductadvisor.org/) is very helpful for patients and carers to navigate and to learn what products may suit them best, especially if they are self-purchasing. It has been co-designed by the University of Southampton and the International Continence Society. It is free from industry sponsorship and is straightforward for anyone to use. 

In the authors’ opinion, the Association of Continence Professionals (2023) guidelines are the best place to start when designing, or redesigning, a containment product service as they are detailed and designed by expert clinicians in the field. They are usually updated every 2 years.

Containment products 

The term ‘containment products’ covers any item that ‘contains’ urine or faeces (Table 1). The most common items that healthcare professionals will be familiar with are disposable, absorbent continence pads or pants but containment products also covers catheters, washable pads and pants, as well as containment devices such as Convene catheters or even urine bottles. The key product areas are outlined in Table 1, and excellent guidelines and resources can be found in the documents referenced earlier.
 

What were the issues?

The product service had been established for many years but the structure and function of the service had not been reviewed recently, so the recruitment of a new clinical lead was a good time to review and restructure the service.
 

• Cost – the Trust was spending £750 000 per year on prescriptions of containment products for community-dwelling adults and children, including 15 care homes for adults
• Environmental impact – almost all the products prescribed were disposable products that can take up to 500 years to break down in landfill. Transport for deliveries and packaging add to the environmental impact
• Pads first – many patients had received a very limited clinical assessment, or none at all, and were given containment products as a first-line management solution. These were usually disposable products rather than something more sustainable
• Expectations – patients, carers, relatives and other staff often felt that containment products were the first solution for continence issues. It was hard to educate staff about lifestyle changes, assessment processes and alternative treatments. There is also a commonly held belief that it is normal and expected to receive containment products free from the NHS in most situations but the Association of Continence Professionals (2023) guidelines state that products should only be supplied at the end of a thorough, appropriate assessment and treatment process.

 

What changes were made? 

A number of incremental changes were made over several years (Table 2). These varied in size and impact, and some took much longer to action than others. There was no formal or structured process to identify where to start as there were multiple areas to tackle within the service. A ‘common sense’ approach was used that took the simplest action to start with and worked from there.

The changes are described below, and separated into four categories: service changes, staffing changes, product changes and communication. It is hoped that this will provide a ‘pick and mix’ selection for other services to look at and consider against their service, evaluating what changes might be possible for them to implement.

Table 1. Types of containment products

Product	Description
Disposable pads (insert pads or shaped pads)	Rectangular pads of different sizes and absorbencies, some shaped for a better fit. They sit inside close-fitting underwear, with smaller ones using an adhesive strip to secure them in place
Pull-up pants	Designed to look and feel similar to standard underwear, but are disposable and have an absorbent gusset
Wrap-arounds or slips	Similar appearance to nappies designed for babies, with adhesive strips at each side to secure them in place
Faecal pads	Similar to insert or shaped pads but without the absorbent inner layer. They are designed to capture formed faeces rather than urine
Washable, reusable underwear	Designed to be as close to normal underwear as possible, with an absorbent gusset. They can be washed and re-used many times and are often a more sustainable option
Catheters	These should rarely be used as containment devices but are useful in some situations
External and Convene catheters	These are designed to reduce the risk of catheter-related complications, particularly infections, by avoiding urethral insertion
Bottles and external devices	There are a multitude of products, such as urine bottles, bedpans, commodes, Shewee and Afex Men’s Liberty, that offer urine (and/or faecal) collection rather than holding it in a pad or underwear

Table 2. Changes made to the containment product service 

Service changes	New service name New service sub-divisions New product service motto Dedicated e-mail address Establishing a product lead Improved assessment processes Stakeholder group Caseload reviews  Product prescription processes Patient information Product website checks Maintenance Annual reviews Paediatric service Face-to-face product clinic
Staff changes	Training Clinical skill development
Product changes	Guideline-led local formulary Removal of protective bedding prescriptions Washables Automatic deliveries cancelled Restrictions around prescription of pull-up pants Restrictions around prescription of belted products Removal of procedure pad prescriptions Absorbencies
Communication	Training Patient information Suppliers

Service changes 

New service name 

We chose a name ‘Bladder, Bowel and Pelvic health service’ to reflect the variety of bladder, bowel and pelvic health issues seen, and we deliberately removed the word ‘continence’ as we felt that this often narrowed down the service offered. Many of the conditions we see are not continence-related as such, including constipation, prolapse and overactive bladder (dry). The term continence is often followed up by, or associated with, ‘continence pad’ and we wanted to separate these out a little more.
 

New service sub-divisions

We separated out aspects of the service into the care home service, catheter service and containment product service. This ensures each area is optimally managed and receives the recognition it needed. 
 

New product service motto 

We chose a positive motto for the containment product service – ‘Products for people, purse and planet’ to reflect the areas we felt were most important, and to ensure that sustainability was part of the vision.
 

Dedicated e-mail address 

We established a dedicated e-mail address for product-related queries. This supports service efficiency, and the product lead has regular slots marked out to deal with these queries quickly.
 

Establishing a product lead 

We allocated one member of the team’s nursing staff to manage the product service, with support from the clinical lead. This ensured a consistent approach to patient assessments and reviews. 
 

Improved assessment processes 

We wanted to provide a comprehensive and appropriate assessment for every patient. This was done by designing simplified forms, establishing direct communication between the care home staff and the Bladder, Bowel and Pelvic Health team, and having one clinician specifically to support the care home service.
 

Stakeholder group 

We established a group to review and agree our proposals, including key members of the integrated care board, senior managers within the community division, a local GP, a local care home manager and (eventually) a patient focus group. This enabled us to have confidence in our plans, and to have them embedded as Trust guidelines.
 

Caseload reviews 

An initial caseload review was undertaken of all patients who were originally on the product caseload, first by the clinical lead and then joined by the product lead. This involved removing 5000 patients (around 60% of the list) in the early stages and identifying issues such as a patient who had died 15 years ago but was still receiving containment products every 8 weeks. A number of reviews of the whole caseload have been performed to support the changes, and it took 5 years to reach a strong level of confidence that the caseload was correct and that each patient was receiving the correct products.

Alongside this, a gradual caseload review was undertaken of patients identified as being on incorrect or suboptimal products. This was then extended to patients who had not been adequately assessed and treated, and then to patients who had been prescribed products that were not covered by the agreed Trust guidelines. It has been accepted that changing prescriptions for some patients would cause too much anxiety or distress and so prescriptions have been left or only slightly amended where it has been safe to do so.
 

Product prescription processes 

The product lead established guideline-led assessment processes for product prescription, including bladder diaries or fluid and voiding charts, alongside pad weigh tests where appropriate.
 

Patient information 

A ‘patient commitment’ sheet was developed to be sent to all new patients who were prescribed products. This includes details of how to re-order products, who to contact if there are any issues with deliveries or the products themselves, how to book a review, what to do if products are no longer needed, and the Trust rules on product prescription.
 

Product website checks 

Daily and weekly checks are performed on the NHS Home Delivery website to pick up issues such as failed deliveries or patients not re-ordering products as expected. This allows early detection of problems, and reduces waste and cost by dealing with any problems promptly.
 

Maintenance 

This involved gradually aligning the service with the agreed proposals, and dealing with concerns and complaints from patients, carers and relatives as the changes took place. This was an exhausting part of the process as past expectations had been that patients could access products on request and before any assessment or treatment. Product choice had been determined more by patient opinion than clinical judgement.
 

Annual reviews 

In line with guidelines, annual reviews are now performed. These may simply be a review of documentation and prescriptions, or may involve communicating with the patient via emails or telephone calls, clinic appointments or occasional home visits.
 

Paediatric service 

At each stage, the paediatric service has been supported to align with the changes in the adult service. There is work ongoing to improve the process of transitioning from paediatric to adult services.
 

Face-to-face product clinic 

We established a weekly half-day product clinic to support selected patients with product selection and use. We also arrange home visits for patients who would benefit from this clinic but are housebound.

Staff changes

Training 

A comprehensive team training programme was established, and the team now has four training days per year, attended by the core team members across the service (12 clinicians), along with staff who work closely with us and non-Trust staff who pay a small fee to attend.

 

Clinical skill development 

We are developing team expertise in bladder and bowel assessment and treatment to ensure products are only prescribed appropriately. This is done by regular team training, case reviews and attendance at courses and conferences.

 

Product changes 

Guideline-led local formulary 

It was essential to gain a thorough understanding of the current guidelines, evidence and best practice of product prescription. This was done by the clinical lead and then the product lead and clinical lead worked with the product representatives to develop a suitable, local formulary.

 

Removal of protective bedding prescriptions

Protective bedding is not a containment product, and correct product prescription and use should minimise any risks of leakage. Therefore protective bedding is no longer prescribed by the service. 

 

Washables 

We were keen to introduce washable products because of their environmental benefit. Many patients (or relatives and carers) find washable products less acceptable than disposable, so washable products are only prescribed after careful discussion. A trial pair (postage free) is sent before checking acceptability and following up with a prescription for a larger amount.

 

Automatic deliveries cancelled 

The service has removed the option for automatic delivery of products every 8 weeks because of the high number of deliveries that were going to patients who had been discharged from the service, were deceased or were living in a different borough.

 

Restricting prescription of pull-up pants

Disposable pull-up pants are significantly more expensive than other products but have a smaller absorbent section which often makes them a less effective product. They are also less suitable for use if the patient is lying down as the urine often escapes past the smaller absorbent strip. As a result, the service has introduced restrictions about prescribing pull-up pants. 

 

They are used when a patient is toileting independently or with minimal help and can maintain this level of independence only if they have pull-up pants. This is usually found in patients with significant dexterity issues where manipulating an insert/shaped pad is challenging or in patients with advanced dementia who struggle to accept an insert/shaped pad. This tends to be more of an issue with men, as women are more accustomed to using pads for sanitary protection.

 

Restricting prescription of belted products 

The service is reducing the use of belted products unless there is no other suitable alternative, as these are some of the more expensive products and the alternative products (such as wrap-arounds) are often found to be just as effective and acceptable.

 

Removal of procedure pad prescriptions 

Procedure pads, often known as ‘inco pads’ or ‘bed pads’, are not suitable as containment products and so are no longer available on prescription. Over 100 people were being prescribed these at the time the service changes started.

 

Absorbencies 

The service is adhering to the Association of Continence Professionals (2023) guidelines for not prescribing low absorbency products. It now prescribes for working absorbencies of 400 ml and above via the following measures:

• Careful prescription of product absorbency as more absorbent products are more expensive. They also have a higher concentration of ‘super absorbent polymer’, which may affect skin integrity, although as yet there is no firm evidence to support this.
• The expected maximum number of products prescribed for a 24-hour period is four.
• Removal of the option to prescribe fixation pants unless they are specifically requested as there is no benefit of using these rather than using close-fitting underwear.
• Removal of the option for emergency deliveries as this doubles the delivery charge and only reduces the wait for delivery by around 1 day.
• Changing the delivery cycle from 8 to 12 weeks. This has a significant impact on costs and environmental impact by reducing lorry trips (a significant issue in London).

Communication 

Training 

Training staff in care homes about the correct use of products has had the additional benefit of building relationships and rapport with care home staff and managers. Training for carers, care agencies and community staff was given by working alongside staff in some of the care homes, and by using product representatives to train care home staff on the correct use of the products. The service also provides weekly newsletters and training tips. 
 

Patient information 

Leaflets were produced for patients and carers explaining the correct use of containment products. 

We established a link with our local foodbanks, asking patients to donate unused products that could not be collected by the Home Delivery Service. The foodbank staff will display our team posters and direct people requesting containment products to the self-referral service so that they can access treatment.

Results 

The containment product service at Lewisham & Greenwich NHS Trust is now in excellent shape. The caseload is correct, and the service is adhering to the Trust guidelines that we developed. The product service runs efficiently with a quick response time to queries and problems. This used to be dependent on staff availability and could take several days, but now we consistently respond within two working days. We have a popular and effective face-to-face clinic. There is consistently good feedback in the Family and Friends test, and some comments from relatives that stood out are shown below:

‘I wish to let you know the excellent caring work by (clinician) in dealing with my wife’s illness and support, helping me to cope. Her kindness and words of encouragement show someone who really cares’

‘I am writing to say how much I have appreciated the contact I have had with my clinician. I am the sole carer for my elderly and frail husband, who is now housebound with heart failure and COPD. He is also doubly incontinent. We were recently informed that the pads we had been buying for years can be prescribed, and were put in touch with the Bladder, Bowel and Pelvic Health service. The clinician rang me, and from the first it was obvious that she had every care for his and my situation. She took great pains to listen to our needs, and was able to arrange a delivery very promptly. When it became clear that the prescription was not quite right, she changed it, and changed it yet again. She was adamant that it must be exactly right. Each time I e-mailed her, I received an extremely swift telephone response, and Sue was kind, patient and warm as well as efficient. I was never made to feel a nuisance (though I think I was!).
It is very refreshing and encouraging to receive such contact within the NHS – it is not always thus. I particularly appreciate the personal nature of the response, which is very supportive and affirming in situations such as ours.
I hope such service is recognised as the good thing that it is.’

The Trust is currently spending around £550 000 per year on prescriptions of containment products rather than the £750 000 per year that it was spending before the service changes were implemented. This is despite an increase in containment product costs of around 21% and an increase in referrals from around 200 per month to 250. The increased referral rate is in part a result of greater awareness of the service and a high level of satisfaction from referrers. The service is normally spending less than the average amount (across the NHS Home Delivery Service) in all areas yet we are confident that our patients are being prescribed the best products for their needs. This is largely because of our staff’s detailed knowledge of, and adherence to, guidelines and best practice. It is also the careful assessment of each patient, including carers and family members where possible, to understand each situation and match the products to clinical, environmental and practical requirements.
 

What next? 

The team has plans to develop this service further, including a greater focus on advising, prescribing and trialling alternatives to disposable products.

The team is linked with the NHS group set up to look at the future of product prescription.

A trial is currently running with the product company around supplying an extended period of samples of insert pads or shaped pads to patients who are used to using pull-ups and who are considered to be likely to struggle with a change to insert pads or shaped pads. The trial allows us to supply patients with a 5-day prescription of samples, to see if this allows time for them to get used to the new product. Using insert pads or shaped pads rather than pull-ups has two benefits: the product is more absorbent, particularly at night, and it is less expensive. It may be valuable to adjust patients to these earlier in their treatment journey so that they are on the more robust products if their incontinence worsens or they spend more time in bed, where pull ups are less effective.

Conclusions

Transforming the containment product service was a challenging but very rewarding process. It supports improving patient care as well as having a positive impact on finances, resources and environmental impact. Every person, regardless of their age, clinical condition, cognitive status, place of abode or presence of mental, physical or learning disability has the right to expect excellent, appropriate and specialised bladder, bowel and pelvic health care. Where treatment is not possible, or has reached an end, containment products can make a huge difference to an individual’s quality of life and health. It is vital that we make sure this aspect of the service reaches the highest standards of cost-effectiveness and clinical and organisational excellence.

Key points

• Containment product services often work suboptimally and tend be given less attention than other services. There are great clinical, financial and ecological gains to be made by reviewing these services and considering changes that could be made.
• Correctly prescribed and used containment products can dramatically improve an individual’s quality of life, but they are not a first-line solution other than in emergency or end-of-life situations.
• There is a need to challenge the myths that ageing inevitably leads to incontinence, and that containment products are a first-line solution.