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Preventing paediatric continence services going down the pan.

Outcomes for children with bladder and bowel problems nationwide are being adversely affected by the transfer of commissioning responsibilities for school nursing services from central to local government. These changes, introduced in April 2015, saw many local authorities withdraw continence from their core offer, thereby reducing capacity for early intervention and placing greater pressure on both primary and tertiary care. This has also meant job losses for community practitioners and a rise in inappropriate treatment for children with continence issues.

Well-publicised budgetary pressures will prevent local authorities from reversing these decisions, leaving the community to look elsewhere to fill the void. Our first step should be to encourage clinical commissioning groups (CCGs) to commission integrated, joined-up, community-based paediatric continence services. This will improve outcomes for children, deliver NHS savings, and ensure that community practitioners who specialise in paediatric continence are able to use their skills. A better focus on improving school readiness through training and education will also be necessary.

This is not as big a task as it seems. The CPHVA, along with the Royal College of Nursing and the Royal College of Paediatrics and Child Health, has already endorsed guidance for commissioners on how to commission such a service: The Paediatric Continence Commissioning Guide. This was produced by the Paediatric Continence Forum (PCF), a national group of healthcare experts, and has also been accredited by the National Institute for Health and Care Excellence (NICE). The challenge for community practitioners will be to ensure its widespread use and adoption.

CHANGING ROLE

School nursing services are a vital Tier 1 pre-service element of a paediatric continence service. Along with health visitors, community nursery nurses, other community nurses and GPs, school nurses identify and provide advice and information to children, young people and their families on nocturnal enuresis (bedwetting), constipation, soiling and toilet training problems, and initiate first-line treatments. Through early intervention, school nurses can identify and manage problems before they become serious. They also refer children with complex conditions to specialist clinicians to ensure serious conditions are not missed and are treated accordingly (DH 2012, Tappin et al, 2013).

The full commissioning responsibility for school nursing was transferred from Public Health England to local authorities in April 2015 as part of a two-year process initiated in 2013. This process also saw the transfer of health visiting services in October 2015, with many local authorities choosing to integrate the two services to create a single Healthy Child Programme Service (HCPS).This has resulted in a withdrawal of the Tier 1 continence clinics currently being provided by many school nursing services, raising concerns over the future of paediatric continence services nationally and what this will mean for both children and community practitioners.

DECISION FOR CHANGE

The transfer of responsibilities should have presented new opportunities for a robust approach to improving overall outcomes for children and young people, but the opposite has proven to be the case. The PCF learnt in July 2015 that a mixture of budgetary pressures and an increasingly limited list of public health priorities has led many local authorities nationwide to remove continence from school nurses' core offer.

The primary motivation for the local authorities' decision is financial. In June 2015, Chancellor George Osborne unveiled plans to cut the local authority public health budget by 200 million [pounds sterling] nationally--the equivalent of a 6.2 per cent reduction across all local authorities. This has caused directors of public health to re-evaluate how much they are spending and what they are spending it on. As continence is not considered a public health issue, like obesity, diabetes and smoking, but a clinical need, it was determined that continence should no longer be considered a priority. The fact that education is part of the universal-plus service may also have contributed to this decision.

In addition, local authorities have very little scope to make up the shortfall through cuts to other services. A survey conducted by the Local Government Association (LGA) before the recent general election found that 75 per cent of MPs believed adult social care should be ringfenced in the same way that NHS funding is, compared with 15 per cent of MPs who diasagreed and 4 per cent who strongly disagreed. Local authority attempts to make cuts in these areas would prove to be extremely unpopular, and public health budgets provide a softer target.

IMPACT ON CHILDREN, FAMILIES AND THE NHS

The impact of the withdrawal of Tier 1 on continence services has already led to an overwhelming increase in the number of inappropriate referrals to emergency departments, outpatient clinics and waiting lists in tertiary care, and ultimately poorer long-term health outcomes for children and young people (DH 2012, 2011).

Many children with continence problems who would ordinarily be dealt with in a cost-effective manner in the community setting are now being transferred to tertiary units by their GP These referrals are expensive. Staff are struggling to cope with the quantity of referrals, and lack the capacity to follow up on a regular basis to ensure patients receive the quality of care they deserve.

Withdrawal of Tier 1 continence services is a retrograde step both in terms of its financial impact on the NHS and on the health and wellbeing of children and young people and their families. Continence problems can have a significant emotional impact. They increase the risk of bullying and behavioural problems in children and young people, and may affect their education and learning. Managing the problem can also cause additional financial stress in a family, with extra laundering and bedding protection costs (NICE 2010 a, b).

The change has already impacted on many community health practitioners, particularly those whose primary role is health education, offering advice, support, robust assessment and first line treatment and referral to Tier 2 continence services. This has left many community practitioners feeling frustrated that incontinence is not considered a priority, or seen as a public health issue.

PCF COMMISSIONING GUIDE

The Paediatric Continence Commissioning Guide is a resource designed to assist commissioners, clinicians and managers to deliver integrated and evidence-based community paediatric continence services that meet the needs of children and young people with continence difficulties (bladder and bowel dysfunction) across England. The aim is to improve outcomes for these children and young people through supporting local service redesign that is high quality and cost effective, takes into account the patient experience, the "Voice of the Child", meets Domain 2 of the NHS Outcomes Framework Enhancing quality of life for people with long-term conditions, and reduces health inequalities (DH 2014).

Continence problems should be prioritised in partnership with Local Joint Strategic Needs Assessment (JSNA) teams as highlighted in the NHS Outcomes Framework 2015/6 (DH 2014) to review local health needs. This is essential to ensure the right services are in place to achieve better health outcomes and reduce long-term conditions for children and young people. Assessing the impact of withdrawal of paediatric continence services on the quality of life of children and young people, regardless of their ability, is their entitlement and access to care is key (United Nations Convention for the rights of all children and young people).

Gaps in services remain despite clear recommendations by the Department of Health (2006) to bring care closer to home. Large numbers of children with constipation are being seen at secondary or tertiary level, which is costly to the NHS. All children and young people from birth to 19 years with bladder and bowel dysfunction (continence problems), including children with learning and/or physical disabilities, should have access to an integrated, community paediatric continence service (CPCS). If the CPCS model were to be implemented nationally, it would improve the quality of care in helping children and young people to achieve complete continence, or to manage the condition discreetly and effectively in cases where full control was not clinically possible. It would also create significant cost savings (PCF 2014).

Key outcome indicators

* Rates of A&E attendance and unplanned hospitalisation for constipation and urinary tract infection.

* Percentage of children and young people with bladder and bowel dysfunction successfully treated within the service or post discharge.

* PROMS (Patient Reported Outcome Measures)/FROMS (Family Reported Outcome Measures) from the perspective of the child, young person and family.

Improving school readiness

Increasingly many children entering school (4.5-5 year olds) are not toilet trained and are still wearing nappies. This presents a range of issues both for the child and the school--for staff who have to assist with nappy changes, and for children through the impact on learning of interruptions to lessons, as well as the emotional upset of not being able to be independent and the risk of teasing and bullying. A new approach to delivering Tier 1 services could be achieved through training and education of other health professionals and partner agencies including parents and carers, to help promote and manage incontinence issues as early as possible. Once a child has reached the age of 2.5 years the health visiting team have no further input before it starts school, unless additional or more complex health needs have been identified. Following the final health check at 2.5 years, health visitors and/or community nursery nurses are ideally placed to offer early intervention support to help the child and family establish good toilet training routines and to encourage independence on transition to school. This will make every contact count and reduce the pressures placed upon early years settings and school entry (NHS Future Forum). Improving outcomes for children requires senior managers to view school readiness as a priority and to ensure relevant practitioners undertake this essential work before school entry.

Despite the financial climate affecting the NHS, social care and education services, it is imperative that further action is taken to raise awareness of the impact that withdrawal of Tier 1 continence services will have on children, young people and their families, as well as on school nursing and community health practitioners.

If you would like to get involved please visit the PCF website www.paediatriccontinence forum.org. It includes further background on the situation, actions that you can take and template letters to your local MP, CCG and Healthwatch organisation. Contact details are listed on the website should you wish to receive further information.

NORMA WILBY, continence lead/school nursing, Cambridgeshire Community Services NHST, PCF member, Quality Improvement Fellow (QIF) Kings Fund, MSc, public health, BA (Hons) Specialist Community Public Health Practitioner (SCPHN) (School Nursing)

BEN CHIU, the Whitehouse Consultancy working on behalf of the Paediatric Continence Forum Update (PCF)

References

NHS Future Forum: Summary Report -Second Phase. http://www.gov.uk/govemment/uploads/system/upbads/ attachment_data/file/216422/dh_132085.pdf (accessed online: 27/09/15)

Department of Health 'Getting it right for children, young people and families'; maximising the contribution of the school nursing team: Vision and a call to action. Department of Health, London: 2012.

Department of Health. 'You're Welcome': Quality criteria for young people friendly health services. Department of Health, London: 2011.

Department for children, schools and families. Healthy Child Programme: From 5-19 years old. Department of Health, London: 2009.

Department of Health. Our Health, Our Care, Our Say: A new direction for community services. DH 2006.

Department of Health. The NHS Outcomes Framework 2015-16. NHS Group, DH: FN-NHSG-NHSCPS-17185. December 2014 www.gov.uk

National Institute for Health and Care Excellence (NICE) (a). Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. NICE clinical guideline 99. May 2010. http://www.nice.org.uk/guidance/cg99/resources/guidance-constipation-in-children-and-young-people-pdf

National Institute for Health and Care Excellence (NICE) (b). Nocturnal enuresis the management of bedwetting in children and young people: Clinical Guideline 111 (CG111) October 2010 last modified: August 2015 http://www.nice.org.uk/guidance/ cg111/resources/guidance-nocturnal-enuresis-pdf

Paediatric Continence Forum (PCF). Paediatric Continence Commissioning Guide: A handbook for the commissioning and running of paediatric continence services http://www. paediatriccontinenceforum.org/wp-content/uploads/2013/09/ PCF-Commissioning-Guidance-for-NICE-11-August-2014-Final.pdf

ERIC the children's continence charity. http://www.eric.org.uk/ assets/Bedwetting/Why%20commission%20a%20Paediatric%20 Bladder%20and%20Bowel%20Service.pdf

Tappin D, Nawaz S, McKay C, MacLaren L, Griffirths P, Mohammed T A. Development of an early nurse-led intervention to treat children referred to secondary paediatric care with constipation with or without soiling. BMC Paediatrics 2013, 13:193 http://www.biomedcentral.com/1471-2431/13/193

A Summary of the United Nations Convention on the Rights of the Child http://www.unescocentre.ulster.ac.uk/pdfs/pdfs_uncrc/ uncrc_summary_version.pdf
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Title Annotation:CLINICAL FEATURE
Author:Wilby, Norma; Chiu, Ben
Publication:Community Practitioner
Geographic Code:4EUUK
Date:Nov 1, 2015
Words:2089
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