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Theme: Person-Centred Care
The World Health Organisation estimates that one third of women are affected by Urinary Incontinence (UI) after childbirth. UI affects both sexes, but tends to be more prevalent in females than in males. The NHS estimates that one in five women aged over 40 and 24% of people over 65 are affected by UI.
The National Institute for Health and Clinical Excellence (NICE) recommend three months of Pelvic Floor Muscle Training (PFMT) as the first line of treatment for stress incontinence (UI caused by exertion or sneezing/ coughing). NICE recommends that PFMT is carried out in primary care. However, there are currently insufficient levels of staff trained to provide PFMT for all women with UI. Work carried out locally has shown that primary-care nurses, trained using a short course, can deliver similar outcomes to those of specialist nurses. If this package is offered routinely, it could improve incontinence and quality of life, with fewer referrals to specialist care.
Our aim was to ensure that the majority of women with UI have access to PFMT at an early stage to prevent the problem becoming worse, as well as a form of primary prevention (preventing UI in the first place) and as a form of treatment.
The aim of this project was to evaluate if a package of Pelvic Floor Muscle Training (PFMT) delivered in primary care results in fewer referrals to secondary care for UI, thereby reducing the number and associated costs of surgical procedures for UI.
The study, based on a previous intervention study using the same training programme, was to consist of two populations – a prevention group and a treatment group who were both offered PFMT in primary care. The prevention group would consist of parous women (women who have previously given birth) aged 25-64 attending for a routine cervical smear. Their pelvic floor would be assessed by the practice nurse and a baseline data form would be completed that asked about frequency and associated bother of urine leakage. The second (treatment) group was to include women of any age who may or may not have had a vaginal birth presenting to their GP with UI.
We were going to ensure that short-course training were delivered to primary care nurses, who would then carry out pelvic floor assessments and gave basic PFMT to a range of women. It is highly likely that this will significantly reduce the number of women referred to secondary care with UI.
Semi-structured, in-depth interviews were to be conducted with a subset of patients and staff with the aim of identifying barriers and facilitators in delivering PFMT in primary care.
Key to our implementation would be raising GP awareness of the importance of managing incontinence.
Although the implementation of this project was provisionally agreed by the Sentinel Clinical Executive Committee (SCCE) in 2011, the subsequent National reorganisation of health services, particularly commissioning services in this case, resulted in this project being put on hold for the foreseeable future. However, the anticipated impacts of the implementation remain as follows:
If delivered effectively, PFMT will offer a means of preventing UI, as well as a method of treatment. Referrals of out-patients to specialists should be reduced by between 100 and 200 cases over 2 years. Primary care nurses will have the skills to treat a common problem effectively, leading to cost avoidance. Patients are likely to avoid delays in treatment and avoid living in severe discomfort for longer than may be necessary.
To find out more, please read the project protocol.
Mark Pearson is currently working on a related project: 'APPEAL' will be researching the delivery of pelvic floor muscle exercise education for women during pregnancy. This project arose from an NIHR programme grant awarded to the University of Birmingham.
Professor Bob Freeman, Sister Ann Waterfield, Dr Alice Bateman, Dr Sue Child