Cinderella or an ugly sister?

Comment and Opinion

Frank Booth, Retired RGN

Further Reading

Cinderella or an ugly sister?

Over the years there have been many attempts to bring many of the so-called "Cinderella Services" into the forefront of practice. Continence was one of them.

In 1990 I was involved in the development of the document 'Good Practice in Continence Services' [1]. It was embraced by the Department of Health (DH), and we believed that this would revolutionise continence services within the United Kingdom.

It didn’t take long for the bubble to burst. Why? Well, a simple matter of semantics. We thought we had produced a set of guidelines, whereas the published document was said to be guidance. So what’s the difference? Perhaps not much when we look at dictionary definitions:

  • Guidance (noun): Advice or information aimed at resolving a problem or difficulty, especially as given by someone in authority; for example, "he looked to his father for inspiration and guidance". Synonyms: advice, counsel, direction, instruction, teaching, counselling, enlightenment, intelligence, information
  • Guideline (noun): A general rule, principle, or piece of advice; for example, ‘the organisation has issued guidelines for people working with prisoners’. Synonyms:  recommendation, instruction, direction, suggestion, advice

In relation to the document, guidance is in effect, a good idea, but not set in stone.  If the term guidelines had been used, the document would have more clout as it would have been considered more of a ‘must-do’ plan. And indeed, this was proven by some clinical commissioning groups (previously primary care trusts, and any other number of names…) and acute organisations; while they saw the need to follow guidance, it wasn’t deemed entirely necessary, so the service was poorly funded by both parties.

Many of the continence leads on the working group fought to have the words changed in order to ensure that the document was implemented and their work wasn’t a waste of time.

Fast-forward 25 years and a new document has been published, Excellence in Continence Care:  Practical guidance for commissioners, providers, health and social care staff and information for the public [2]. Interestingly, the guidance is used throughout, but NHS England state;

"We have published this continence care guidance to help support best practice, promoting equal access to services and treatment for all. It is applicable to all children, young people, adults and the elderly, taking into account their diverse needs from assessment, diagnosis and treatment to recovery where possible. The purpose is to promote consistent practice, improve the experiences of people with continence needs, drive advances in clinical outcomes and reduce health inequalities.

It brings together evidence based resources and research and provides a practical means for commissioners to understand continence needs within their local population, as well as specify and contract for continence services, effectively measure outcomes and experience and work towards reducing health inequalities."

As good as that sounds, I fear more of the ostrich approach from the commissioners as again, this is guidance. I wonder if anyone in clinical commissioning fully understands that to have a quality service it must be properly and effectively funded?.

Oxtoby [3] has reviewed this document. She opines;

‘Effective community-based continence services can save valuable NHS resources while restoring dignity to patients and improving quality of life (All Party Parliamentary Group for Continence Care, 2011). Establishing “what good looks like” will help all involved to understand services and help health professionals to understand what they should be delivering when it comes to standards and outcomes. The new guidance outlines the measurable principles for continence services commissioned for adults, children and young people'.

However, even within this document there is a number of restrictions to care delivery; working notes that clearly indicate that the nominal maximum number of products are four per day, most of which will be of the 2 piece variety. Does that really facilitate decisions based on clinical need, which would represent best practice? I think not…

Perhaps the only answer if to use national guidelines as a framework, and encourage your organisation to develop local guidance and policies related to local need (if your organisation hasn’t produced these already).

I look forward to the day when the DH will genuinely take the advice of the experts and ensure that their knowledge and skills are enshrined in mandatory best practice.