Health CommitteeWritten evidence from Coloplast (LTC 64)

Summary

Coloplast is a leading medical technology company specialising in intimate healthcare needs. Coloplast develops products and services to make life easier for people with very personal medical conditions, including urology and continence care, ostomy care and wound care.

Continence and ostomy care are an important factor in a wide variety of long-term conditions, such neurological diseases, spinal injuries and cancer. We supply our products into the NHS, both into secondary care and into primary care through Part IX of the Drug Tariff.

Access to appropriate products and specialist continence advice is very important for patients with long-term conditions; it helps reduce ill health, improve outcomes, and allows more independent living. However, patients often experience difficulties accessing specialist advice and/or the most appropriate products for their needs.

Both clinical staff and procurement staff need to consider the overall impact of decisions made about continence management, including in terms of patient outcomes, amount of care required, and the overall cost to the health service.

There is also a need to ensure proper coordination between treatment in primary care and treatment in hospitals, particularly for patients who may move between the two.

Introduction

1. Coloplast is a leading medical technology company specialising in intimate healthcare needs. Coloplast develops products and services to make life easier for people with very personal medical conditions, including urology and continence care, ostomy care and wound care. These products are used by people with a wide variety of long-term conditions, such as those with neurological diseases, spinal injuries and cancer. We supply our products into the NHS, both into secondary care and into primary care through Part IX of the Drug Tariff.

2. Currently, urology and stoma products are supplied to patients in primary care via Part IX of the Drug Tariff, which lists the urology and stoma products that have been approved by the Secretary of State for Health for prescription on the NHS and the price which should be paid for each product. All products listed on the Drug Tariff are considered to be clinically effective and cost effective at a national level. This offers a number of benefits, including the protection of patient choice, the avoidance of a post code lottery and price certainty for the NHS.

3. Products are prescribed to patients by GPs and nurses, but often there are local measures, put in place by procurement officials, which aim to restrict the choice available to prescribers and patients—these include restrictive formularies, tenders and the use of preferred providers.

4. Having access to the right products can help patients to manage long-term conditions more independently, to reduce their incidence of urinary tract infections and to maintain a work and social life. Therefore, while directing patients towards cheaper products may lead to small, short term savings, it can lead to wider spending elsewhere in the health and social care system. This response explores how continence and stoma care are managed as part of long-term conditions.

How does Continence Impact on Long-term Conditions?

5. Continence problems form a part of many complex long-term conditions. This could include neurological conditions such as Parkinson’s disease and MS, cancer, stroke and spinal injuries. Many of these patients will require support with their continence needs for long-periods of time—for the rest of their lives in a lot of cases. However, continence care does not always received significant attention as part of a strategy to manage long-term conditions, and more needs to be done to increase the focus in this area and ensure that patients are getting the support which the need.

6. The Royal College of Physicians previously identified in their National Audit of Continence Care, published in 2010, that there was a lack of consistency between NHS trusts in terms of the type, quality and quantity of continence supplies available to patients, as well as identifying other concerns about the quality of service provided.

7. One particular concern which is frequently raised in relation to continence and stoma care is that patients cannot always access the products which they need to ensure that their needs are met. This could mean being able to access a particular type of catheter which offers the discretion they need, being able to access leg bags which are suitable for those with a lack of manual dexterity, or being able to access bowel management products such as our innovative anal irrigation system, Peristeen, when more conservative methods have failed to offer them the freedom, comfort, and sense of security which they need. The differences between products are not always obvious to those who do not use the products or have specialist training, but directing patients towards the wrong products or trying to limit access to new innovation can have very real consequences across a number of areas, such as increased wastage of inappropriate products, increased urinary tract infections from having to use less suitable products or increased reliance on carers or reduced ability to remain in employment.

8. For example, for a patient with MS who is suffering from chronic constipation, if methods such as enemas, laxatives, and suppositories have not worked, they may be required to use manual evacuation. As well as the obvious concerns which this raises about patient dignity, it also creates significant costs in terms of nursing care and leaves the patient much less able to leave the house and participate in work and social life. Despite evidence showing that Peristeen can lead to significant improvements in patient outcomes as well as saving money compared to conservative bowel management methods, it is not universally available across the NHS.

9. The reasons for the lack of consistent good quality continence care include a lack of knowledge among non-specialist healthcare professionals, which means that they are unable to recommend the best treatment for patients, a lack of willingness to directly address these issues with patients and refer them on to specialist continence nurses, and the use of formularies and other methods designed to limit the choice of urology product available and direct patients towards cheaper products.

The readiness of local NHS and social care services to treat patients with long-term conditions (including multiple conditions) within the community

10. Given the large number of patients who have their continence problems dealt with, alongside other conditions, in the community, it is essential that good quality care is available within this setting.

11. Effective management of continence needs in patients with long term conditions impacts their quality of life and can help reduce repeated hospital admissions through reducing problems such as urinary tract infections.

12. However, many patients with long-term conditions will need to be admitted to hospital for other reasons as part of their care, and it is vital that there is coordination between primary and secondary care so that patients are able to access all the devices and other treatments in hospital which they use during their normal day-to-day life.

13. As alluded to above, one problem which is often experienced is the tendency for those in charge of commissioning care to think about issues in isolation, rather than as a whole. This can lead to, for example, the introduction of formularies which aim to reduce the amount of money spent on stoma and urology products—while not taking into account the increased costs which could result if this leads to worse outcomes for patients or less effective management of long-term conditions.

14. Therefore, we would recommend that there needs to be incentives for staff within Clinical Commissioning Groups and other NHS organisations to make a more holistic assessment of the impact of their decisions.

15. Staff, both on the clinical and procurement side, could also benefit from further training which aims to increase knowledge of how many long-term conditions impact on continence care. GPs and nurses should be actively encouraged to ask patients with long-term conditions if they are having any problems with either urinary incontinence or bowel management, rather than waiting for patients to raise these issues.

16. There should also be a fresh look at the patient pathway to see if the route to specialist continence advice for those patients who do need it could be made simpler, if the NICE guidance in this area is still fit for purpose or needs updating.

The practical assistance offered to commissioners to support the design of services which promote community-based care and provide for the integration of health and social care in the management of long-term conditions

17. In addition to training, better provision of information could help to ensure that commissioners are able to design services which are fit for purpose and ensure that those with continence patients are able to access necessary advice.

18. This could include information for GPs and nurses who are not specialists in this area on the kinds of conditions which feature continence problems, to encourage them to ask more proactive questions. It could also include increasing knowledge of where clinicians can point patients for more specialist information, such as magazines, websites and suppliers.

19. As we have noted above, innovation is very important in improve the quality of continence care offered to patients, and healthcare professionals need to be kept up to date with new products on the market. We are aware of examples where study days have been organised to increase knowledge of the urology or stoma products available, but only products or companies included on the local formulary are included. This is a particular problem where formularies are only updated every two years or more, meaning a long-period where knowledge of new innovations remains low.

The ability of NHS and social care providers to treat multi-morbidities and the patient as a person rather than focusing on individual conditions

20. To ensure that patients are treated as a person, with their condition or conditions considered as a whole, there is a need to improve the amount of consideration given to continence care.

21. For example, if patients have conditions which may include continence problems as an element, their GP or nurse should actively ask about their condition and whether they are experiencing any problems with continence. This is an issue which patients (and sometimes GPs) are often reluctant to discuss due to embarrassment, and there needs to be a greater focus on ensuring that these issues are actively raised, and that patients are referred to specialist service such as continence advice services where necessary.

22. As we have noted above, GPs and nurses also need to ensure that they are considering the individual needs and preferences of their patients, so that they can find the best solution for their needs.

The extent to which patients are being offered personalised services (including evidence of their contribution to better outcomes)

23. One factor which would contribute to more personalised service for patients would be if more patients were able to access a continence adviser to received specialist, tailored advice on how they can deal with particular problems—including which devices might be best utilised to manage their conditions.

24. As we have noted above, many GPs and nurses do not take the initiative to ask about bowel or continence problems and should be incentivised to do so, particular with those suffering from long-term conditions such as spinal injuries, MS, or Parkinson’s disease where continence is a common factor. This would lead to more patients being given appropriate advice or referred to a continence service where appropriate.

25. Patients should also be made more aware of the fact that they have the ability to self-refer to a continence service if they do not wish to go through their GP.

26. Conclusion and recommendations

GPs and other healthcare professionals should be incentivised to be proactive in managing continence problems in those with long-term conditions, such as through the Quality and Outcomes Framework.

The referral pathways for patients to continence services should be reviewed to ensure that they are simple and effective, and allow patients to access the advice which they need.

Patients should be made more aware of the fact that they are able to self-refer to a continence service if they could prefer not to go through their GP.

Healthcare professionals should be encouraged to stay informed about the latest innovations in medical devices so that patients are able to access products which can improve clinical outcomes and their quality of life.

Commissioners should ensure that they consider the wider implications of decisions they make about access to particular products, rather than aiming to make short-term savings.

May 2013