Streamlining Specialist Care: Fixing Problematic Pathways in Female Urinary Incontinence
In 2018 Katie Griffiths, a Service Improvement Manager in Shaping Change was tasked with addressing a referral bottleneck for female urinary incontinence. After various challenges and hurdles, patients are now receiving the most effective treatment for their specific condition, here’s how the problem was addressed...
Whereas men with urinary incontinence have a defined pathway either through the community Bladder and Bowel team or Urology, there was no defined pathway for women. It was possible for women to be referred to up to four different specialties including Community Bladder and Bowel Team, Physiotherapy, Urology and Gynaecology. Referrals were frequently being made to the incorrect specialty leading to lengthy waits of up to a year at which point the patient would discover they weren’t on the right pathway and would need to start the whole process again, causing further delays to their treatment.
Life for these patients
As you can imagine, living with incontinence can have a significant impact on your life. One patient described not being able to work due to her incontinence, and not being able to walk very far without leaking. Another patient described experiencing very low moods due to her symptoms.
To help solve this problem, Katie was asked to join the project team and utilise improvement tools to develop a clearly defined, evidence-based pathway, with the aim of reducing waiting times and providing the right care at the right time.
“Katie explained: ‘My role in the team was to bring everyone together and keep that shared goal, and the patient, at the centre of what we were doing. I was able to support the team by using stakeholder mapping to ensure we had the appropriate representation in the project team and using improvement tools such as process mapping to identify the problems with the current pathway.’”
Together, they identified that the referral bottleneck wasn't the only problem. A key challenge was the underutilisation of the Community Bladder and Bowel team within primary care. Many GP surgeries lacked awareness of the service and its comprehensive offerings. This valuable resource, providing services like full continence assessments, conservative therapies, pelvic floor treatments, bladder scanning, and medication advice, remained largely unused. This meant patients were often referred into secondary care for surgery before trying non-invasive conservative treatments in line with national guidance, or they were offered solutions like incontinence pads, which manage the symptoms but don't offer a chance for treatments or recovery.
Some patients were even directly referred for surgery, without proper consultation or explanation so were often unaware of the reasons behind it. This led to elderly patients waiting extended periods to see consultants in secondary care only to discover what awaited them and they often weren't comfortable with the idea of surgery.
Scalable solution emerges
Data analysis conducted by Katie revealed a significant number (over 70 patients monthly) were on inappropriate secondary care waiting lists. Further investigation showed many weren't receiving the treatment offered by this pathway, indicating they were wrongly placed. The Director of the Continence Services, Ann Yates, also provided data showing that some GP surgeries were not referring any patients to the Community Bladder and Bowel service at all.
Katie said ‘We used the data to create examples of patient journeys which was a great way to emphasise the impact that the current process was having on real people, it’s not just about numbers on paper!’
Katie and Ann worked together to map out the current process and identify all issues. All four specialties were able to collaborate and design a pathway that would ensure all women with urinary incontinence were referred for conservative treatment first, before being referred for surgery. By attending the Community Bladder and Bowel service first, patients could be assessed, treated and if needed, directed to the appropriate secondary care specialist, ensuring they received the most suitable treatment in a timely manner. This service, championed by Ann, offered a scalable solution to address the wider problem.
Challenges and glimmers of hope
The challenge of scaling this service was twofold. Firstly, primary care colleagues weren't utilising the service correctly to triage individuals effectively, limiting its reach by referring these 70 individuals directly to secondary care. Secondly, the current service set up and personnel wasn't equipped to handle the potential patient volume in either clinic space, professional capacity within the clinical nurse specialist role or admin support.
Despite these challenges, a potential solution emerged. The Welsh Health Implementation Group developed by Welsh Government impressed by the teams work on the pathway, recommended its adoption in their All-Wales Pelvic Health Pathway. While the pathway itself had merit and government endorsement, it lacked the resources to truly function as effectively as it could. An additional staff member at Clinical Nurse Specialist (CNS) level to undertake initial assessments, complete all required investigations and initiate treatment plans was crucial to bridge the gap and ensure smooth operation as the demand would be too great to deal with incoming patients with the current level of staff.
Financial hurdles and perseverance
Unfortunately, financial constraints put the project on hold. The pathway's benefits for patients were undeniable, but funding for the essential staff position remained unavailable. This lack of resources became the biggest obstacle to implementing a solution that could significantly improve patient care.
At the time these individuals were either still being referred into secondary care or if referred to the Bladder and Bowel team, they were still seen. However, this added numerous patients to the caseload and extended the waiting list times by all to be seen by the Bladder and Bowel Clinical Nurse Specialists. This had a dramatic knock-on effect for all patients referred to the Bladder and Bowel team.
Shaping Change kept pushing the project’s potential at every opportunity. Eventually, it came to the attention of the Chief Executive and the Health Board requested a business case for the additional staff position. Ann seized the opportunity and presented a compelling argument. Recognising the project's merits, the Health Board finally allocated funding for the much-needed position.
From problematic pathways to patient recovery
This additional resource allowed Ann's team to scale up the service and provide adequate resource to be able to cope with the influx of these additional patients. Patients are now efficiently directed to the appropriate service, receiving the most effective treatment for their specific condition. This approach combats the misconception that incontinence is simply an inevitable part of life. By providing the right care in the right place, this service empowers patients to heal and reclaim their quality of life.
By implementing the new pathway, the Bladder and Bowel service now runs community clinics in all sectors of the UHB community. These patients are seen at these clinics by a CNS and can access treatments in line with national guidance. The service is still able to refer into secondary care when required. Following on from this project the service has been directly involved with the new Pelvic Health Hub (the first of its kind in Wales) and the establishment of community care pathways relating to female urinary incontinence for appropriate referrals.
The secondary care waiting list now receives appropriate referrals, ensuring only patients who need those services are referred. Bladder and Bowel referrals have risen steadily but despite the increase, the team effectively assesses, treats, and redirects patients to the appropriate services. All departments continue to collaborate, ensuring the referral pathway runs smoothly.
“‘...the project would not have been such a success without the guidance of Katie.’”
Ann explained that: ‘Even though all parties concerned knew of the issues around female urinary incontinence pathways, the project would not have been such a success without the guidance of Katie. She brought together all the relevant professionals from the different specialties and made sure we focused on the common goal – to improve patient outcomes and access to the correct relevant services at the right time. It has been a pleasure and privilege to work with such dedicated people and have such a positive result that will impact on future care.’
Katie said: ‘I was delighted to work with this dedicated and passionate group of people. To see physiotherapists, specialist nurses, community nurses, managers, consultants and doctors from different specialties all come together with a shared goal and create a patient centred pathway was inspirational, and I was grateful for the opportunity to support them in achieving that goal.’