Bladder and Bowel Continence Care

Many people are too embarrassed even to talk to their GP about these issues. People suffer in silence and can become depressed and isolated, before eventually seeking help. That can affect employment, education and socialising. There is some evidence that half of people with those conditions will wait five years or more before seeking medical advice. The lack of awareness and promotion of pelvic floor health leads to acceptance of bladder weakness, particularly as part of ageing or as a result of childbirth; by the way, pelvic health is every bit as important for men as for women.

I note that NHS England’s maternity and women’s health team has an excellent initiative on perinatal pelvic health, which is very encouraging to see. I also commend NHS England for launching a programme in 2021 for pregnant women and new mothers to prevent and treat incontinence and other pelvic floor issues. It has 14 pilot sites around the country, and I would like to know what learning has come from these and what the next steps for the NHS are.

One of the most important things I can do in this debate is to promote the bladder and bowel CONfidence app, which is packed with helpful pelvic floor health advice. It was commissioned by the Florence Nightingale Foundation to celebrate the year of the nurse and midwife in 2020. The project was led by Dr Nikki Cotterill, professor in continence care at the University of the West of England. The app aims to provide quality-assured health and wellbeing information, promote safe self-care and aims to reduce avoidable demand on services. It signposts services and other sources of support and makes it easier for people to get help. I would like to know from the Minister what the NHS can do to promote the app and ensure that the information on it is widely known.

I understand that the NHS workforce plan is imminent. I very much hope that there is a plan to increase the number of specialist continence nurses, as many of them are retiring. I ask the Minister if NHS England is working with the General Medical Council to mandate that the medical, nursing and physiotherapy curriculums include bladder and bowel continence training more extensively in their syllabuses in all these areas. I would also like to know if Health Education England will be providing more specialist education courses for both stoma and urology continence nurses to enter the profession.

The APPG has worked with the Nursing and Midwifery Council to get basic training for bladder and bowel continence in their standards for nurses and midwives. We would like to see this mandated in their curriculum and be applied to general practitioner education standards as well. I would also like to know if the Minister has had any conversations with the Royal College of General Practitioners and the Royal College of Nursing about continuing professional development, including one-day training courses on continence care. This has huge potential to upskill the existing workforce to deal with this problem.

For many people, incontinence should not be accepted as a normal part of life. A high proportion of cases are curable, particularly bladder weakness. Consulting a medical professional may flag indications of underlying causes such as bladder, bowel or prostate cancer, which is why the five-year waits for a first consultation are so concerning. There is variability of access to specialist support across the country.

One of the clinicians who advises the APPG, Professor Charles Knowles, wrote the excellent report on pelvic floor services in 2021. I hope the Government took careful note of it, because it was a combination of work by 30 experts and made recommendations in six areas: awareness and education, technology-enabled care, integration of expertise, surgery procedures and premises, utilising human resources and novel approaches to freeing up resources.

As parliamentary co-conspirator with my friend and constituent Tim Briggs CBE, the originator of the Getting It Right First Time programme, I would like to know whether there is a GIRFT programme for continence care. If there is not, there certainly should be, because it has had amazing results in all the other specialisms. Are the royal colleges and the Department of Health and Social Care able to give greater direction on the need for so-called benign surgery for bladder and bowel conditions, which people are currently waiting longer for and can badly affect quality of life and wellbeing? I understand that clinicians who work with the APPG have highlighted that they believe there is racial inequality in the provision of continence care. Can we start investigating this by publishing ethnicity data on NHS treatment rates in continence care?

The APPG has led the Boys Need Bins campaign, given that men’s toilets very rarely have sanitary disposal provision. Around 11% of men in the 60-to-64 age group have urinary incontinence—that would include quite a few Members of the House—and the percentage rises with age. That figure does not include other continence issues, such as the need to use stoma bags. Men who need to use pads, catheters, stoma bags and other related items need to be able to dispose of their used products hygienically, discreetly and correctly.

One in eight men diagnosed with prostate cancer is likely to experience some degree of incontinence as a side effect, and men often say that this poses a greater problem to them than the cancer diagnosis itself. Prostate Cancer UK alerted me to the following comment in its survey regarding men having to use disabled toilets:

“Consequently, men are often forced to use disabled toilets in order to dispose of their pad or associated stoma bag products in the provided sanitary bin. It is important to note that nearly 1 in 4 men stated that they are not disabled so find it ‘embarrassing’ to use this toilet to access a sanitary bin whilst 42% stated feeling embarrassed, stressed, and anxious about using a disabled toilet, as they had experienced or felt that people will judge them. Indeed, one man told us that: ‘Whilst at a football ground, I had to ask a (male) steward if I could have access to an accessible toilet…(and) he commented, “You don’t look very disabled”’. This experience…felt inappropriate, degrading, humiliating and embarrassing.”

What do the Government expect these men to do when there is no disposal provision where they work or are being educated?

In June 2022, the BBC Radio 4 “PM” programme had a discussion about this issue that led Prostate Cancer UK and a number of other organisations to support the Boys Need Bins campaign. The campaign targets employers, hospitality venues, sports venues, retail outlets and local authorities—Winchester Council, for example, has successfully implemented such as scheme.

We have had reports of a postcode lottery in the supply of products needed. Getting the right products could lead to a reduction in urinary tract infection and skin problems such as dermatitis and pressure ulcers, and reduce costly hospital admissions. I would like reassurance that the NHS will look at the total costs in the patient pathway and not just at the unit cost per product, which could be a false economy, leading to higher costs for the taxpayer and less good outcomes for patients.

One of the most upsetting facts I discovered while preparing for the debate is that of hospital-acquired incontinence. A National Institute for Health and Care Research-funded study was published in June 2022 by the Geller Institute of Ageing and Memory, which is based at the University of West London. The research revealed that among patients with dementia admitted to hospital, over a third developed hospital-acquired incontinence, having previously been continent. There were some very upsetting accounts of patients who were not allowed to leave their bedside to reach the toilet, and even patients who were able to get to the toilet unaided were required to ask permission. Should there not be a right to self-toilet if someone can get to the loo on their own? The Spinal Injuries Association has contacted me to say that some of its members’ carers were not allowed to accompany them to hospital, leading to deep distress when people were not able to get to a toilet.

This is a very sensitive and delicate issue that does not get enough attention, and let me say straight away that I have all the sympathy in the world for nurses and healthcare assistants, who are rushed off their feet. We will not find the right way forward in this debate, but I implore the Minister to take this issue back to the Department so that we can preserve the continence, and therefore the dignity, of as many hospital patients as possible. If we get these issues right, we can save the NHS money that is currently spent on pads and appliances, reduce comorbidities and hospital admissions, and improve the lives and wellbeing of so many people.

A large number of people are admitted to hospital with urinary tract infections caused by catheter-associated urinary tract infection, and that greatly increases A&E attendance and unplanned admissions. Clinicians who advise the all-party group say that improving catheter care in the community would significantly reduce A&E attendance and hospital admissions.

I draw Members’ attention to a new service in Cornwall that has been piloting a continence car service run by NHS Cornwall 111. The cars are staffed by specialist paramedics who have additional skills, including catheter/continence management. The service reports that this has meant fewer patients being transferred to hospital and has taken the pressure off the local ambulance service. That seems to be yet another shining example of best practice in the NHS, so my question to the Minister is: what is NHS England doing to urgently evaluate it? If it is as good as it appears to be, we should mainstream it across all integrated care boards.

I want to give the last word to a young person in their 20s who has lived with chronic issues of bowel and bladder continence all through their life. This person wrote to me this week after seeing the debate advertised to say that they had never been referred to a specialist unit outside of paediatrics. It was only through a friend that they found out about the world-leading continence facilities at Northwick Park Hospital.

The pads that this person used suddenly stopped at one point because they had not been graduated from the paediatric to the adult system. They were discharged from the paediatric system and were no longer on anyone else’s system even though they have a lifelong condition. Despite the issues, this young adult works in an office and shares a flat with friends, ostensibly having a normal life even though since infancy they have needed to change pads three times a day to maintain cleanliness.

This person has three requests: first, they want the whole issue to be destigmatised in the public’s mind. Secondly, they want schools, colleges and universities and employers to care for students and workers experiencing these conditions sensitively and in an informed way. Lastly, they want proactive support for people living with bladder and bowel incontinence to explain the range of possible treatments available and the offer of mental health support for patients living with these conditions.

I salute the courage of this outstanding young adult for not being defeated by these issues and for working and leading a normal life. I want the Minister to take their comments to heart and back to the Department for action.

As I said earlier, many men do not go to see the doctor when there is something wrong. They should. It could be to do with pride, or embarrassment or shame, or just because they do not want to bother anybody. Whatever it may be, it needs to be addressed. I hope the Minister can tell us what is being done. The hon. Member for South West Bedfordshire said that sometimes men do not go to see their doctor even when they have had symptoms for five years; that is just too long to wait.

A poll of 500 men, half of whom have been diagnosed with prostate cancer—which shows that they are more likely to have these difficulties—shows that some men are resorting to desperate strategies to overcome the near certainty that they will be unable to find somewhere appropriate to dispose of used products outside the home. The survey found that their strategies include taking a bag out with them that they empty when back at home, and asking their partner to keep used products in their handbag, which creates a public health concern by its very nature, is unnecessary in the times we live in, and adds further pressure to partners who may also be in a caregiving role. They love their partner—that is never in doubt—but it can be quite challenging.

Approximately one in three men surveyed—32%—said that they were wearing pads longer than advised, which can cause further health risks. A quarter, or 25%, acknowledged that they have resorted to flushing them down the toilet, even though the water companies and the health service say that should not be done. Their initial response is to get rid of it, which is perhaps why that is happening.

Of the 504 men surveyed with experience of urinary incontinence, two in five, or some 44%, experience anxiety about using public toilets; more than a third leave the house less often—in other words, they just do not bother going out, because they feel that is the best way to deal with it; and almost eight in 10 stated that they feel anxious about a lack of suitable facilities when leaving the home, which is another indication of their concerns.

More than one in four men feel depressed about the impact that experiencing urinary incontinence has on their life, with that figure soaring to 100% of those aged 16-25—the hon. Member for South West Bedfordshire gave an example of a young fella at work. Everyone will agree that this situation is unacceptable. Mental health support should be made readily available.

There is currently no obligation on businesses, local councils or organisations with bathroom facilities to provide male sanitary bins in male toilets. It is time for that to be considered. The Government must change the situation so that men who experience incontinence can dispose of products easily, hygienically and with dignity, offering them the opportunity to live a better quality of life, free from embarrassment, stress or shame.

The Dispose with Dignity campaign is calling for the Health and Safety Executive-approved code of practice and guidance to be updated—the Minister’s thoughts on this would be helpful—to ensure that men have adequate access to male incontinence bins, thereby enabling them to have a better quality of life, free from shame and embarrassment. If that guidance is not updated, men will be forced to resort to unsanitary or environmentally damaging means of disposing of incontinence pads. Providing bins in disabled toilets is not an acceptable solution on its own; distinct and separate provision must be made for men in male toilets.

Urinary infection is not experienced exclusively by older men, so support, guidance and provision for all men is crucial. We have to look at the bigger picture— the spectrum of men from 16 to 66. I had a very positive meeting with the Dispose with Dignity campaign. Is the Minister prepared to meet that group? I think the hon. Member for South West Bedfordshire seeks the same thing. Even going through the civil service would be a positive step forward. It would enable other interested MPs to understand the physical and mental health implications of not having access to adequate sanitary provision, and to discuss potential regulatory solutions.

I believe that we can and must do better to ensure that men and women have dignity in their bladder and bowel continence care. I know that the Minister will take all that on board and will consider how we can do this better. This debate is the first step in achieving just that.

It is important to deal with the common myth that men do not seek support for their health, and that they want to tough it out because they are men. Recent research from the Movember Foundation shows that men are more likely than women to make an appointment to see a health practitioner as soon as they think they have a physical health problem. Research from the Men and Boys Coalition shows that three in five men say they face barriers to seeing GPs.

The increasing problem with men’s health, which is in crisis, shows that the health sector is not male-friendly enough. Whether through the NHS, public health provision via councils or support through mental health services, supporting a men’s health strategy would start to change that, as would the initiative we are discussing today. People wrongly say, “Men do not speak up about their health,” when on issues like this they do and have. We must listen and act or men will think, “What’s the point?”

The Prostate Cancer UK campaign led by the actor Colin McFarlane shows that men are speaking up. There is even the annual March for Men happening next month—I encourage Members to sign up. We can no longer ignore these men, so we need the Government to change the code of practice and we need councils and health bodies to take a lead. I see that Winchester City Council is already doing so. We need to make it normal for bins to be provided—a new normal so that it is not seen as an issue or a pain, but just as the normal way of doing things. We need this normal and a new way of supporting men’s health.

I urge the Government to change the code of practice and—importantly—create a men’s health strategy and a Minister with accountability for this issue. We owe it to the men in our society and the women they share their lives with to deliver all this and more.

There are excellent innovations and surgical products for stoma wearers, and I pay tribute to the health staff, from specialist nurses to pelvic floor physios, who go over and above to support those with continence issues and to help people to adjust to life-changing surgery. Too often people with continence issues face unnecessary hurdles, and we have heard some today—whether that is a lack of public toilets, lack of awareness or, indeed, the normalisation of continued incontinence following childbirth. Those impacts cannot be underestimated, and I know from my constituents how a lack of amenities can cause isolation, while a lack of awareness around care can lead to people living with these problems for far longer than they should have to. There are also financial pressures on the NHS as a result of poor continence care, from costs associated with hospitalisation or catheterisation to high workload pressures and increased laundry costs. That means the cost to the NHS of incontinence-related care is more than £5 billion every year.

Many people are admitted to hospital with urinary tract infections, often caused by catheter-associated urinary tract infections. That increases A&E attendance and costly unplanned admissions. Improving catheter care in the community would significantly ease the burden and reduce A&E attendance and hospital admissions. That is one reason why the Labour party will shift more care out of hospitals into the community, so that the NHS becomes more of a neighbourhood service.

In Bristol, we are fortunate to have highly recognised work in this area. The CONfidence app, which has already been mentioned, is led by Dr Nikki Cotterill in association with the University of the West of England and Bristol Health Partners. I commend that work to the Minister. It aims to address inequalities for patients with pelvic floor disorders and improve services for the future, as well to provide vital care and support to people who are suffering in silence.

Another project conducted by Bristol Health Partners and the West of England Academic Health Science Network highlighted six opportunities, which I think are worth listing. We need to help people by improving perception; communication; the environment; health services; recognition and support, particularly for mental health issues and anxiety; and participation in society.

The hon. Member for South West Bedfordshire addressed the issue of race inequalities, which we are looking at in Bristol. We have a project to explore the barriers faced by women with incontinence in the Somali community, which I hope all of us across the country can learn from. Not everyone everywhere has the same experience, so it is important that we share. However, everyone facing these problems deserves access to high-quality information and suitable treatment in an NHS that is supported and fit for the future. You would expect me to say this, Sir Graham, but 13 years of Conservative Government have not helped the health service. Waiting lists and preventive care in the community are at breaking point.

People who support those living with incontinence need quality training to ensure the right bowel and bladder care regime for each patient. That is particularly important for those with mobility issues who rely on carers either at home or in a community setting. Nurses are currently required to learn specialist continence care on the job, because of the removal of NHS training courses over the last few years. That adds additional pressure to already overworked nursing and caring staff, putting patients’ quality of life and their health at risk. We are still waiting for the workforce plan, although we hear that it is imminent. I agree with the hon. Member for South West Bedfordshire that those living with incontinence would welcome an update from the Minister on whether the Government will introduce NHS training courses on stoma and continence care for nursing and care professionals.

This is not just an individual health matter, but a public health matter. It would be helpful if the Minister could explain what discussions he is having with integrated care boards throughout the country about tackling incontinence as a prevention issue, knowing, as we have heard, that it affects one in five people across the country. From the examples we have heard, it is clear that specialist treatment and support, including mental health support, is vital. How are the Government ensuring that those who need that support receive it, and particularly those in harder-to-reach communities?

Much has been promised in the women’s health strategy, but we are still awaiting action on things from tackling gynaecology waiting lists to appointing a deputy women’s health ambassador. We have heard good promises but we need to see the findings. Also, any disruption to the flow of medical devices into the UK would have a devastating impact on those who rely on them, and urology projects are no exception. Can the Minister give any assurances to the industry in respect of the sustainability of production and regulatory alignment post Brexit?

Finally, can the Minister provide any information on updating the guidance regarding the disposal of sanitary dressings in the building regulations and in approved document M? I understand that that work has been ongoing since 2020, but it would address many of the issues that have been raised today. If he cannot provide an update now, will he do so in writing? I think the hon. Member for South West Bedfordshire would appreciate that too.

To improve continence care across the whole public health and care system, NHS England has established the national bladder and bowel health project to improve continence care. As my hon. Friend rightly pointed out, it has also published “Excellence in Continence Care”, which is a practical guide for leaders and commissioners. That includes guidance for commissioners—so ICBs—and leaders in healthcare systems to ensure that people who are diagnosed with UTIs receive high-quality treatment.

I have heard my hon. Friend’s concerns about the implementation of the continence care guidelines. I will, as he asked, take this back to the Department and raise it with the Minister for Social Care, my hon. Friend the Member for Faversham and Mid Kent (Helen Whately), to discuss what more we can do alongside NHS England.

On 9 May, NHS England published its delivery plan for recovering access to primary care. It is an ambitious plan that includes proposals to improve options for community-based services to treat urinary tract infections. As part of that, appropriately trained community pharmacists will be commissioned to provide a clinical service to care for patients with urinary symptoms, providing timely access to assessment, information and advice.

In addition—this does fall within my direct remit in the Department—the National Institute for Health and Care Excellence has produced guidance on the management of faecal incontinence in adults, which healthcare professionals and commissioners are expected to take fully into account as part of the delivery of services. That guidance outlines that management strategies should consider diet, bowel habit, toilet access, medication and, importantly, coping strategies. Those management strategies will be required to account for the sensitive and socially stigmatising nature of incontinence, as my hon. Friend the Member for South West Bedfordshire set out. We know how important that is to patients, their families and—as the hon. Member for Strangford (Jim Shannon) pointed out—their carers.

I want to touch on another area, which my hon. Friend the Member for South West Bedfordshire touched on also, which is antimicrobial resistance, because we have updated the 2019 to 2024 national action plan on tackling antimicrobial resistance. The plan is core to this debate because it outlines that the UK will enhance the prevention of UTIs by providing early, accurate diagnosis and treatment of suspected and confirmed UTIs. That includes the prescription and use of antibiotics and therapeutics for older people, both in their own homes, which is critical, and in care homes, so that patients get the care they need, when and where they need it, and are less likely to suffer from the discomfort of urinary tract infections, or indeed secondary infections, which we know can follow.

To improve bowel care for people with spinal cord injury, NHS England has also published a service specification, with specialist multidisciplinary teams that provide advice and care in bowel management, including promoting and managing continence. My hon. Friend also referred to medtech, and I am really passionate—

The reason I labour the point about patient choice is that we must ensure that patients have a voice in the product range available in the drug tariff, so that patients’ interests are at the heart of how the tariff operates. We are currently engaging with patient groups, which is really important, and a targeted consultation will be launched later this summer to ensure that the tariff continues to be able to provide effective products to patients.

My hon. Friend and others also referred to the long-term workforce plan and the need for specialist continence nurses. I have spent the last few months saying that the plan will be published “soon”, then “very soon” and now “imminently”. I do not know if I can say “very imminently” —I am not sure there is such a thing—although I have spent most of today talking about the NHS long-term workforce plan. I anticipate spending most of tomorrow, and indeed Monday, talking about the NHS long-term plan. My hon. Friend and others will not have to wait very long before they will be able to read the plan in full. I am sure that he and others will understand why it would not be right for me to share details of it ahead of publication, but I mean it when I say that he will not have to wait very long at all.

On the points about public toilets and accessible toilets, I am conscious that I am straying into the territory of the Department for Levelling Up, Housing and Communities, which has responsibility for building regulations. It approves documents for the provision of toilets in publicly accessible buildings, which falls under the Building Act 1984 and the Building Regulations 2010. That legislation does not currently require sanitary bins in men’s toilets, but I understand the points made by my hon. Friends the Members for South West Bedfordshire and for Don Valley (Nick Fletcher), as well as the hon. Member for Strangford, about the anxiety that men feel. They make a compelling argument, and I would encourage them to raise it with the relevant Minister at DLUHC—I will do that too.

I understand that Colostomy UK has a stoma-friendly toilet campaign that is aimed at organisations, businesses and individuals. The campaign focuses specifically on accessible toilet facilities and the needs of people living with a stoma. The hon. Member for Strangford makes a fair challenge to the civil service and Government Departments to lead by example on that point. I will raise the issue with the Cabinet Office to see whether it is something we should explore further.

I thank my hon. Friend the Member for South West Bedfordshire for alerting me to the bladder and bowel CONfidence app, which was something that I was not aware of before my research ahead of the debate. I now know that a number of NHS trusts and medical centres are aware of the app and promote its use. Following this debate, I will look into whether NHS England could reference the app on its health webpages, which would be really helpful. I will also look into what more we can do to promote the app, as it sounds like a great tool.

My hon. Friend the Member for Don Valley raised the possibility of a men’s health strategy, and specifically a Minister with responsibility for men’s health. I know it is an issue that he is hugely passionate about and has campaigned long and hard on. I can give him the assurance that the major conditions strategy will take into account the needs of both men and women. Of course, we recognise that different approaches need to be taken for men and women in the provision of treatment of major conditions, especially over the whole course of life.

The Secretary of State for Health and Social Care, in Men’s Health—which is not a magazine I have read, but I have seen the cover—explicitly invited men to respond to the call for evidence to help us to ensure that the strategy takes into account the needs of men. I know that my hon. Friend the Member for Don Valley wants the Government to go further on this issue. He has already raised the issue with the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Lewes (Maria Caulfield), and I would also be happy to meet with him to discuss it.

To conclude, I know that many people who experience bladder and/or bowel problems experience stigma, a point made eloquently by my hon. Friend the Member for South West Bedfordshire. They can be embarrassed to talk about the symptoms with friends, family and even, to some extent, healthcare professionals. That is why I am particularly pleased that my hon. Friend secured today’s debate, which has provided me the opportunity to play a small part in tackling the stigma that surrounds this issue. I think all hon. Members that have taken part in this debate have helped to defeat the stigma that surrounds the issue. I am not so naive as to think that there will be thousands watching this debate at home, but the debates are kept online and I hope people will watch. They will realise that it is vital to talk to medical professionals about their health issues and problems in this space and, wherever they feel it is necessary, to seek out professional care.