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Chamber and committees

Meeting date: Thursday, November 16, 2017

Meeting of the Parliament 16 November 2017

Agenda: General Question Time, First Minister’s Question Time, Incontinence, Pow of Inchaffray Drainage Commission (Scotland) Bill: Preliminary Stage, Veterans and Armed Forces Community, Business Motions, Parliamentary Bureau Motions, Motion without Notice, Decision Time



The Deputy Presiding Officer (Linda Fabiani)

The next item of business is a members’ business debate on motion S5M-08218, in the name of Alex Cole-Hamilton, on incontinence in Scotland. The debate will be concluded without any question being put. I ask members who wish to speak in the debate to press their request-to-speak buttons.

Motion debated,

That the Parliament understands that incontinence has the potential to affect everyone at some point and that the condition can arise as a symptom of a range of varied medical conditions, such as obesity, traumatic childbirth and muscle weakness; believes that 20% of women between 17 and 30 will experience so-called giggle incontinence, which has the potential to lead to greater complications in later life, in particular the need for surgical interventions, including transvaginal mesh implants; understands that the only country to have calculated the costs associated with this is Australia, which estimates these to be around $43 billion (£25 billion) per year as they go beyond the provision of sanitary wear, medication and surgery, and include the cost of dealing with the depression and anxiety that can arise; recognises what it sees as the importance of physiotherapy in alleviating the symptoms, and notes that, when provided early, this has reportedly proved effective in 80% of cases; understands that there is no formal training around basic incontinence prevention in Scotland for the midwifery, health visitor or physiotherapist workforce; acknowledges the taboo around the subject, which, it believes, suppresses an open discussion about it and often prevents people experiencing the condition from seeking help, and notes the view that the case for a national incontinence strategy is compelling, as it would be important to improving the life quality of hundreds of thousands of people in Edinburgh and across the country and would be of benefit to the public purse.


Alex Cole-Hamilton (Edinburgh Western) (LD)

I thank the Cabinet Secretary for Health, Shona Robison, for remaining for the debate.

If we ask anyone in this chamber or beyond it what their top five fears of age or infirmity might be, we can be sure that the subject of this debate will sit right up there. However, I state from the outset that, if we, as legislators, assume that incontinence is a condition only of the old or infirm, we are mistaken and are part of the problem. I called for the debate because women and men of all ages suffer in silence. It is high time that they are made aware of, and given, treatment, support and—most important—hope.

Incontinence is still taboo. Patients are shy and embarrassed to talk about it or to seek medical help, and many of them assume that nothing can be done for them. This may be the first time that we have debated the problem with such a focus in the Parliament. I am glad that members from all parties are present today and are prepared to put aside our hang-ups on the issue and look collectively towards relatively straightforward solutions.

Here are the facts: one in three women and one in nine men leak urine. A remarkable 30 per cent of women who have given birth vaginally will have damage to their pelvic floor, while those who sustain a third or fourth-degree tear during childbirth are likely to have problems with faecal incontinence. Statistics show that incontinence has a bigger impact on a person’s quality of life than nearly any other condition, and a recent survey of those over the age of 60 and in hospital characterised incontinence as a fate worse than death.

We do not know the true cost to Scotland of incontinence, associated products and the causal impact on physical and mental health. However, in 2010, Australia made a stab at researching the scale of the problem. A study there examined the cost not only of sanitary wear, medication and surgery, but of dealing with the depression and anxiety that can arise from the condition. It amounted to $43 billion dollars annually, which is astronomical. Our two countries have similar societies and face similar health challenges, so we can extrapolate that to around £5,000 for every Scot with the condition every year.

A range of additional health complications stem from incontinence, and they have much bigger associated costs. For example, incontinence is linked to falls. Many older people fall and break their hip by slipping in the night after not making it to the loo in time and may become part of the 25 per cent of those over the age of 80 who will be dead within a year after such a fracture. We are still waiting for the national falls strategy, which will build on the 2014 falls framework that the Scottish Parliament voted for earlier this year.

One of the only surgical interventions available when sufferers are beyond the help of physiotherapy is the transvaginal mesh implant. Last year, along with colleagues from all parties, I met mesh survivors on a visit arranged by Neil Findlay. Thanks to their campaigning efforts, we have all heard the awful traumas that they have endured as a direct result of botched treatment for incontinence.

There is also a direct causal relationship between male incontinence, erectile dysfunction and male mental health issues. Given that much of the increase in the suicide rate last year related to young Scottish men, we cannot afford to ignore that link.

There are, nevertheless, solutions to this terrible condition, and they are not rocket science. Those women who, after childbirth, are left with rectus abdominis diastasis—separated tummy muscles—are more prone to developing back pain and vaginal prolapse. They could easily be identified on the maternity ward and referred to a physiotherapist. We also have a six-week postnatal check in place, but there is currently no requirement to check how those muscles have healed and not all general practices routinely follow that up. We can prevent more women finding themselves with that debilitating condition if they are empowered with knowledge both before and after giving birth.

It is astonishing that a country that provides a box to new parents that contains a poem from the makar does not yet routinely train midwives and health visitors in basic pelvic physiotherapy. We must ensure that that is done as a matter of course, so that mothers are informed about post-partum exercises, what to look out for after tearing and when to seek treatment.

An understanding of pelvic floor exercises must be included as part of the curriculum in either personal and social education or physical education, so that young people are aware of their own pelvic health. There is evidence that physiotherapy works for all ages as well as years after the onset of symptoms, yet many people who suffer incontinence do not realise that treatment could improve their symptoms.

We need to normalise the discourse around the issue. Given that only 30 per cent of sufferers are coming forward for help, we need to build awareness so that everyone who is affected knows how to get help and that they are not alone. That would not cost much money but could significantly improve the quality of life of those who experience the condition at any time of life.

Incontinence is a huge and underrecognised public health issue in our country, but evidence shows that we can prevent and manage it with physiotherapy. We need to better support the many Scots who contend with the problem every day, some of whom are known to us personally.

I will close by thanking my friend and constituent Elaine Miller, who is a pelvic physiotherapist and comedian. She is leading a one-woman campaign to bring the issue out of the shadows and to an international audience. She is sitting in the public gallery today and will bring her show to the Parliament next Tuesday. I heartily recommend it to colleagues.

Incontinence is one of those health conditions that are indiscriminate of class or lifestyle. It ruins lives but we seldom give it the attention that it deserves.


Fulton MacGregor (Coatbridge and Chryston) (SNP)

I thank Alex Cole-Hamilton for bringing forward this important debate. I remind members that I am the parliamentary liaison officer for the health secretary.

I will focus specifically on care homes—my reason for that will become clear—although I completely accept what Alex Cole-Hamilton said about the condition affecting not just one group.

Incontinence is common among care home residents, with its prevalence ranging from 30 to 80 per cent. Research has identified incontinence as a risk factor for increased skin damage, infection and falls in older people.

In care homes, incontinence is primarily managed with absorbency pads, which contain rather than promote and improve continence. National continence guidance suggests that interventions such as toilet assistance, optimal fluids, nutrition and medication can promote continence rehabilitation and reduce the use of pads in older people by up to 50 per cent.

Taking on that guidance, the care home continence improvement project was developed by teams in NHS Lanarkshire and NHS National Services Scotland with the aim of improving the continence care of people living in care homes in Lanarkshire. The primary outcome that was sought was a reduction in the use of high-absorbency products, and a secondary outcome was a reduction in the safety risks that are associated with incontinence.

A pilot took place in David Walker Gardens in Rutherglen and Summerlee house, which is a Balmer Care Homes residence in my constituency of Coatbridge. Both homes were recently put forward for awards, and Elaine Smith and Clare Haughey have lodged parliamentary motions recognising that. On 25 October 2017, the homes were successful at the recent UK-wide GO awards, which celebrate excellence in public procurement.

By chance, I had the pleasure of visiting Summerlee house on Monday and personally congratulated those who were involved in the project. I spoke to a number of individuals including Alice Macleod, the nurse adviser for national procurement and the project lead, and Margaret McDonald, the care home manager, as well as the owners, who have a particularly good reputation locally for providing good care home services. Far too many people were involved in the project for me to mention them all, but they include Irene Barkby and Jean Donaldson.

I especially thank the carers, residents and families who were involved. When I was at the care home on Monday, I was shown a video of some of the families and residents talking. It was emotive to hear them talk about how their loved ones’ lives had changed since the project started.

The initiative involved the interventions of frequent toilet assistance, medication reviews, regular fluids and reduced caffeine intake, and the results were better than anyone expected. Episodes of incontinence and pad use were reduced and less distress was experienced. Record keeping improved and staff had more quality time for residents, and that was reflected in the video. There was a 65 per cent reduction in the number of falls and a 50 per cent reduction in urinary tract infections, and skin damage was reduced by one third. There was also a 40 per cent reduction in unplanned hospital admissions for falls relating to UTIs, and residents began asking to be taken to the toilet—as I heard that day, some of them had not asked for such assistance for years.

The initiative demonstrates how small changes can make a big difference to people’s lives, but there is a wider impact. It means less pressure on hospitals and a reduction in procurement. The economic analysis showed a saving of £250,000 in nine months, so there is real potential in that aspect.

The initiative could be transferable to other care homes across Lanarkshire and Scotland. I am in the process of setting up a reception, which I will ask the cabinet secretary or ministers to attend.

I see that the Presiding Officer is asking me to finish. I therefore thank Alex Cole-Hamilton for bringing the debate to the chamber and giving me the opportunity to speak about the good work on continence that is going on in my constituency.


Annie Wells (Glasgow) (Con)

I thank Alex Cole-Hamilton for bringing the debate to the chamber. It is a very important subject, as incontinence can affect a person’s physical and mental health at any point in their life. The Scottish intercollegiate guidelines network’s 2004 clinical guideline on the management of urinary incontinence states:

“Urinary incontinence is not a condition in itself but is a symptom resulting from one or more underlying conditions.”

Therefore, the effective treatment of urinary incontinence depends wholly on thorough assessment and diagnosis.

Estimates of the prevalence of urinary incontinence vary widely due to differences in definition and the expectation that many of those who are affected will not admit to having continence difficulties. National health service research estimates that between 3 million and 6 million people in the United Kingdom suffer from some degree of urinary incontinence. Estimated figures show that between 210,000 and 335,000 adults in Scotland endure significant problems with urinary incontinence, which equates to between 5 and 9 per cent of our adult population.

Urinary incontinence affects both men and women at varying points in their lives, although women are five times more likely to experience it than men. The broad forms of urinary incontinence can be brought on by factors including age, the menopause, pregnancy and childbirth, a high body mass index and a history of urinary continence problems in childhood.

Fifty per cent of women will experience urinary incontinence at some point, but figures show that only one in five will seek clinical help. In 2004, an American survey by the National Association for Continence reported that, on average, after beginning to experience bladder control problems, women wait six and a half years whereas men wait just over four years before seeking the advice of a healthcare professional.

Urinary incontinence is consistently associated with adverse effects on the quality of life of those with the condition, which are extensive and particular to the individual. Those effects include social isolation, loneliness and sadness, depression, severe embarrassment, stigmatisation, effects on sexual relationships and disturbed sleep. Quality of life is also adversely affected by the practical inconveniences associated with the condition such as the frequent changes of clothes and bed linen and having to bathe more often. Such things greatly impact on a person’s day-to-day life.

Given that only about half of those with moderate or severe urinary incontinence seek clinical help, we desperately need to identify barriers and improve awareness so that those who experience incontinence can live full lives. By tackling the lack of awareness of treatment options and promoting the perception that incontinence is a normal part of getting older, we can start to change the fact that many adults with the condition attempt to manage the problem themselves, often resorting to inappropriate measures that may worsen their condition.

SIGN suggests that adults with urinary incontinence can benefit from changes in lifestyle and adherence to behavioural advice as much as, if not more than, from pharmaceutical or surgical interventions. Simultaneously improving awareness-raising campaigns, reducing people’s perception of the associated stigmatic barriers and promoting awareness of physiotherapy techniques for managing urinary incontinence will undoubtedly encourage more people with urinary incontinence to seek life-changing help.


Monica Lennon (Central Scotland) (Lab)

I congratulate Alex Cole-Hamilton on bringing forward this motion for debate. As the motion rightly highlights,

“incontinence has the potential to affect everyone at some point”

in life and can arise from a variety of medical conditions, but the taboo around the subject often prevents the vital discussion that enables people to get help. Stigma and embarrassment prevent many people with the condition from seeking help. Research shows that more older women experience incontinence than breast cancer, heart disease or diabetes, but the condition is very rarely discussed and fewer than one third of those who are affected seek professional help.

That is why I welcome the fact that we are debating the issue openly in Parliament and why we should explore any actions that we can take to implement policy to improve life for people with the condition. I note in particular the calls from researcher Jo Booth of Glasgow Caledonian University, who has outlined the need for a national strategy on continence that considers bladder and bowel health across the lifespan, as well as a public health campaign to challenge the normalisation of the issue of incontinence.

We should encourage people to seek treatment and help from preventative services, because the bladder condition of almost three quarters of those who experience incontinence can be significantly improved or even cured with lifestyle and behaviour techniques. There is clearly more work to be done to get the message out there that, for many people, incontinence is a medical issue and is not something that they just have to put up with or that is a natural part of ageing. People can take action to help ease the condition. I hope that the cabinet secretary, in her closing remarks, will address some of the issues around the need to tackle stigma and raise public awareness of incontinence and its treatment.

One of the vital issues that were raised during my preparation for the debate is the obvious and necessary requirement for those who experience incontinence to have access to public toilets. Crohn’s and Colitis UK has raised the important point that incontinence is a hidden disability. Being unable to access a toilet has a huge impact on the ability of people with bladder conditions to access public life and go about their everyday lives, including activities that many of us take for granted such as travelling, shopping, socialising and working.

The social model of disability points out that disability is caused by the way in which society is organised and, using that model, we can see that those with bladder conditions that cause incontinence can be disabled from full participation in daily activities because of the inaccessibility of public toilets. I fully agree with that view. Ensuring access to toilets is a public health concern. There should be a duty on authorities to ensure that there is an adequate supply of local toilet facilities. When council budgets are experiencing sustained year-on-year cuts, it is perhaps not surprising that there is pressure on councils to try to make savings by closing facilities such as local public toilets. However, we should recognise that access to those facilities is a right and that they are a public good. Any savings that are made by closing public toilets are surely offset by the even greater social and economic costs that are caused by social exclusion.

I recently raised the issue of access to public toilets with Network Rail as part of my on-going campaign to improve access to vital sanitary products and ensure that legislation is in place so that no one goes without them. In many railway and bus stations, a charge is in place to access toilets, which is a real barrier for those who need to access a bathroom urgently. I hope that all public bodies in Scotland will look more closely at that issue.

I would welcome any progress on the calls for a national strategy or action plan on continence, which would address some of the issues that have been raised in the debate.


Alison Johnstone (Lothian) (Green)

I am pleased that we are having the debate and I thank Alex Cole-Hamilton for making it possible. We have heard that incontinence is a public health issue that affects millions but is covered up and hidden from view for a variety of reasons, including stigma, as Monica Lennon mentioned. It is also a public health issue with some real win-win solutions. The advice for preventing urinary incontinence is in many ways the same as that for reducing a whole spectrum of medical problems and living a healthy life. NHS Choices advice suggests working towards a healthy weight, cutting down on alcohol, keeping fit and, for incontinence in particular, keeping those pelvic floor muscles strong. Following that advice will not mean that people never experience incontinence, but it can help.

For those who are living with incontinence, access to the right medical help is vital, and getting treatment early can help massively. Incontinence should not be allowed to limit our life choices. That phrase kind of brings to mind some of the adverts that members will have seen on television, but I am trying to make the broader point that the brilliant physiotherapist-comedian—there’s a job title for you—Elaine Miller made in an email to all MSPs. She said that a

“significant, and almost totally unrecognised factor is that incontinence is a barrier to exercise—diseases of inactivity are now responsible for 1:6 premature deaths, which is on a par with smoking.”

Indeed, in Parliament last week, Professor Nanette Mutrie said that inactivity has actually exceeded smoking as a global killer.

However, incontinence is largely missing from obesity management. Once a person’s BMI is over 36, they will probably wet themselves when they run, which may be significant in the consideration of poor exercise compliance.

Alex Cole-Hamilton spoke about how incontinence can affect both men and women of all ages, but it is something that I started discussing with other mums after my child was born, which was some time ago. After having a child, one is more likely to find oneself trampolining with toddlers, but less likely to do so without worrying about incontinence. The link with physical exercise is well made and it is important.

I have not seen Elaine Miller’s award-winning show but I am looking forward to a taste of it on 21 November when the arts company, Fair Pley, the Chartered Society of Physiotherapy and Elaine will visit Holyrood. I hope that we all see one another there again. Elaine Miller may also be the only comedian to star on the NHS Choices website and to have her show accredited as continuing professional development for healthcare professionals. However, importantly, tackling incontinence in the most effective way will require more physiotherapists to guide people through exercise, more people in health and outwith who are comfortable and have the time to talk about this issue, and less taboo as a whole about recognising and discussing incontinence, especially among younger people.

The chartered society’s main message is that physiotherapy is highly clinically effective, and cost-effective too. It reports that 50 per cent of women reporting incontinence said they were moderately or greatly bothered by it, 27 per cent were unwilling to go places where they were unsure about the availability of a toilet, and 31 per cent dressed differently because of the problem.

Monica Lennon highlighted the important issue raised by Crohn’s and Colitis UK and I would be grateful if the cabinet secretary could address that in closing, as well as the issue of free access to incontinence pads for those who need them. I would also be grateful if the cabinet secretary would address how we might all work together in this Parliament to make sure this issue will no longer be taboo. Today should be the start of a broader discussion in order that we tackle this issue with the seriousness and urgency that it deserves.


Stewart Stevenson (Banffshire and Buchan Coast) (SNP)

In essence, this debate is about the competition and tension between social embarrassment about talking about the functions of our bowels and bladders and the underlying medical urgency that might be associated with dysfunction in that regard. If social embarrassment wins, there is a risk that we delay engagement with the medical assistance and advice that might well be necessary to protect us from the severe impacts of underlying conditions that need urgent attention.

I often learn things in members’ business debates that I had not previously been aware of. It had never occurred to me that the issue that we are considering had a gender aspect to it. Members might forgive me, given my age, for being a little fixated on the future operation of the older gentleman’s prostate and for neglecting to understand issues that are associated with pregnancy and incontinence in females. We have heard that the problem is bigger for the female than it is for the male. I have learned something.

I am grateful to Alex Cole-Hamilton for securing this debate, which I hope will, more broadly, enable people to feel a little more comfortable about talking about issues that are rarely discussed at the dinner table.

The issue is important. Glasgow Caledonian University reports that 30 to 40 per cent of people over 65 who live in their own homes and 70 per cent of frail older people who live in care homes struggle with incontinence—so it is not a trivial matter.

Despite what Alison Johnstone said—I will look out some of the references that she cited—I had not previously thought that incontinence was a matter of humour. However, if humour can be used as a vehicle that allows us to talk about and recognise the condition, that is very much to be welcomed.

A lot is expected of healthcare professionals. I hope that practice nurses, who will often be the ones to be consulted on the condition rather than general practitioners, have the appropriate training and the sensitivity to raise with patients something that may be of considerable embarrassment to them. Patients often go to their primary health provider for a reason other than incontinence, and the condition may emerge as a secondary issue, or it may simply be that questions about general health reveal an incontinence problem that is part of their deterioration in health.

I hope that midwives, health visitors, physiotherapists, practice nurses and GPs are, in future, better equipped for, and more comfortable with, raising difficult issues about incontinence. As the Australian numbers illustrate, the key point is that if we tackle incontinence early, there is an economic saving in addition to the benefit to the quality of life of sufferers. Sustained and regular exercise is important and helpful, with the caveats that I have just heard about from Alison Johnstone.

We have the potential to alleviate unnecessary pain, anxiety and aggravation, and to improve the quality of mental health of incontinence sufferers. The topic has been neglected for too long. This debate is a contribution, but not the end of the story in improving matters for incontinence sufferers.


Brian Whittle (South Scotland) (Con)

I refer members to my entry in the register of members’ interests. In addition, a close relative of mine is a healthcare professional working in the NHS.

I, too, congratulate Alex Cole-Hamilton on securing time in the chamber to raise awareness of this issue. Many people find incontinence difficult to talk about—indeed, the motion

“acknowledges the taboo around the subject”.

Even when we find ourselves talking about incontinence, it is frequently as the basis of a joke rather than a serious discussion. That is not to say, as has been said, that we should not make light of a serious subject. The first step towards dealing with the impact of conditions such as incontinence is to make people more comfortable when talking about them.

I am reminded of how Billy Connolly deals with his Parkinson’s disease by weaving it into his show and leaving the stage to the track, “Whole Lotta Shakin Goin On”. We find ourselves laughing at that black humour, even though we probably find the material uncomfortable. His legendry skit in “An Audience with Billy Connolly” is how I know that incontinence strikes at all ages.

It is important that we never lose sight of the people who live with incontinence. As has been mentioned, the condition can have a profound physical, psychological and economic impact on a person’s life. It can place a hurdle between them and their being able to undertake the day-to-day activities that many of us take for granted. Because of their condition, they always have a question in the back of their minds about whether they will be able to do something.

There are those who see incontinence as little more than an inconvenience, but the reality for many is that it is a life-changing condition. That was forcibly brought home to me during the Public Petitions Committee’s on-going work on transvaginal mesh issues, which are mentioned in the motion. The committee has heard harrowing details of the fallout when the procedure goes wrong. Often, it is linked to incontinence issues after childbirth. The evidence sessions that I have taken part in have been some of the most challenging of my short time in this Parliament. We heard from many who suffer horrendous pain in the aftermath of the operation, as well as having to deal with the realisation that the normal everyday life that we all take for granted has been ruined for them. Many of the sufferers are young women

The image of the cabinet secretary and the chief medical officer being cross-examined in committee with rows of women in wheelchairs sitting behind them reacting to their answers has stayed with me as the most challenging session that I have been involved in, such was the strength of feeling in that room. It certainly highlighted the responsibility that we as MSPs carry in this place and how the decisions that we make and the discussions that we have can have a profound effect on the lives of others.

Unfortunately, there appears to be a connection between our difficulty in talking about incontinence and a lack of joined-up support and treatment for sufferers. As Alex Cole-Hamilton points out in his motion, many cases of incontinence could be prevented through greater and more consistent training for nurses, midwives, health visitors and other medical professionals.

It is worth pointing out that some cases, such as those caused by obesity, can be treated at least partially by encouraging changes in lifestyle. Such joined-up thinking, especially in early intervention, is a crucial element in preventing such conditions or, potentially, at least lessening the need for more invasive interventions. The role of the GP in that is vital, which is why Conservative members put such an emphasis on primary care.

Early intervention with physiotherapy has been shown to be effective in addressing incontinence. The key to that early intervention is incontinence being taken seriously and enough trained physiotherapists being available. I am concerned that that might not be the case at the moment. That need for more physiotherapy specialists will have to fight for oxygen in an atmosphere in which many other healthcare professionals are crying out for more investment. Therefore, it is crucial that we use members’ business debates such as this to highlight those issues and the subsequent needs.

I thank Alex Cole-Hamilton for bringing the debate to the chamber.


Neil Findlay (Lothian) (Lab)

I declare an interest in that my wife and daughter work in the healthcare sector.

I thank Alex Cole-Hamilton for bringing this important debate to Parliament and for agreeing to sponsor jointly the event next week at which we will hear from Elaine Miller. Its theme is, “Is pee a feminist issue?” I look forward to that performance on Tuesday night. Of course, everyone is welcome to attend.

We often hear revelations in members’ business debates. Today has been no different: we found out that Stewart Stevenson has learned something today, when most of us who have listened to his contributions over the years had thought that he already knew everything. Apparently not. That is today’s revelation, for me.

Incontinence is a deeply personal issue and has a huge impact on people’s quality of life. I am glad that Brian Whittle mentioned Billy Connolly’s sketch, which was a very funny routine. However, for the people who are affected by it, incontinence is far from funny because it affects their relationships, jobs, sex lives, social lives and their ability to do normal everyday things. That is no laughing matter: it is thoroughly miserable.

As members have said, for many women childbirth causes the problem. Tears, strains, prolapses and damaged muscles are all contributing factors. For many, it is the start of a life of trying to cope with the constant fear of embarrassment and of their thought processes being dominated by wondering where the nearest toilet is.

Of course, many women who have suffered could have their condition improved or completely resolved through better prenatal and postnatal education, and better care and rehabilitation. Simple checks—we read about questionnaires and self-assessment tools in the briefings for the debate—pelvic floor exercises and physiotherapy can all help. They can all have dramatic results, but many people do not get that information, advice and care.

Far too many women were told that the problem could be solved quickly by a new gold-standard procedure that would fix their prolapse or incontinence. That new gold-standard procedure was sold to them by the medical multinationals such as Boston Scientific and Johnson & Johnson, and was enthusiastically promoted by surgeons who bought the spin or were pressured by health boards and the medical establishment. The reality is that that gold-standard procedure has left tens, if not hundreds, of thousands of women throughout the world horribly injured, disabled, unemployed, wheelchair bound and with broken relationships and broken dreams. Mesh implants are, though, still being implanted in women. I hope that Parliament will debate the mesh scandal in the next few weeks. It is the least that we can do for the people who have been suffering. We must get answers to the problems that have been exposed in that global scandal.

Incontinence is not just “part of life”; it is a condition that can, with the right interventions, be improved and resolved, which gives people back their lives, confidence, wellbeing and self-esteem.

I thank Alex Cole-Hamilton for securing the debate, and I look forward to women and men receiving much better help and support for this distressing condition. I urge the Cabinet Secretary for Health and Sport, and you, Deputy Presiding Officer, to join us next Tuesday for a performance of “Gusset Grippers”, in which Elaine Miller will use comedy to address this serious issue.


The Cabinet Secretary for Health and Sport (Shona Robison)

I, too, thank Alex Cole-Hamilton for lodging the motion. I am sure that there will be a fantastic turnout for Elaine Miller’s performance on Tuesday night.

As Alex Cole-Hamilton and others have said, continence issues affect people of all ages and can have a profound effect on an individual’s quality of life. There may also be an impact on wider health issues, including through increased risk of falls and fractures for some people. In order to achieve better outcomes for patients, it is vital to diagnose the cause of incontinence, rather than just treating the symptoms. I am therefore determined to ensure that all patients with continence issues receive the first-class service that they deserve. My aim is that patients should see the right person at the right time, and certainly early enough, to provide them with support and advice on how to manage their condition.

Early intervention is crucial, and NHS boards are trying to address that. For example, NHS Lothian is piloting a system for redirection of patients from consultant care to physiotherapy care, where that is clinically appropriate. Patients can, thereby, access the most appropriate care, reduce unnecessary consultant appointments and be seen faster. In addition, an increasing number of specialist physiotherapists are being trained in prescribing, which is improving patient care and decreasing the need for multiple general practitioner appointments. That, again, reduces time.

My aim is that, whatever the setting, care will be provided to the highest standards of quality and safety, with the patient being at the centre of all decisions, in line with recognised standards and best practice.

Alex Cole-Hamilton

I am grateful to the cabinet secretary for delineating the clinical response. As she will have heard, there is much unanimity in the chamber about the issue—all party politics has been stripped from it. Will the cabinet secretary take that unanimity and commit to considering a national strategy on continence that addresses not just the clinical response, but all the social aspects relating to the issue, including awareness, access to public toilets and other matters that members have raised?

Shona Robison

I will certainly look at what more can be done and at what is the appropriate way to address the many issues that have been raised in the debate. The motion mentions—as did many members—the lack of formal training on basic incontinence provision for the midwifery, health visitor and physiotherapy workforce. Members will be aware that, as part of their undergraduate preparation, midwives receive education on incontinence that results from childbirth. Significant training resources are also available for staff at local level, including for the care sector. Those include e-learning opportunities and modules that are provided by board continence teams. We need to ensure that those resources are being used and that staff are getting the opportunity to train.

The majority of boards have dedicated continence teams that provide direct care and support to patients. They also provide advice and support to other health professionals, including the care sector and carers, who manage bladder and bowel problems. It is important that all NHS and social care staff are aware of the effect that their practice can have on a patient’s continence status: for example, some medication may exacerbate continence issues.

With the appropriate continence care, there is huge potential for achieving an improvement in people’s quality of life. Midwives, nurses and allied health professionals have particularly important roles in supporting people with continence issues.

Boards also provide continence care for residents of care homes. I was particularly interested in what Fulton MacGregor said about that. That can vary from providing direct care through boards’ continence teams to providing support to registered nurses in care homes to enable them to carry out patient assessments. Although many older people remain fit and well, health problems generally increase with age and many of us will need some help and support at some stage.

It should be acknowledged that many people are supported to manage their continence issues by the NHS as well as the third sector so that they can live full, independent and, in many cases, active lives at home and at work.

I am aware that barriers to seeking help include embarrassment, lack of knowledge of available treatment options and misconceptions, such as that suffering from incontinence is a normal part of ageing, which of course it is not. I therefore encourage anyone who has a continence problem to seek help from our caring and compassionate health professionals. I also thank the wide range of NHS staff who are doing excellent work in supporting people who have continence issues.

Boards also seek to promote good bladder and bowel health, as part of a public health message, in order to prevent continence problems arising in the first place. For example, many boards have public information leaflets on how to maintain a healthy bladder and bowel.

In addition, NHS Grampian holds a joint clinic that focuses on a 12-week health promotion and education programme on continence.

NHS Greater Glasgow and Clyde has also redesigned its continence service to focus on preventive measures. It aims to support patients to manage their symptoms better, and it aims to break down the myths and stigma that are often associated with incontinence. I am delighted that the board’s specialist bladder and bowel service was awarded the national care award for 2016-17.

Members will, I hope, be aware that there is a national contract in place for supply of continence products, which is tendered for every three years. I appreciate the sensitivities of continence provision and the degree of distress that is caused if patients are not confident in the products that they use. People already have access to free continence pads—the issue that Alison Johnstone raised. People may, of course, choose to buy extra pads. Continence pads are also free to people in care homes.

I expect all boards and staff who are involved in the provision of continence care to engage appropriately and sensitively with patients, and to support them fully to ensure their dignity, comfort and independence.

The Scottish Government is also keen to have continued dialogue with stakeholders, including the Association of Continence Advice’s Scotland branch, on how services and care can be improved nationally and locally. Perhaps that would be a good starting point for exploring how some of the issues that have been raised in the debate can be taken forward. Some of that work is already happening: for example NHS board continence leads meet quarterly to discuss and share good practice. I get the sense from members who have spoken today that there is more to be done, so I am happy to consider whether we can use the existing structures for that.

A number of members mentioned transvaginal mesh implants. I could spend a great deal of time going over many of the issues that have been raised and the experience of the Public Petitions Committee. I look forward to using the debate opportunity that we will have in the near future to update Parliament on progress that has been made on some of the actions that the chief medical officer and I undertook to progress—not least, the independently chaired mesh oversight group that is being set up by Healthcare Improvement Scotland, which will meet before the end of the year. I look forward to providing more detail on that in the debate.

Neil Findlay

We look forward to the Public Petitions Committee having a debate, but the cabinet secretary has the option of having a debate in Government time.

Shona Robison

As Neil Findlay knows, the Public Petitions Committee has spent a great deal of time going into all the detail of the issue. It is therefore quite right that the information be brought forward through a committee debate. It is as valid for a committee to bring forward debate as it is for the Government to do so.

We have to think carefully about the purpose of the debate. NHS England published a report on mesh during the summer, which made similar recommendations to the report that the Public Petitions Committee discussed. During the committee debate, we can reflect on the NHS England report and what it adds to this complex and difficult issue.

I thank members for their contributions and for sharing patient experiences with Parliament. I certainly recognise that more can be done. I am happy to ask the chief medical officer and the chief nursing officer to write jointly to NHS boards to reinforce the importance of a continence service that is person centred and tailored to people’s needs, including prevention and early intervention—which picks up on some of the points that have been made in this important debate.

We must and will keep looking at what we can do better, how we can transform and improve care and how we can equip ourselves to deliver even better health and social care services in the future for those who live with continence issues.

13:34 Meeting suspended.  14:30 On resuming—