Abstract
Background and context Most people with urinary incontinence are given limited choice when provided with absorbent products through the British National Health Service (NHS), even though the available range is large.
Objective To investigate users’ preferences for four disposable designs (inserts, all‐in‐ones, belted/T‐shaped and pull‐ups) and towelling washable/reusable products, day and night.
Design Shopping experiment.
Setting and participants Community‐dwelling women and men in England with moderate‐to‐heavy urinary incontinence recruited to a larger trial.
Intervention Participants tested each design and selected products they would prefer with a range of different budgets.
Main outcome measures Design preferences (rankings); ‘purchasing’ decisions from designated budgets.
Results Eighty‐five participants (49 men) tested products, 75 completed the shopping experiment. Inserts, most frequently supplied by the NHS, were ranked second to pull‐ups by women and lowest by men. When faced with budget constraints, up to 40% of participants opted to ‘mix‐and‐match’ designs. Over 15 different combinations of products were selected by participants in the shopping experiment. Most (91%) stated a willingness to ‘top‐up’ assigned budgets from income to secure preferred designs.
Discussion Participants displayed diverse preferences. Enabling user choice of absorbent product design through individual budgets could improve satisfaction of consumers and efficiency of allocation of limited NHS resources.
Conclusion Recent policy for the NHS seeks to provide consumers with more control in their care. Extension of the concept of individual budgets to continence supplies could be feasible and beneficial for patients and provide better value‐for‐money within the NHS. Further research is warranted.
Keywords: absorbent products, choice, incontinence, individual budgets
Introduction
Incontinence is a common and embarrassing problem which has a profound effect on social and psychological well‐being. Despite advances in treatments and therapies for incontinence, completely reliable bladder or bowel control is not an attainable goal for everyone. Many people need support from products to achieve ‘contained incontinence’ 1 to enable them to carry out their everyday lives confidently and to maintain their quality of life. Successful management with continence products can help people avoid the stigmatizing consequences of incontinence, which can threaten social and working lives and also personal relationships. 2 , 3
Absorbent products are the most common type of continence product in use. The users are a heterogeneous group, including younger women, particularly those who have had children, older men with prostate disease, people with neurological conditions and older people with mobility and mental impairment. Whilst small absorbent pads for light incontinence are adequate for some users with low volumes of urine loss, for others with higher volumes, more absorbent products are needed. In many countries, people buy their own products, but in some countries and institutions (such as nursing homes), supplies are purchased by health services.
Urinary incontinence affects around 5 million adults in the United Kingdom (UK), many of whom receive absorbent products to manage their condition at a cost of around £100 million per annum to the British National Health Service (NHS). 4 Individuals are supplied with products through continence services in Primary Care Trusts (PCTs, – the geographically defined agencies with responsibility for commissioning health care for their local populations). Although the Department of Health guidelines recommend that absorbent products should be available to anyone (including children over the age of 4) in quantities appropriate to their needs, there is evidence of widespread rationing, the most common adult allowance being four products per day. 5 Moreover, few continence services use clear or detailed criteria for issuing products, and many operate arbitrary thresholds for measuring severity of incontinence. 5 For logistical and cost reasons, they provide a limited range of products. Most people receiving products from continence services are given little information about the range of designs and products available and no choice of supplies. In a recent study, two‐thirds of women with light incontinence in the community reported that they received no choice of product, and a further 30% stated they had limited choice. 4
This paper reports the results of a ‘shopping experiment’ that explored the product choices that a sample of community‐dwelling men and women with moderate‐to‐heavy urinary incontinence in England reported they would make under different budgetary constraints. This task was added onto a randomized crossover clinical trial comparing the performance of four disposable and one washable product design, the results of which have been fully reported elsewhere. 4 Individual budgets, which enable people to choose and purchase healthcare and social care services for themselves, have been introduced in several countries and have given rise to increased satisfaction and improved quality of care. 6 The concept of individual budgets is being promoted in the UK as part of a package of measures that are designed to increase consumer choice and control in the NHS 7 , 8 but have not previously been suggested in the domain of incontinence product provision.
Types of absorbent products
There are two main categories of absorbent product: disposables and washables (reusables). Practical factors associated with the use of washables may discourage many community‐dwelling people with incontinence, and care homes, from using them. As with nappies (diapers) for babies, a debate exists about the environmental implications of disposable vs. washable products, and each has different adverse effects. 9
Within the disposable category, there are four main designs for adults: inserts, all‐in‐ones, belted all‐in‐ones (T‐shaped) and pull‐up pants. Each design comes in a range of absorbencies and sizes, with most products being produced by a small number of multinational manufacturers who seek to differentiate their product by means of packaging or by adding special features, such as different kinds of elastication, odour control and wetness indicators. Accordingly, prices per product can vary markedly. Washable products (worn with plastic pants) may be in the form of purpose‐made shaped garments made of towelling or needlefelt material, which fasten with poppers or Velcro, or simple towelling squares that are folded and pinned. Washable inserts and pants are also available for people with light incontinence, and men with light incontinence may use penis pouches. There is limited evidence on the cost‐effectiveness of alternative products. 10 , 11
Distribution of continence products
The continence services in each PCT purchase the products that they distribute to individuals either from NHS Supply Chain (the centralized procurement agency) or directly from the manufacturers. Supply Chain provides 42% of products acquired for use in the community or acute trusts (personal correspondence). By virtue of bulk purchasing and a competitive tendering and e‐auction process, Supply Chain negotiates favourable contracts with major producers. However, it does not carry the full range of products. The shaped insert pad, which is priced at the lower end of the market, is the disposable design that is in highest demand by continence services and accordingly accounts for about 66% of the products provided by Supply Chain (see figures in the Box 1). Very few washable products are provided through the NHS.
Whilst manufacturers of disposable products energetically seek to secure the large NHS contracts, they also sell to private individuals through retail outlets or (more extensively) via mail order. Many consumers prefer mail order because a wider range of products is typically available than on the shelves at local supermarkets or pharmacies, and the inconvenience of carrying such bulky products is avoided. Moreover, mail order is a more discreet way of shopping for personal items. Individuals make private purchases for a variety of reasons: they may have been too embarrassed to bring their incontinence problem to the attention of their GP, their problem may be too small to qualify to receive products from the NHS, or the products they get from their continence service may fall short of their needs either on quantity or on quality grounds. Individuals who buy their own products, or ‘top‐up’ their NHS supplies, are disadvantaged because retail and mail‐order prices are up to twice as high as the NHS procurement price. It is not unknown for people to improvise using toilet tissue or other substitutes because they cannot afford to purchase absorbent products.
Methods
Multicentre ethical and research governance approvals were obtained for the main trial. 4 Volunteers were sought through local continence services in England and advertisements circulated by national user groups. Inclusion criteria were that participants must be resident in the community, must have moderate‐to‐heavy incontinence that was consistent and stable, and must be without acute or terminal illness. Background information on sociodemographic characteristics and incontinence history were collected at baseline. Independence in activities of daily living was assessed by researchers using the Barthel scale. 12 Participants were asked to test (in random order) five unisex designs (four washables and towelling washables), by night and day. As features and quality can vary, participants tried (in random order) three different products (each for 2 weeks) for each day and night design. Detailed feedback on different aspects of performance (such as leakage, comfort and ease of changing) was collected from participants at the end of testing of each design (not reported in this paper). A full description of the trial methodology is available elsewhere. 4
After they had completed the testing of all five designs, a final interview was arranged either at the research centre or in the participant’s home. At the interview, participants were asked (separately for day and night) to rank the designs according to their overall opinion, to state the good and poor aspects of each (open question) and whether each was acceptable to them or not, in general, at home and for going out. They were then informed of the monthly cost of each design (assuming three products per day and one per night) and asked to revise their design ranking, if necessary, in the light of this additional information. People in receipt of NHS supplies are generally unaware of the cost of them, and the purpose of this line of questioning was to explore whether knowledge of relative costs would affect stated preferences for designs. The derivation of the design costs used in the study is explained in the footnote to Table 2.
Finally, participants were invited to take part in a ‘shopping experiment’. They were shown an example of each of the five designs and the associated costs based on average mail‐order prices for a packet of 28 disposable products, or 28 uses for towelling washables (day and night separately). Initially, they were asked to imagine they were buying their own daytime supplies for 4 weeks (28 days) and were using three products per day and to select three designs (or multiples of the same design) that they would choose for day use with three different budgets presented in descending order (£75, £50 and £25). The exercise was repeated for night‐time, selecting one design, 28 products (one per night) with three different budgets in descending order (£24, £16 and £8). The monthly costs of designs were rounded to make the calculations for the ‘shoppers’ easier. The budgets were chosen so that the most generous would enable respondents to ‘buy’ the most expensive products, if that is what they preferred, and the lower budgets then required compromises in terms of the designs selected. The lowest budget would just enable the purchase of the cheapest product. Respondents were told to imagine that they could ‘top‐up’ their allocations with their own money if they wished (and as many currently do) and that they could keep any portion of their budget that they did not spend on absorbent products, because it was thought that might make them more price conscious in their shopping. 13 Individuals choosing washables would make considerable ‘savings’, even on the tightest budget offered. A more complex shopping task had originally been designed, but piloting showed this was too burdensome for respondents.
Quantitative data were entered into Microsoft Excel (2003), cleaned and checked, and transferred to SPSS version 14 (SPSS Inc., Chicago, IL, USA) for descriptive analysis. Design rankings were analysed by gender, for day and night. Variability between participants in design choices and their willingness to ‘save’ or ‘top‐up’ their budgets in the shopping experiment was explored. Stated opinions about designs were grouped into themes and frequencies calculated.
Results
Characteristics of sample
A total of 184 (of 286) volunteers met the inclusion criteria, 134 consented and 85 completed the final interview. However, the study proved demanding for participants and some did not provide full data. The characteristics of participants are summarized in Table 1. Just over one‐half were men, and the reported causes of incontinence were varied. Most were in receipt of NHS supplies and were using either inserts or all‐in‐one designs prior to recruitment.
Table 1.
Characteristics of the participants (n = 85)
| Characteristic | Categories | N | % |
|---|---|---|---|
| Age (years) | ≤39 years | 17 | 20.0 |
| Mean: 52.8 | 40–59 years | 43 | 50.6 |
| SD: 15.5 | 60–79 years | 20 | 23.5 |
| ≥80 years | 5 | 5.9 | |
| Gender | Male | 49 | 57.6 |
| Highest level of education N = 81 | ≤18 years of age | 45 | 55.6 |
| College/diploma | 13 | 16.0 | |
| University | 23 | 28.4 | |
| Employment status | In full‐time or part‐time employment | 33 | 38.8 |
| Living arrangements | Lives alone | 43 | 50.6 |
| Annual household income | <£10 000 | 38 | 44.7 |
| £10 000–£19 999 | 22 | 25.9 | |
| £20 000–£29 999 | 11 | 12.9 | |
| £30 000–£39 999 | 5 | 5.9 | |
| £40 000–£49 999 | 3 | 3.5 | |
| ≥£50 000 | 6 | 7.1 | |
| Cause of incontinence (self‐reported) | Overactive bladder | 19 | 22.4 |
| Neurological (MS, CVA) | 9 | 10.6 | |
| Post‐surgery/illness/obstetric | 8 | 9.4 | |
| Accident/injury | 10 | 11.8 | |
| Unknown | 24 | 28.2 | |
| Other | 15 | 17.6 | |
| Barthel (activities of daily living score)* | ≤4550–65 | 513 | 5.915.3 |
| Mean: 82.6 | 70–85 | 27 | 31.8 |
| SD: 11.5 | 90 | 40 | 47.1 |
| N | % | ||
| Design most used before study day (night) N = 84 Mean: 3.4 SD: 1.9 | All‐in‐ones | 35 | 41.7 |
| Insert pads | 38 | 45.2 | |
| T‐shaped/belted | 3 | 3.6 | |
| Pull‐ups | 8 | 9.5 | |
| Washables | 0 | 0 | |
| Design most used before study day N = 84 Mean: 1.3 SD: 1.0 | All‐in‐ones | 39 | 46.4 |
| Insert pads | 33 | 39.3 | |
| T‐shaped/belted | 2 | 2.4 | |
| Pull‐ups | 6 | 7.1 | |
| Washables | 4 | 4.8 |
*Barthel score 12 : Range 0 (total dependence) to 100 (independent). Note Maximum for this group 90, as 10 deducted for incontinence.
MS, multiple sclerosis; CVA, cerebrovascular accident; SD, standard deviation; NHS, National Health Service.
Evidence on preferences
Preferences for the designs differed within and between gender groups, and between day and night. Inserts, the most frequently supplied design by the NHS, were not the most popular. Women ranked them second to the more expensive pull‐up style, which is infrequently provided by continence services. Inserts were the least popular design for men and deemed generally unacceptable by a high proportion of male respondents who mainly preferred all‐in‐ones in the day, but towelling washables (not normally provided by the NHS) at night. All‐in‐ones, the other main style available through the NHS, was relatively unpopular amongst female participants. Some switching of design preferences away from more expensive products occurred after participants were told relative monthly costs (Table 2). An analysis of open comments by participants about their perceived strengths and limitations of designs reveals reasons underlying the rankings and also the individual nature of preferences (Table 3). Any given design can be deemed a good fit/leak‐proof and comfortable by one individual but a poor fit/prone to leakage and uncomfortable by others.
Table 2.
Stated preferences for five disposable designs
| Design (Monthly cost, assumes 3 products/day) | Day – Men n = 49 | Design (Monthly cost, assumes 3 products/day) | Day – Women n = 36 | ||||
|---|---|---|---|---|---|---|---|
| % Ranking design 1st (top) | % Stating design is generally acceptable to them | % Ranking design 1st (top) | % Stating design is generally acceptable to them | ||||
| With cost not known | When cost disclosed (n = 45)* | With cost not known | When cost disclosed (n = 29)* | ||||
| All‐in‐ones (£43.70) | 43 | 49 | 86 | Pull‐ups (£78.80) | 61 | 59 | 95 |
| T‐shaped/belted(£75.50) | 25 | 16 | 84 | Inserts (£43.70) | 17 | 28 | 83 |
| Pull‐ups (£78.80) | 20 | 16 | 80 | All‐in‐ones (£43.70) | 11 | 7 | 56 |
| Washables (£7.00) | 6 | 13 | 51 | T‐shaped/belted(£75.50) | 11 | 7 | 42 |
| Inserts (£43.70) | 6 | 6 | 37 | Washables (£7.00) | 0 | 0 | 11 |
| Design (Monthly cost, assumes 1 product/night) | Night – Men n = 49 | Design (Monthly cost, assumes 1 product/night) | Night – Women n = 36 | ||||
| % Ranking design 1st (top) | % Stating design is generally acceptable to them | % Ranking design 1st (top) | % Stating design is generally acceptable to them | ||||
| With cost not known | When cost disclosed (n = 45)* | With cost not known | When cost disclosed (n = 30)* | ||||
| Washables (£5.95) | 53 | 56 | 82 | Pull‐ups (£25.50) | 53 | 47 | 92 |
| All‐in‐ones (£14.80) | 25 | 22 | 86 | Inserts (£22.60) | 19 | 30 | 77 |
| T‐shaped/belted(£25.15) | 10 | 13 | 61 | Washables (£5.95) | 11 | 10 | 25 |
| Pull‐ups (£25.50) | 8 | 4.5 | 50 | All‐in‐ones (£14.80) | 8.5 | 6.5 | 64 |
| Inserts (£22.60) | 4 | 4.5 | 22 | T‐shaped/belted(£25.15) | 8.5 | 6.5 | 53 |
*Some participants declined to repeat the ranking exercise after the costs of products had been disclosed.
Derivation of costs: There are many alternative products within each design group and considerable price variation amongst products. The costs used were based on retail/mail‐order prices prevailing in April 2005, because not all the products tested were provided through National Health Service Supply Chain. The cost of the most preferred product (of the three tested) in each design was used as the basis for the comparisons. For towelling washable items, costs allow for replacement at rates based on manufacturers’ data about product life (270 washes for absorbent product and 30 washes for plastic/fixation pants) and an assumption that users would hold stocks of 12 day products and six night products (to allow for laundry time). The laundry costs are not included.
Table 3.
Strengths and limitations of designs stated by 85 participants
| Design | Design strengths | Design limitations | ||||
|---|---|---|---|---|---|---|
| Number (%) of comments | Stated reasons, day and night* (in order of frequency) | Number (%) of comments | Stated reasons, day and night* (in order of frequency) | |||
| Women | Men | Women | Men | |||
| Pull‐ups | ||||||
| Day | 64 (40.8) | 52 (26.9) | Comfortable Easy change Like normal pants/discreet No leaks | 20 (11.0) | 45 (20.9) | Difficult to change (with trousers) Leaks |
| Night | 50 (41.3) | 37 (22.6) | 17 (13.6) | 39 (21.9) | ||
| Inserts | ||||||
| Day | 36 (22.9) | 26 (13.5) | Easy change No leaks Discreet Comfortable | 32 (17.6) | 54 (25.1) | Do not stay in place Leaks Bulky |
| Night | 18 (14.9) | 17 (10.4) | 27 (21.6) | 44 (24.7) | ||
| All‐in‐ones | ||||||
| Day | 27 (17.2) | 39 (20.2) | No leaks Easy change Comfortable | 41 (22.5) | 35 (16.3) | Bulk Difficult to change Tabs do not stick Sweaty/hot |
| Night | 18 (14.9) | 36 (21.9) | 24 (19.2) | 28 (15.7) | ||
| T‐shaped/belted | ||||||
| Day | 22 (14.0) | 47 (24.3) | No leaks Easy change Comfortable | 41 (22.5) | 28 (13.0) | Difficult to change Tabs/belt problems Leaks Uncomfortable |
| Night | 20 (16.5) | 26 (15.8) | 30 (24.0) | 34 (19.1) | ||
| Washables | ||||||
| Day | 8 (5.1) | 29 (15.0) | No leaks Comfortable Cheap Good to environment | 48 (26.4) | 53 (24.7) | Bulky Difficult to change Laundry Infantile |
| Night | 15 (12.4) | 48 (29.3) | 27 (21.6) | 33 (18.5) | ||
| Total | ||||||
| Day | 157 (100) | 193 (100) | 182 (100) | 215 (100) | ||
| Night | 121 (100) | 164 (100) | 125 (100) | 178 (100) | ||
*Strengths and limitations were similar for day and night use and are combined.
Responses to questions that probed the acceptability of products in different situations revealed that many participants would like to ‘mix and match’ the products they used. For example, women would like to have pull‐ups for going out and special occasions, when confidence is important, but could ‘make do’ with the less desirable but cheaper inserts at home. However, most participants reported that they were only supplied with one type of product through their continence services (data available elsewhere). 4
Shopping experiment
Seventy‐five participants (45 men, 60%) completed the shopping experiment and chose a large variety of different design combinations. On the simplifying assumption that subjects would change their pads three times during the day, they were asked to chose the combination of designs they would use (up to a maximum of three) from the five designs available. A total of 19, 21 and 16 different preferred combinations were recorded with the £75, £50 and £25 budgets, respectively (Table 4). As the budgets were reduced, a rising proportion of participants selected combinations of products (rather than three products of the same design). Gender differences in preferences are apparent, with larger proportions of women opting for pull‐ups and men more likely to select towelling washables, all‐in‐ones and T‐shaped/belted products (Table 4).
Table 4.
Shopping experiment: product combinations selected and amounts participants stated they were willing to spend (top‐up) or would save through their choices of products at different budgets
| Product cost for 28 items/uses (Range of possible monthly expenditure) | Monthly budget | N | No. of different product combinations chosen | Number (%) of participants selecting each combination, with gender breakdown (M = Male; F = Female) | Mean (SD)of savings (−)/top‐ups (+) from choices* at each budget | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3 Pull‐ups (£75) | 3 T‐shaped/belted (£72) | 3 All‐in‐ones (£45) | 3 Inserts (£42) | 3 Washables (£15) | Mix of any 2 products (£ varies) | Mix of any 3 products (£ varies) | ||||||
| Day Select any 3 products | Pull‐ups: £25 T‐shaped/belted: £24 All‐in‐ones: £15 Inserts: £14 Washables: £5 (Range: £15 to £75) | £75 | 45M | 19 | 21 (28.4) 5M, 16F | 9 (12.2) 8M, 1F | 14 (18.9) 14M, 0F | 6 (8.1) 2M, 4F | 3 (4.1) 3M, 0F | 18 (24.3) | 3 (4.0) | −18.68 (17.52) |
| 29F | ||||||||||||
| £50 | 45M | 21 | 8 (10.8) 3M, 5F | 7 (9.5) 6M, 1F | 20 (27.0) 16M, 4F | 12 (16.2) 4M, 8F | 3 (4.1) 3M, 0F | 19 (25.7) | 5 (6.7) | +0.99 (14.87) | ||
| 29F | ||||||||||||
| £25 | 45M | 16 | 7 (9.6) 3M, 4F | 5 (6.8) 4M, 1F | 10 (13.7) 9M, 1F | 17 (23.2) 5M, 12F | 5 (6.8) 4M, 1F | 27 (37.0) | 2 (2.7) | +18.55 (17.16) | ||
| 28F | ||||||||||||
| 1 Pull‐ups (£24) | 1 T‐shaped/belted (£24) | 1 All‐in‐ones (£20) | 1 Inserts (£14) | 1 Washables (£8) | N/A | N/A | ||||||
| Night Select 1 product | Pull‐ups: £24 T‐shaped/belted: £24 Inserts: £20 All‐in‐ones: £14 Washables: £8 (Range: £8 to £24) | £24 | 45M | 5 | 21 (28.0) 2M, 19F | 8 (10.7) 6M, 2F | 8 (10.7) 8M, 0F | 9 (12.0) 3M, 6F | 29 (38.7) 26M, 3F | N/A | N/A | −7.73 (7.24) |
| 30F | ||||||||||||
| £16 | 45M | 5 | 9 (12.0) 2M, 7F | 4 (5.3) 3M, 1F | 18 (24.0) 9M, 9F | 12 (16.0) 2M, 10F | 32 (42.7) 29M, 3F | N/A | N/A | −1.87 (6.24) | ||
| 30F | ||||||||||||
| £8 | 45M | 5 | 7 (9.3) 2M, 5F | 4 (5.3) 3M, 1F | 15 (20.0) 3M, 12F | 9 (12.0) 2M, 7F | 40 (53.3) 35M, 5F | N/A | N/A | +4.99 (6.14) | ||
| 30F | ||||||||||||
N/A, not applicable; 1 month = 4 weeks; 1 product = pack of 28 disposable items or 28 uses of washables.
*Choices may have resulted in a ‘saving’ (i.e. spending less than the allotted budget) or necessitated ‘top‐ups’ by participants (i.e. using own money).
At the high budget allocations, choices of lower‐priced designs resulted in savings, and conversely, at lower budgets, participants expressed a willingness to ‘top‐up’ from their own funds to afford the more expensive products. The average amounts saved at lower budgets and contributed at higher budgets are fairly evenly balanced (Table 4). Only seven people (9.3%) did not offer extra money to acquire the combinations of their choices. Trade‐offs were apparent: when the allotted day budget was £75, a total of 16 women stated a preference for three pull‐ups (total cost £75), but when the budget was reduced to £50, five of them opted for one pull‐up (£25) and two inserts (£14 each): a ‘top‐up’ of £3. The association between household income (reported by participants at baseline) and their willingness to pay out, or desire to save money, was explored for each budget and for day and night selections. Although no statistically significant correlations were found for any day budget, higher income was associated with a stated willingness to top‐up less within each night budget (n = 75; Spearman’s rho: −0.318, −0.268, −0.263; P = 0.005, 0.020, 0.023 for the £24, £16, £8 budgets, respectively).
Discussion
Community‐dwelling men and women with moderate‐to‐heavy incontinence in this study displayed varied preference patterns for absorbent products. Evidence from the shopping experiment suggests that it could be feasible for this group of users to manage a personal budget from which they would purchase their containment products according to their personal needs and preferences, and that such an arrangement would result in a different product utilization pattern from that occurring through the current centralized arrangements. When faced with budget constraints, up to 40% of participants opted for combinations of daytime designs, suggesting that individual budgets, giving people control over the range of products they use, would enable them to benefit from mixing and matching their designs to suit their own lifestyles. This is not generally possible with current practice within the British NHS, where product availability is usually controlled by continence services which purchase a limited range of products to make available to their clients.
Participants in the study indicated approximately equal propensities to ‘top‐up’ allocated budgets that were low, and save from more generous allowances. Many people in receipt of NHS products are used to ‘topping‐up’ their supplies because they are insufficient for their needs, or of an unsatisfactory quality. No association was found between stated willingness to ‘top‐up’ and income for day selections, but for night product choices, higher income was significantly correlated with a stated lower willingness to spend personal resources. This may be because towelling washables (the cheapest design) were the preferred product for over half of the male participants. Hence, their product of choice enabled them to make significant savings at the higher budget allocations and break even with the lowest allowance.
Recent policy has sought to make the NHS more responsive to the needs and wishes of consumers, and initiatives that extend and enable choice of non‐emergency care have been central to this endeavour. 14 , 15 , 16 In social care, the choice agenda has been advanced through direct payments to patients so they can choose their service providers, or individual budgets, which combine resources from different agencies so clients can select services in collaboration with their case managers. 17 Both are designed to provide services tailored to personal needs and preferences. Although take‐up in the UK has been relatively low, evidence from Europe, North America, Australia and New Zealand shows that clients appreciate the choice, autonomy and control that comes with such schemes. 6 Additionally, they help to ensure value‐for‐money and to control costs. 6 Independent evaluation of pilot individual budget schemes in the UK identified some challenges for staff associated with shifts in culture, roles and responsibilities, but clients reported benefits including improved quality of services. 18 The extension of the concept of personal budgets to health care is being promoted, 7 , 8 and purchase of incontinence supplies might be one area where such a scheme could be applied.
Providing individual budgets to community‐dwelling men and women with incontinence who would like to control the purchase of their own supplies could improve patient satisfaction and result in a more efficient allocation of NHS funds in this area. By aligning expenditure more closely with users’ preferences, the value‐for‐money obtained from the limited resources could be improved. A further advantage would be that increased demand for more expensive products (such as pull‐ups) might enable manufacturers to realize economies of scale in production and pass lower costs onto consumers. The market for absorbent products is large and competitive, so individual budgets may give further incentive to manufacturers to develop products that meet consumers’ needs and preferences at affordable prices. Whilst central management costs may be increased by running a service that offers greater choice of products direct to users, this may be offset by the reduced administrative burden on local continence services that individual budgets would bring.
Implementation of such a scheme would require certain safeguards to be put in place for consumers. Guidelines would be needed to ensure that local continence service budgets were set appropriately and administered equitably. It would also be important that consumers could purchase supplies from NHS Supply Chain (either directly or through the brokerage of their local continence service), so they were obtained as cheaply as possible. Consumer involvement in governance of Supply Chain could help regulate prices and quality of service, ensure effective distribution of information and enable preferences to be met through the addition of new products to the range that is currently available.
The research reported in this paper is limited in several ways. The sample size was relatively small, and it is difficult to know how well the participants in this study are representative of all community‐dwelling men and women with incontinence. Although all participants had tested all products, the preferences they expressed at the final interview and shopping experiment (up to 9 months after they had started testing the first design) could have been affected by recall bias. Product development means that the characteristics and availability of individual products change over time, but the designs are much more stable. However, market changes mean that relative prices can alter. There is high variation in prices for given designs, and different relative prices could have been used in the study. Participants already found completion of data collection burdensome, and it was not possible to conduct a sensitivity analysis of preferences around different relative prices.
Despite these limitations, the findings confirm the diversity of design preferences of absorbent product users and provide justification for increasing individual choice in healthcare systems where this is restricted. Further research is warranted to ascertain the extent to which individual budgets are workable and beneficial for people with incontinence in the British NHS.
Source of funding
This paper derives from work conducted as part of the NIHR Health Technology Assessment programme, project number 01/11/02. The views and opinions expressed are those of the authors and do not necessarily reflect those of the Department of Health.
Conflict of interest
None declared.
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