Mounting pressures on district nursing laid bare in new report

District nursing services help people receive care in their own homes, but pressures are compromising quality warns research from health think tank The King’s Fund.

District nursing services help people receive care in their own homes, but pressures are compromising quality warns research from health think tank The King’s Fund

A new report offers comprehensive evidence on the state of district nursing and urges NHS leaders to recognise the vital, strategic importance of the service.

By far the most significant obstacle to delivering good care is the ‘profound and growing’ gap between the demands on the service and its capacity to meet those demands, it says.

‘Our research indicates activity has increased over the years, both in terms of the number of patients seen and the complexity of care provided,’ says The King's Fund.

Staff well-being


Approximate proportion of NHS spending on community health services in England in 2014-15 on district nursing – about 2% of the total NHS budget

It offers examples of an increasingly task-focused approach to care; staff being rushed and abrupt with patients; reductions in preventive care and lack of continuity of care.

‘This is having a deeply negative impact on staff well-being, with unmanageable caseloads common and some leaving the service as a result.’

One district nursing team leader is quoted as saying nurses end the day ‘completely exhausted and drained’.

‘Sheer exhaustion – people are just in tears, people are broken,’ says another.

Recruitment and retention

Annual NHS workforce statistics show a 48% drop in the number of full-time equivalent (FTE) district nurses between September 2000 and 2014 in England. Monthly workforce releases suggest that this decline is continuing: the number of FTE district nurses fell by 13.6% between March 2014 and 2016.

These figures show that recruitment and retention is a key challenge. One district nursing senior manager says: ‘There is just not enough time in the service: people are working a lot of unpaid extra hours and becoming very stressed and tired.

‘We have a lot of sickness and we have had a lot of turnover.’

Unfair blame

Staffordshire and Stoke-on-Trent Partnership NHS Trust district nurse manager Vicki Smith agrees the demands of the service are leaving nurses frustrated and demoralised.

Vicky Smith
District nurse manager Vicki Smith. Photo: Neil O'Connor

‘They go in and complete tasks to keep patients safe but they are not giving the extra they want to give – morale in the community nursing sector is really low.’

Ms Smith believes the community sector is often unfairly blamed for crises in the acute sector, such as lack of beds, when blame lies with a lack of resources in district services.

‘District nurses see a lot of funding aimed at acute care, which has come off the back of the Francis Report, but there is a corresponding lack of services in the community.

‘People often work longer hours than they should and from a morale point of view, given the increased demand, they are on a knife edge.’

Other barriers to high quality care raised by district nurses in the report include:

  • Challenging working – cramped or unclean – environments.
  • Unpredictable appointment lengths due to unexpected deterioration in patients’ conditions.
  • Poor planning or communication from hospitals and others, particularly around discharge.
  • Unpredictable travel time between appointments.

A key message in the report is district services do not operate in isolation.

Negative implications

Reductions in quality or volume of care may have significant negative implications for the wider health and care system.

Between 2005 and 2014

The number of people in England aged above 65 increased by almost one fifth; by 2035 this number will accelerate and increase by almost half

Queen’s Nursing Institute (QNI) chief executive Crystal Oldman says: ‘We have been flagging these issues for some time.

‘Where can that funding and capacity be released from?

‘If there is no new funding, decisions have to be made about decommissioned hospital beds and investing in the district nursing service.’

Dr Oldman also reiterated the importance of the district nursing specialist practitioner qualification, which she says is ‘critical’ to the management of the service.

The King’s Fund recommends several antidotes to the problems threatening to overwhelm the service including:

  • Matching stated intentions to move care into community settings with: direction of resources, monitoring and oversight and new care models.
  • Involving district nursing service leaders in local plans for service redesign.
  • Establishing robust national data on capacity and demand in district nursing services.
  • Developing a meaningful form of oversight for care delivered in people’s own homes, such as the framework proposed in report.
  • Accelerating uptake in digital technologies to help support district nurses.
  • Urgent action to reverse current trends in the workforce.

NHS Improvement executive director of nursing Ruth May acknowledges the essential role district nurses play.

Half of district nurses in England plan to retire within 10 years, and the community nursing workforce has an older age profile than the rest of the nursing workforce

‘In many cases, being treated in the community is not only more appropriate for the patient, but reduces demand on overstretched hospital services, such as emergency departments,' she says.

‘We want to support district nurses to make sure they can continue to deliver quality care to patients in their homes across England.’

Deputy chief nursing officer for England Hilary Garratt recognises the pressures many district nurses are feeling and says work is ongoing to recruit and retain staff in the field.

District nurse Candice Pellett, a transition project manager at QNI, is optimistic: ‘I feel 2017 will be the year for district nursing to be recognised.’ 

A quality framework for district nursing

To aid the development of national oversight systems for district nursing, The King’s Fund has created A Quality Framework for District Nursing.

This has arisen from interviews with patients, carers and staff, who have a strongly aligned view of what constitutes good care.

The King’s Fund says the framework should be developed for assessing and assuring the quality of care delivered in community settings.

Policy researcher Anna Charles says: ‘At its best district nursing offers an ideal model of person centred, preventive, community-based care.’

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