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Why we need an improvement resource for the district nursing service

Independent charity the Queen's Nursing Institute has been working towards providing a safer enviroment for staff in community settings.

The Queen's Nursing Institute (QNI) has been closely involved in work around safe staffing in community nursing in recent years. As an independent charity, unconnected with employers or unions, we offer expert and objective evidence informed by consultation with practitioners, including members of our national network of Queen’s Nurses.


Questioning the safety of staff in community settings is still prominent today. Picture: Alamy

The issue of safe staffing achieved national importance after publication of the Robert Francis’ 2013 report into care failings at Mid Staffordshire NHS Foundation Trust and subsequent debates around whether setting a maximum number of patients per registered nurse on a hospital ward was necessary or desirable. The same question is as pertinent for community nursing, most delivered in people’s homes, often without supervision by a district nurse specialist practitioner.

Follow-up failures

NHS England’s Five Year Forward View, published in 2014, called for more care to be moved into the community setting. However, to date this has not been followed by major investment in or reallocation of staff or other resources. In fact, falling numbers of qualified district nurses have led to teams that now have much higher ratios of unregulated staff.

District nursing services often act like a sponge, absorbing additional work in an environment without the physical limits of having a defined number of beds on a ward. To remedy this, some community services began to speak in terms of numbers of beds their teams manage, in the hope of helping commissioners compare their volume of work to that in the hospital environment more easily.

Modelling demand for the district nursing service is important for current services, but crucially also to plan for the future, taking into account population health, demographics and opportunities for remote monitoring and supported self-care. Despite this, there is a lack of robust data about how to measure and predict what a ‘safe caseload’ is, which has led to uncertainty among commissioners, service providers and team leaders.

Predicting needs

In 2014, we published a district nursing workforce planning report commissioned by NHS England. This drew attention to the many variables that can affect safe levels of staffing in the community and the importance of measuring them, to predict current and future staffing needs. It argued for the creation of standardised workforce planning tools and locally adjustable operational scheduling tools.

Last year, we published a discussion document, Understanding Safe Caseloads in the District Nursing Service, which develops this earlier work by providing a thematic overview of the issues that should be taken into account when determining a safe caseload. These included: patient need; complexity of care required; rate of hospital discharge; skill mix in the team; capacity of other services; use of technology; and local geographic factors, such as housing.

The document summarises the challenges in managing safe caseloads in the district nursing service, and points to specific actions the QNI believes are necessary to improve and safeguard quality. A useful piece of evidence in this context is Understanding Quality in District Nursing Services, published by the King’s Fund, but significant work is still required to establish a standardised way of predicting patient need and to achieve desired clinical outcomes.

Looking ahead

Bringing us up to date, I have been chairing an NHS Improvement working group that has consulted widely on the issues of safe staffing in the district nursing service. The draft improvement resource, published for consultation earlier this year, builds on research by the National Institute for Health and Care Excellence and will be useful to anyone involved in providing, leading, managing or commissioning district nursing. At the time of writing, it is anticipated that the final document will be published by NHS Improvement and NHS England by the end of this month.

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About the author

Crystal Oldman is chief executive of the Queen's Nursing Institute

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