Analysis

Pressures on district nursing affecting quality, says King's Fund

The decline in district nurse numbers is well known. A fall of 48% between 2000 and 2014 has seen numbers drop below 6,000 full-time roles in England.
community nursing

The decline in district nurse numbers is well known. A fall of 48% between 2000 and 2014 has seen numbers drop below 6,000 full-time roles in England. The wider community nursing workforce has also been hit after a period of growth. Since 2009, numbers have fallen by 8% to just over 36,600.

This trend has once again been highlighted by a Kings Fund (2016) report, but through interviews with staff, managers and patients the think tank has also uncovered what goes on behind closed doors.

36,683

Nurses working in community services in England an 8% drop since 2009

The report makes grim reading. It described the workforce as being broken, exhausted and on their knees.

Older patients told researchers staff could sometimes appear rushed and rude, and there is lack of

...

The decline in district nurse numbers is well known. A fall of 48% between 2000 and 2014 has seen numbers drop below 6,000 full-time roles in England. The wider community nursing workforce has also been hit after a period of growth. Since 2009, numbers have fallen by 8% to just over 36,600.

community nursing
Nursing in the community. Photo: Science Photo Library

This trend has once again been highlighted by a King’s Fund (2016) report, but through interviews with staff, managers and patients the think tank has also uncovered what goes on ‘behind closed doors’.

36,683

Nurses working in community services in England – an 8% drop since 2009

The report makes grim reading. It described the workforce as being ‘broken’, ‘exhausted’ and ‘on their knees’.

Older patients told researchers staff could sometimes appear rushed and rude, and there is lack of continuity of care, delays and less frequent visits.

One said: ‘It doesn’t seem there is a personal touch there now. It’s jim, jam, thank you ma’am, see you.’

Complex care

The report points out the service is responsible for providing treatments – managing chemotherapy, wound drains and tracheostomies – that were once the preserve of hospitals. The result is a service that is too ‘task orientated’ and where lower priority help, such as wound care or prevention and education, slips.

This is made clear by the story of one district nurse who told the King’s Fund how she kept going back to a patient who had a leg ulcer that would not heal.

‘I would go in, do the leg and leave. But it got to the point where I started saying to myself “Why is that not healing, what’s happening?” So I spoke with her.’

The nurse found the wound kept opening because the patient was alone and trying to reach a top cupboard to prepare her meals. The food was moved to a lower cupboard and the wound got better.

‘It was such a simple thing – you just need to sit down and talk,’ she concluded.

Proving difficult

But, unfortunately, in the modern health service, time to talk is proving difficult. Set time slots mean it is 'constant run, run, run, run, run', in the words of a community nurse quoted in the report.

Queen's Nursing Institute (QNI) chief executive Crystal Oldman says such sentiments are not surprising. Her organisation has just produced a report on safe staffing, which warns nurses are 'overstretched' and 'struggling to cope.'

‘The issue of safe caseloads has been a growing concern to district nurses in recent years and we receive more questions on this subject than any other,’ she says.

Managers acknowledged that it was only the ‘dedication and goodwill’ of staff that was keeping the service going in some places. But, as the King's Fund report pointed out, there is a limit to how far nurses can, and will, go.

5,667

District nurses in England – a 48% drop since 2000

Recruitment and retention are problems with the vacancy rate running at between 15% and 20% across community nursing teams. But it is not just in people’s own homes that the effect is felt.

Independent nurse consultant Deborah Sturdy, nurse adviser to Care England, says nursing homes are missing out too. They have also struggled to retain nurses and have found that the community services they used to call on are no longer there.

The result is rising rates of hospital admissions. ‘It’s a vicious circle. You cannot see this in silos,’ she says.

‘It leaves those nurses who are working facing difficult professional dilemmas. They can only spend the bare minimum of time with patients, meeting their immediate needs rather than spending the time they really need to provide proper care.’

'Professional risks'

Cliff Kilgore, a nurse consultant in intermediate care and chair of the British Geriatrics Society nurses and allied health professionals group, says it is getting to the point where there is a ‘professional risk’ to nurses as well as patients. 

15% to 20%

Vacancy rate in community nursing teams

He believes district nursing has become a victim of its ‘can-do’ culture. ‘They are the ones who have been looking after patients when they are most in need – caring for them when social care is not available, providing end of life care and meeting the needs of people with long-term conditions in the community. 

‘Such a mentality can be positive, but it can also be their undoing. At times they need to say no to care that should be delivered by others.’

The solution

Increased investment is the obvious answer – as the King’s Fund points out, district nursing gets just 2% of the NHS budget. But the think tank also said NHS bosses must do more to acknowledge the ‘strategic importance’ of district nursing, reverse declining staff numbers and develop a robust way of measuring resources, activity and workforce.

It contrasted how little is known about the care being provided compared to what happens in the hospital sector.

The King’s Fund also set out a number of priorities for good care:

  • Caring for the whole person.
  • Continuity of care.
  • Personal manner of staff.
  • Predictability and reliability of visit times.
  • Ability to contact services between appointment times. 

Much of this is dependent on workload. The typical district nursing team covers a population of 5,000 and includes two district nurses, five registered nurses, one community matron and two support workers, along with one clerical/administrative staff member. 

But there is also much variation. For example, 16% of teams have no district nurses, 38% no clerical support and 43% no community matrons.

This lack of consistency makes planning workloads tricky, says the QNI. Its report stopped short of recommending an ideal caseload as the complexity of cases was just as important as patient numbers.

The QNI says careful consideration needs to be given to patient profile, skill mix of the nursing team, geography of the area and duration of cover expected, which is dependent on GP out-of-hours services. 

It also adds that the impact of other services is important, including the number of residential homes and nursing homes in the area. 

So will the recommendations be heeded? NHS England says they already have been.

Deputy chief nursing officer Hilary Garratt says efforts are under way to help attract nurses back to the sector and train more, citing the 502 district nurse training places made available last year, a 16.5% rise on the previous year.

‘We recognise the hard work of district and community nurses and the pressures many are feeling.

‘It is why the NHS continues to work with others, including Health Education England.’

 


Further information

King’s Fund (2016) Understanding Quality in District Nursing Services

Queen’s Nursing Institute (2016) Understanding Safe Caseloads in the District Nursing Service


Nick Evans is a freelance journalist

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