Comment

Protect patients against the pressures on district nursing by supporting staff

Kings Fund researcher in policy Anna Charles describes a worrying picture of a declining workforce
pressures on district nursing

King's Fund researcher in policy Anna Charles describes a worrying picture of a declining workforce

There is a profound and growing gap between capacity and demand in district nursing, jeopardising the quality of patient care.

It is notoriously difficult to accurately measure activity and track workforce trends in community health services. But despite their limitations, available sources paint a worrying picture of declining community nurse numbers with a particularly dramatic drop among those in senior district nurse posts.

Meanwhile, in the context of a service that plays a key role in caring for frail, elderly patients and people living with chronic conditions, it is clear that demand has risen, even if it isnt possible to precisely track this change.

Over the last year, The Kings Fund has conducted research to develop a more detailed understanding of

...

King's Fund researcher in policy Anna Charles describes a worrying picture of a declining workforce

There is a profound and growing gap between capacity and demand in district nursing, jeopardising the quality of patient care. 

pressures on district nursing
Pressures on district nursing. Photo: Alamy

It is notoriously difficult to accurately measure activity and track workforce trends in community health services. But despite their limitations, available sources paint a worrying picture of declining community nurse numbers with a particularly dramatic drop among those in senior district nurse posts. 

Meanwhile, in the context of a service that plays a key role in caring for frail, elderly patients and people living with chronic conditions, it is clear that demand has risen, even if it isn’t possible to precisely track this change.  

Over the last year, The King’s Fund has conducted research to develop a more detailed understanding of pressures facing district nursing, and what this means for its staff and the patients who rely on them. 

We found services struggling to cope with a substantial increase in the number of patients requiring care, and increasing complexity and intensity of the work.

These pressures were compounded by significant workforce challenges, with issues in recruitment, retention, staff-turnover and skill-mix. 

Strategies in place   

Services have adopted a range of measures in response. These include considered strategies to improve efficiency, many of which seemed positive in terms of their potential to sustain or improve patient care.

Examples include greater use of technology, adopting evidence-based clinical pathways, working closely with other local health, social care and voluntary sector services, and ensuring appropriate triage of referrals by senior staff. 

Worryingly, we also came across examples of short-term survival strategies that could negatively impact on quality of care. These include increasing reliance on agency staff and cutting back non-clinical activities that promote and assure quality, such as staff training and joint visits. 

Despite efforts to improve efficiency and the huge commitment of staff, who are routinely working additional unpaid hours, quality of patient care appears to be suffering: we found examples of an increasingly task-focused approach, reductions in preventive care and a lack of continuity.

This is having a deeply negative impact on staff wellbeing; we heard of staff being ‘exhausted’, ‘broken’ and ‘on their knees’.

This situation has arisen despite the long-stated policy ambition of offering more care closer to home. But to keep pace with rising demand – and deliver more high quality and effective care - surely we need more staff, not fewer, to deliver it? 

Recognising the importance of services

A crucial first step in addressing these issues is for system leaders to recognise the vital importance of community services. With the NHS under unprecedented financial pressure, the temptation will be to renew the focus on hospitals to bring down deficits and improve performance against headline-grabbing targets. 

But this is counter-productive. Urgent attention is needed to reverse the downward trend in staff numbers, and community services must be central to new care models and Sustainability and Transformation Plans. 

In the meantime, what can be done at the frontline? A key finding from our research was the strong alignment between the views of nurses and patients about the components of ‘good’ district nursing. 

Based on this consensus, we have developed a framework, which can be used by staff to reflect on local practice, and we hope this offers a useful resource for local services to assess and improve the quality of care they provide. 

In addition, managers should ensure that activities designed to support staff - such as training, management and clinical supervision – are protected wherever possible. 

District nursing services are a lifeline for many people; to protect the quality of this care, it is essential to also protect the wellbeing of the staff we rely on to deliver it. 


About the author

Anna Charles

Anna Charles is health policy researcher for The King's Fund

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