District nursing’s survival is vital to a modern healthcare system

Once predicted to be facing ‘extinction’ by the RCN, is the value of nursing in the community starting to be recognised? A new think tank aims to find out.

Once predicted to be facing ‘extinction’ by the RCN, is the value of nursing in the community starting to be recognised? A new think tank aims to find out.

  • Despite a greater commitment to district nursing, numbers are still down
  • Wales wants to extend safe staffing legislation in district and community nursing and health visiting
  • Think tank the International Community Nursing Observatory has been launched to communicate the value of district nursing
Is the role nursing plays outside of hospitals finally being recognised? Picture: Science Photo Library
Is the district nursing role finally being recognised?
Picture: Science Photo Library

Five years ago, the RCN warned that district nursing was facing ‘extinction’ by 2025 as staff numbers were declining so alarmingly. Despite successive governments pledging to shift the focus of care from hospital to community, sufficient funding has not followed and the staffing crisis has gone from bad to worse. 

Six months ago, a joint report by the RCN and the Queen’s Nursing Institute, Outstanding models of district nursing report, stated that the number of district nurses working for the NHS in England had plummeted by 43% over the last decade, leaving 4,000 district nurses to care for a population of around 55.8 million people. 

The picture in Scotland and Northern Ireland is slightly better but they too have faced staffing pressures, as has Wales, despite being considered something of a district nursing trailblazer.

But perhaps there are signs of change and the prospects for the district nursing workforce may not be as bleak as feared. One new development is the launch of the International Community Nursing Observatory to build an evidence-based case for district nursing’s value.

Neighbourhood nursing and safe staffing in Wales

Wales chief nursing officer Jean White
Jean White. Picture: David Gee 

Wales is halfway through a £1.2 million scheme testing the Buurtzorg model, a Dutch system of neighbourhood nursing with a focus on continuity of care delivered by a small team of nurses.

The scheme, which aims to bolster the leadership role of district nurses, is being tested with three different populations: urban (Aneurin Bevan University Health Board), rural (Powys Teaching Health Board) and the valleys (Cwm Taf Morgannwg University Health Board).

Wales chief nursing officer Jean White says the initiative is part of a drive to take a more evidence-based approach to healthcare. She told the recent annual Queen's Nursing Institute conference in London that Wales (the first UK country to introduce safe staffing legislation) was hoping to extend the Nurse Staffing Levels (Wales) Act 2016, which applies to surgical and medical wards in hospital, to other areas including district and community nursing as well as health visiting. 

She says: ‘Too many people think the Safe Staffing Act is all about numbers. But it’s about models of care and managing that care around the needs of the patient.

‘If we can’t get care right in the community and continue with our obsession with hospitals, we are not going to be able to make the step change we need to transform patient services.’


Positive change in direction for district nursing

Queen's Nursing Institute director Crystal Oldman
Crystal Oldman. Picture: Kate Stanworth

Meanwhile, the sixth QNI UK district nursing audit has reported a 19% increase in the number of students signing up for the district nurse specialist practitioner qualification (SPQ) in 2017-18 compared to the previous year. The number of district nurses qualifying with the SPQ in 2018 was up 8% compared to 2017.

QNI director Crystal Oldman says she is ‘upbeat’ about the future. She feels a concerted effort from the QNI and the RCN to fight district nurses’ corner is at last having an effect and that addressing the service’s long-standing problems is finally being viewed as a priority.

‘The evidence has been there for some time, but there’s a real sense now of a listening culture at the top and that’s a big change,’ says Dr Oldman. ‘Senior people are asking questions that have not been asked for a number of years.’

One example of the shift in focus is the announcement from Health Education England of £18.5 million to fund the SPQ for 2020-21.

There were fears that, because of a switch from a 12-month full-time programme to a two-year apprenticeship model, with no interim arrangements, no new district nurses would qualify in 2021. Nursing organisations predicted this would lead to a ‘catastrophic’ staffing shortfall. 

Dr Oldman says the announcement is welcome and timely. 

‘Having the guaranteed SPQ district nurse funding so early in the cycle means that recruitment and retention can start in plenty of time to fill places,’ she says. ‘It’s brilliant news for the future of district nursing.’

Benefits of the specialist practitioner qualification

Community nursing consultant  Agnes Fanning
Agnes Fanning. Picture: David Gee

Independent community nursing consultant Agnes Fanning also welcomes the extra funding to help smooth the transition to the apprenticeship model.

Dr Fanning carried out a study for the QNI that led to the Outstanding models of district nursing report, and she is concerned about current trends.

‘The Nursing and Midwifery Council is reviewing post-registration qualifications and that has put a question mark over the SPQ, which is a worry for those of us who are passionate advocates of retaining the qualification. We’re too good a service to be forgotten,’ says Dr Fanning. 

‘The SPQ gives nurses a real understanding of the pressures in the community where you are working with teams and going into patients’ homes, not knowing what you will be confronted with. You have to think on your feet and when preparing people for that it’s important they are given the time to absorb all that training.

Too many commissioners do not know what district nurses do

‘When the apprenticeship courses start next year it’s important nurses get the right experience. I would like to see a place for the 12-month full-time SPQ as well as the two-year apprenticeship.’  

Dr Fanning’s study found some trusts were sending staff on short internal courses on management instead of the SPQ programme. 

‘But all that does is give them a siloed view of leadership, not the strategic grasp of the bigger picture that they get with the SPQ,’ she adds. 

‘Part of the problem is that too many commissioners just do not know what district nurses do’.

A think tank for district nursing

London South Bank University’s Alison Leary is leading the International Community Nursing Observatory
Alison Leary. Picture: David Gee

The International Community Nursing Observatory (ICNO) has been launched by the Queen’s Nursing Institute as part of its commitment to an evidence-based solutions-focused approach to healthcare. 

The initiative is being led by Alison Leary, chair of healthcare and workforce modelling at London South Bank University, who says she views running ICNO as an ‘exciting opportunity to draw a line round issues such as the link between safety and size of caseloads’.

One of the first studies from the new think tank will consider that million-dollar question: ‘How big should a caseload be?’

Professor Leary says there is an issue with policymakers and employers failing to fully understand the safety critical nature of their workforce.

‘There has been a big gap in the intelligence leading to decision-making on workforce, which QNI has largely been filling. We are launching the observatory as a three-year project to gather data that can inform strategic decision-making’.

The ICNO will provide data on whether district nurses are able to deliver good quality care under the current stretched and stressful conditions they are working under.

‘If you try to model nursing it’s complex. And district nursing is some of the most complex work of all’

Alison Leary, International Community Nursing Observatory

‘The thing about professional nursing is, it’s only appreciated when it’s not there,’ says Professor Leary. ‘People who plan the workforce view nursing as a series of tasks to be completed, but if you try to model nursing it’s much more complex. And district nursing is some of the most complex work of all.’

She adds that it is also a concern that workload is something few employers look at. 

‘District nurses are doing unpaid overtime because commissioners don’t look at the real demands on district nurses,’ she says. ‘If you don’t understand demand there’s no way you can do supply. They are looking at supply in terms of how many people they can afford, not how many nurses they need.’

Professor Leary believes the health service is failing to learn the lessons of the past, from the Ely Hospital scandal in 1967 (involving ill-treatment of patients with learning disabilities) to the failings highlighted in the Mid Staffs Inquiry in 2013.

‘Poor care costs, but we’re not good at articulating that. Those running the service make cuts and imagine they’re saving money, but it’s not a good saving,’ says Professor Leary. ‘We have no agreed language on what nurses do. People in different areas describe it in different ways and too many nurses tend to minimise their role and undersell themselves. 

‘My vision for the ICNO is that it will play a pivotal role in moving the conversation on and, through the use of evidence, articulate what nurses do and how they affect outcomes.’


Crucial to delivering the NHS Long Term plan

RCN district nursing forum chair Julie Green’s study of the District Nurse Specialist Practitioner Qualification found it could be ‘transformational’
Julie Green

Julie Green, chair of the RCN district and community nursing forum and dean for education and director of postgraduate programmes at Keele University, carried out a study of the SPQ in 2017 and found that it had a ‘transformational’ impact on nurses.

‘After completing the SPQ, nurses can lead teams and manage complex caseloads and complex patients,’ she says. ‘It’s a wonderful course but it’s also highly challenging. It covers leadership, research, prescribing, health assessment and long-term condition management. If you fragmented that by delivering training through separate modules it would be a real loss.’

Dr Green describes district nursing as ‘an up-to-date acute service but for patients at home’.

‘We’re seeing much sicker patients at home and giving them an extra quality of service from ventilation to intravenous medication,’ she says.

She adds that district nursing is ‘no longer the traditional service of years ago’ and says she believes that district nurses hold the key to delivering on the NHS Long Term Plan and its commitment to shift focus from hospital to community care.

‘District nursing has been chronically underfunded for years, yet we are the people who can take the NHS Long Term Plan forward, building a partnership with patients to encourage them to self-manage and stay out of hospital,’ Dr Green says. 

‘When my students finish the SPQ they’re working in teams that are stretched. We need the investment if we are to deliver.’

She adds: ‘When the RCN predicted extinction for district nursing we were basing it on the downward trends we were seeing. Extinction was how it looked then, but I’m hopeful that there are signs that we may just be able to turn that tanker around and avoid disaster.’ 

Janet Snell is a health journalist

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