District nursing in England is in a “dire state” and unless the situation is addressed the government’s vision in the 10 year plan of more NHS care in the community is unachievable, warn the Nuffield Trust in a new report.
A failure to invest in district nursing services over many years has left it in a “state of crisis”, just when it is needed as a “cornerstone of community healthcare.” The Nuffield Trust called for the situation to be “ urgently addressed” adding that restoring the service to 2009 levels, relative to the current population, could cost £376 million.
Commenting on the report, Steph Lawrence, CEO of the Queen’s Institute of Community Nurses (QICN) noted that the “District Nursing workforce has been overlooked by policy makers for too long. If the 10-year plan and shift of care from hospital to community is to be realised, urgent action is required, as it will not happen without a robust District Nursing workforce.”
Adding that the government must regard this decline in district nursing as “a critically urgent issue” with increased funding needed to train District Nurses.
Huge decline in staffing
From 2009/10 to 2023/24, the district nursing care workforce decreased by 43%, according to the think tank’s analysis, and when adjusted for rising patient needs, that figure is closer to 55%. This decline is equivalent to losing roughly 4,200 full-time-equivalent district nurses.
During the same period, demand for district nursing increased by 24%, and with projections indicating a further rise of 34% over the next 15 years due to an ageing population, doubts emerge about the capacity to move more care into the community if the service is not expanded.
Thea Stein, CEO of the Nuffield Trust, wrote in the HSJ:
“Much of the 10YHP’s ambitions to have more care closer to home revolve around its intentions for neighbourhood health teams, but without urgent intervention on district nurses, that part of the plan risks being a failure. One of the few health professionals who operate in and out of people’s homes, district nurses are already essential members of community neighbourhood teams. Yet with their numbers decreasing, things are going the wrong way.”
District nurses work in homes, care homes, and clinics, managing long-term conditions, supporting patients, and providing palliative care. Operating 24/7, they serve thousands, helping prevent hospital admissions and aiding discharges. Their community-based role also supports the government’s goal to prevent ill health and ease pressure on GPs and social services.
District nursing saves NHS money—costing an average of £57 per face-to-face visit compared to £112 at A&E and £2,245 for hospital admission. However, the workforce is struggling to meet rising demand. NHS contacts dropped from 32 million in 2009/10 to 29.2 million in 2023/24, despite the population growing by 11% and the need by 24%. Many nurses also report doing more than 7 hours of unpaid work each week.
Uneven access
The report also shows a postcode lottery of nursing staff; the relative number of staff recorded in district nurse roles is significantly higher in the North West (13.7 nurses per 100,000 needs-weighted population) than in the East of England (2.8), the South East (3.3) and the South West (4.4).
Another issue highlighted by the report is a change in the skill mix of district nursing teams, with fewer nurses and more lower-skilled staff, such as health care assistants. In 2009, 18% of staff in district nursing services were not nurses; by 2024, this had risen to 28%, with particularly low proportions of nurses in some NHS regions, including the South East.
The report criticises the NHS in England for failing to train enough district nurses, citing limited course places, budget cuts, and staffing shortages that hamper recruitment. Poor staff retention is also an issue, driven by low pay, lack of career growth, and heavy workloads. Additionally, a lack of data on district nursing activity hampers funding decisions, with some tasks, like providing support to families after a patient’s death, difficult to record or code.
Commissioning and funding have also been made more difficult over the last 14 years by the tendering of contracts to non-NHS organisations. Community health services are now fragmented, notes the report, being provided by a large number of organisations, including independent/private providers, hospices, care homes, charities, local authorities and community interest companies or voluntary, community and social enterprises.
This combination of insufficient data and service fragmentation makes contract and funding decisions difficult.
With district nursing services being essential to the shift from hospital to community care, the Nuffield Trust has made recommendations on training, retention, and integration, and called for investment. However, the report highlights that asking ICBs to cut their operating costs by 50% rapidly leaves them with less capacity to implement the strategic changes needed to support the move of care into the community.
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