Quality of district nursing care under threat

Unmanageable caseloads and shortages of staff in district nursing services are compromising quality of care for some patients according to a new report from The King’s Fund.

District nursing services are a lifeline for many people, providing vital care for patients in their homes. Interviews with patients and unpaid carers, conducted for this report, have highlighted the key role that these services play, and their value for many people living with complex health and care needs.

Although government policy is for more care to be delivered by these types of services, new research carried out for the report found district nursing at breaking point due to a profound and growing gap between capacity and demand.

Although limitations to national data make it difficult to establish a robust account of changes to activity and staffing, the report draws together a range of evidence to show:

  • Activity has increased significantly in recent years both in terms of the number of patients seen and the complexity of the care provided.
  • Available data indicates that the number of nurses working in community health services has declined over recent years, and the number working in senior ‘district nurse’ posts has fallen dramatically over a sustained period.

The report highlights that these pressures are compromising quality of care for some patients; the researchers found evidence of an increasingly task-focused approach to care, staff being rushed and abrupt with patients, reductions in preventive care, visits being postponed and lack of continuity of care.

Although some aspects of staff shortages are being managed well, services are generally over-stretched and heavily reliant on staff good-will. The researchers found that this is having a deeply negative impact on staff wellbeing, with unmanageable caseloads leading to fatigue, stress and in some cases ill health. They heard reports of staff being ‘broken’, ‘exhausted’ and ‘on their knees’, with some leaving the service as a result.

The report makes three key recommendations to address the problems in district nursing services:

  • System leaders must recognise the vital strategic importance of community health services in realising ambitions for transforming and sustaining the health and social care system.
  • There is an urgent need to create a sustainable district nursing workforce by reversing declining staff numbers, raising the profile of district nursing and developing it as an attractive career.
  • Robust mechanisms for monitoring resources, activity and workforce must be developed alongside efforts to look in the round at the staffing and resourcing of community health and care services for the older population.

The report also found that staff, patients and carers have a strongly aligned view of what constitutes good quality care. It sets this out as a framework, which it argues should be developed for assessing and assuring the quality of care delivered in community settings.

Anna Charles, Policy Researcher at The King’s Fund said:

“At its best, district nursing offers an ideal model of person centred, preventive, community-based care. For years, health service leaders have talked about the importance of providing more care in the community, but this objective cannot be achieved when district nursing is at breaking point and a poverty of national data means the quality of services is not properly monitored.

“It is worrying that the people most likely to be affected by this are often vulnerable and also among those who are most likely to be affected by cuts in social care and voluntary sector services. It is even more troubling that this is happening ‘behind closed doors’ in people’s homes, creating a real danger that serious failures in care could go undetected because they are invisible.”

Notes to editors: 

1. For further information contact Hetty Crist, Interim Head of Press and Public Affairs, The King’s Fund tel: 020 7307 2679 or h.crist@kingsfund.org.uk

2. The way that national workforce data is recorded means that is difficult to make a robust assessment of staffing levels in district nursing services. The available data shows that:

  • Following a long period of growth, the number of nurses working in community services fell by 8 per cent between 2009 and 2014.
  • The number of staff recorded as working in district nursing posts has fallen dramatically – by 48 per cent between September 2000 and September 2014 (based on annual statistics) and 13.6 per cent between March 2014 and March 2016 (based on monthly statistics).

Some of this decline is accounted for by the Transforming Community Services policy which, since it came into force in March 2011, has resulted in more community health services being delivered by independent and voluntary sector providers. As these organisations are not required to return workforce data, this effectively deflates the figures. However, the impact of this has been limited and we can say with some confidence that there has been a significant fall in the number of nurses working in district nursing teams. This is explained more fully in the report.