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Understanding quality in district nursing services

Learning from patients, carers and staff

District nursing services play an important role in helping people to maintain their independence by supporting them to manage long-term conditions and treating acute illnesses – and demand for such services is increasing. These services will be key to the success of policies that aim to provide more care closer to home.

This report investigates what ‘good’ district nursing care looks like from the perspective of people receiving this care, unpaid carers and district nursing staff and puts forward a framework for understanding the components involved. It also looks at the growing demand–capacity gap in district nursing and the worrying impact that this is having on services, the workforce and the quality and safety of patient care. The report makes recommendations to policy-makers, regulators, commissioners and provider organisations as to how to start to address these pressures.

Key findings

  • Our research suggests that staff, patients and carers have strongly aligned views about the components of ‘good’ district nursing care, valuing a ‘whole-person approach’ with a focus on relational continuity, involvement of family and carers, patient education and self-management support, and care co-ordination.

  • Activity has increased significantly over recent years, both in terms of the number of patients seen and the complexity of care provided. However, there are significant problems with recruitment and retention of staff, and available workforce 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, creating a growing demand–capacity gap.

  • This is having a negative impact on staff wellbeing, leading to poor morale, stress and fatigue. Some staff are leaving the service as a result.

These workforce pressures risk compromising quality of care. We found examples of an increasingly task-focused approach, reductions in preventive care, visits being postponed and lack of continuity.

Policy implications

  • Despite the policy ambition to offer ‘more care close to home’, resources, monitoring and oversight remain stubbornly focused on the acute hospital sector rather than on community health services. This must be addressed.

  • It is important that the system recognises the vital strategic importance of community health services in realising ambitions for the transformation of the health and social care system. Community services must be involved in, and central to, the development of new care models and sustainability and transformation plans.

  • Pressures are not limited to district nursing; general practice, social care and the voluntary sector also face significant challenges of rising demand at a time of constrained resourcing and capacity. To address such wide-reaching problems, it will be necessary to look beyond each service in isolation and respond in the round.


What does ‘good care’ look like in district nursing services? This report sets out a framework of nine characteristics of good-quality care for older people receiving care from district nursing services in their own home. The framework is derived from interviews with people receiving district nursing care, their carers and staff.

We hope this framework and these slides will be a useful resource for you – please feel free to use them in your work, in documents and presentations.

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