Understanding quality in district nursing services: Learning from patients, carers and staff

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Part of Older people’s experiences of district nursing services

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.


Abisola Bakare

Area Manager District Nursing,
Barnet, Enfield, Haringey Mental Health Trust.
Comment date
28 January 2019

RCN & NMC will need to be proactive in supporting Community Services as the caseload is very heavy and it is increasing daily. Workforce is reducing. Community Nurses are visiting 12-17 patients daily per staff in my organisation. Staff are working like headless chickens and the morale is low, sickness is high. Turnover is high, recruitment & retention is low.

Deborah Marshall

Comment date
07 January 2017
I care for my Mum, singlehandedly and 27/7 who now has end stages COPD and is on the palliative list.
I found this article at 2am by searching google with 'does anyone else have problems with bad district nurses.' I was feeling at my whits end, scared feeling very lonely and vulnerable our my situation.
I am part way through reading this report and I am so relieved that this isn't just happening to me and that someone is recognising some, and from what I have read so far, only some, of the problems and issues with the District Nursing care as it stands today.

I am left to manage with my mum on my own, our district nurses have been out 3 times in 6 months, they have been rude and ill mannered towards both me and my mum but particularly me, my data protection has been breached and one of the nurses brought up some of my medical history in front of my Mum which caused pure embarrassment to me and upset to my mum and was information I have no idea how she had due to her not having anything to do with my healthcare, they have at times seemed argumentative and it has been clear on their visits that they haven't wanted to be here at all.
We have been given wrong information on who to call or what to do when my Mum has an exacerbation or deteriorates. I could list a catalogue of dangerous and unprofessional incidents involving the District Nurses which I have tried to complain about or highlight but finding out who and where to go is absolutely impossible, the NHS structure is a very messy machine indeed. The pathways to contact them or how to raise concerns or complaints are very guarded, I have been put through to a variety of people and departments. I phoned one of 3 local CCG's and asked if they commission the District Nurses and the phone was immediately put down on me. I have been to see my local MP who told me it's political and I can't change or influence the politics.

I have felt very scared the lack of medical care my mum has but after the last visit form the district nurse on Thursday, where she seemed that angry it was uncomfortable and intimidating. During the visit my mum was spoken to very badly and handling quite roughly, she is 31kg in weight too, and I was given a dressing down about money they have to pay out over a mattress we managed to get for her as the district nurses have to pay a daily rate for it. My Mum cried when she went and was scared of them having to be the ones we rely on when she gets worse. I'm very scared of that too.

Something really needs doing and someone needs to really get their hands dirty and investigate thoroughly the true extent of the worse hit areas. As I do believe that the district nursing has some amazing nurses giving excellent and valuable care. The district nurses that cover my area for example are made up of community nurses and health care assistants. Apparently the funding for Matrons was pulled and we do not have any community matrons.

Before I took a break in my employment to look after my Mum I worked in the public sector for a Police Force as a Crime Scene Investigator; I guarantee you all sectors of the community, including criminals are treated with a lot more respect and dignity by that profession than they seem to be getting away with in areas of Health Care.

I hope something positive comes out of this report.

Clare Ede

Comment date
16 November 2016
it is so sad to hear of those who have dedicated their lives to DN only to find that the DN of today has as many issues as when they originated in the 1800's, lack of training, lack of support, lack of acknowledgement by government, low moral, lack of a realistic future.
loads of reports by loads of authoritative persons, ending in little or now change. DN's of the future it is your chance to change a culture and an attitude and to nurse the had hoped

helene stone

district nurse,
Comment date
30 September 2016
I have worked in the community for 23 years most of that time the work has been satisfying, enjoyable and although hard it is only in the last 10 years or so that it has become impossible. Patients are a means to reaching targets for the organisation and the staff are expected to jump as high as demanded by the organisations and the commissioners. Working regularly with insufficient staff or skill mix, managers who seem detached from the service and who are out of their depth trying to manage a service in crisis. Staff turn round is a significant problem and most staff are silently expected to do much of their clerical and admin duties at home in their own time, affecting their work/life balance. Fear of making mistakes or missing something resulting in blame also significantly adds to an already stressed workforce. Staff relignment reduce continuity of care for patients and a sense of insecurity for nursing staff as they need to have a support network amongst their colleagues. I would not recommend district nursing to others. I was lucky to have experienced the service during better days when we knew our team members and patients as they knew and trusted us, when our managers cared about their staff and the organisation was more personable.

Professor Ami David

Principal Consultant,
Quest for Community Health
Comment date
14 September 2016
Delighted to see the King's Fund giving prominence to an extremely important part of the Health Service without the provision of which the mantra 'out of hospital care' will not materialise. We are a small consultancy led and managed by District Nurses. Over the last 8 years we have developed and used in audits of DN services across UK, a range of tools including one that assess the care interventions by DNs using four domains of care; a tool that measures the acuity of patients seen by the DN using a universal score and a condition specific score. Our work bears out the findings in the KF report in relation to the 'rushed' nature of care interventions. Our concern is that the care intervention domain does not always correspond to the real acuity of the patient being cared for. Acuity measures therefore should be used alongside quality of service provision to demonstrate via gap analysis the care that patients and n the community should really receive if we are to avoid unnecessary hospital admissions. Thank you KF for highlighting the important contribution the DN service can and should make.
Ami David www.questhealth.co.uk

Matthew Honeyman

The King's Fund
Comment date
13 September 2016
Hi Birgit

Thanks for the kind words about the report.
We were keen to ensure the work to describe quality in district nursing was grounded in the experiences of patients and staff and what they thought was important. The care actually ongoing and the ideal care that people described didn't involve much in the way of telecare.

This could be because it's not much used in those areas at the moment or because people weren't aware of potential, or because they didn't see it as being much of a benefit to their particular situation. We don't know but it would be interesting to understand further.

We did hear a little bit in one trust about how mobile technology was working well for staff and wrote about this in the report. But in some areas, there are infrastructure barriers to overcome before this can be useful.

Of course, we're very interested to hear your thoughts about how the kind of technology you have in mind can help with quality in district nursing.


Rachel Doubleday

senior lecturer,
Teesside University, Queen's Nurse and member of the Association of District Nurse Educators
Comment date
08 September 2016
It has been heartening to see the increased focus on district nursing over the last few years: DH (2013) Care in Local Communities: A new vision and model for district nursing, HEE (2015) District Nursing and General Practice Nursing Service Education and Career Framework, QNI (2015) The QNI/QNIS Voluntary Standards for District Nurse Education and Practice and NHS England (2015) Framework for commissioning community nursing. The QNI have monitored changes in the workforce and in the provision of specialist education to develop district nurses and there did seem to be a renewed investment in this field which was exciting for those of us working in this field. However, this report by the King's Fund has simply provided the evidence to demonstrate what those of us who are in clinical practice or closely aligned to it, already knew: district nursing services are facing a time of pressure which they have not had before. The report eloquently identifies and analyses these. The impact has been felt by the nursing staff for some time as they have tried to absorb this pressure to avoid patients and their families or carers experiencing a lesser service. This has been done at a high personal cost, evidenced through the interviews in this report. What is intensely sad is that is the capacity of the nurses to absorb these pressures has now been exceeded and the care is being affected. How must these nurses feel knowing this?
As the programme leader for programmes teaching the specialist qualification in district nursing and for supporting pre-registration student nurses in their community placements, I am passionately committed to encouraging more people to consider community nursing as an area of practice to move into. I have had 20 district nursing students who have all successfully completed their programme this year and will have 17 starting later this month on the next cohort. This is fantastic but a drop in the ocean in terms of what is needed to address the service requirements across the country. The challenges are multiple but three key areas not highlighted in the report are:
1- the experienced district nurses who can mentor students are less available as recruitment and retention is affected by the issues raised in the report. (The qualification to be a practice nurse and assess student district nurses can take up to 4 years to achieve after initial qualification.)
2- Following the implementation of changes to nurse education funding outlined in DH (2016) Reforming healthcare education funding: creating a sustainable future workforce, the funding for the specialist educational programme for district nurses is no longer coming from the local Health Education England offices and future sources are not yet clear, This means that the source of funding (if any) for places for students hoping to commence in September 2017 is not yet know.
3- as NHS Trusts and other employers providing district nursing services are facing increasing financial pressures and are looking to make savings, often freezing vacancies or expanding teams to cover ever larger areas, are quick ways to make achieve these goals which they are compelled to achieve to avoid triggering "red lights". Thus despite the evidence that care is improved with the key role of the specialist practitioner in district nursing as the team leader (QNI (2015)The Value of the District Nurse Specialist Practitioner Qualification), not all successful students on these challenging programmes secure posts at the end of their studies.
In our local area we have some excellent collaborative relationships with local Trusts, practitioners, commissioners and I feel very lucky to have this as it has ensured that investment in the specialist practitioner qualification in district nursing has been maintained over a difficult time and grown in more recent years. I hope that these wider pressures outlined in the report and above, are not ignored as the current situation described by the King's Fund is not sustainable. Feedback from a patient, to one of my students recently was "She cared." I hope I can see that in future too.

Birgit Stach

Consultant public sector,
PA Consulting
Comment date
07 September 2016
Excellent report.
Question: Why is telecare / care technology not mentioned?

Geoffrey Cox MSc LLb

Managing Director, Nursing Home Group,
Southern Healthcare (Wessex) Ltd
Comment date
01 September 2016
I commend the Kings Fund and the Report authors for this detailed work and for highlighting these issues. I have scanned the report, and will read in greater detail as soon as I can. Meanwhile, I make some observations.

Firstly, whilst I run Nursing Homes, I nevertheless genuinely believe in the desirability of living in ones own Home, so far as is desirable, beneficial and safe. However, in my view, the pendulum has swung too far, to the point whereby living in ones own Home is seen as an desirable end in itself, irrespective of the conditions (i.e. difficulty coping, loneliness & isolation) and consequences.

Secondly, I comment that conversely, (and inappropriately) Care Homes, are simplistically denigrated as institutions, in a somewhat binary fashion (as if Home = good / Institutions = not good) and with the many unsavoury connotations of that manipulative use of language which is now commonplace.

I suggest that instead we should be both improving the support for those desiring, benefiting and able to live safely at Home, and also support the development of better quality of life in Residential care for those who can't, rather than perpetually demeaning those who need them, negatively manipulating the language we use in regard to Residential Care, and constantly undermining its residents through underfunding, poor commissioning, and excessive and destructive safeguarding by the very same commissioning authorities.

Thirdly, turning to the purpose of the report which highlights concerns about District / Community Nursing, I comment on my own experience. District Nurses are also expected to attend Residential Care Home Residents. In that respect, I echo or extend many of the comments made in the report. I speak from both the experience of my late mother's care in her own Home, and also the decreasing support in Residential Care generally over 15 years, which has led to poor / inconsistent Nursing care, and a deterioration of working relationships (through pressure of work on the DN).

Fourthly, whilst I shall not repeat the points made, I will add that this report is sadly reminiscent of the Francis report upon Mid Staffs, and no doubt with similar risks.

Fifthly I highlight the perversity of the graph of reducing Nurse numbers, which is truly shocking given the rise in the numbers of elderly people at Home, and the promoted concept of care at Home which is at best patchy.

Sixthly, I point out the same 'malaise' applies to the commissioning of Nursing beds. Nursing placements have dropped exponentially, which is also paradoxical, given that if there are less Nursing placements, and less District Nurses yet more people with Nursing needs and living longer with them, something is clearly very wrong.

We seem to be on a trend started with grave consequences in 1990, when Government policy was then in theory to support more people at Home (which did not materialise) and back then residential care was decimated, as is happening again now. It seems that cost reduction prevails over all else and a result of that, political dogma and a lack of support for the elderly, our systems for caring for our elderly are in a truly shocking state, at every level.
Geoffrey Cox MSc LLb

George Coxon

Various inc care home owner,
Comment date
01 September 2016
I was surprised to see no reference to the essential support DNs provide to non nursing residential care. Perhaps I missed it? We rely on them so much for the increasingly complex array of older vulnerable people coming into care homes much later than they once did due to funding pressures primarily I think. Equally the emphasis on 'keeping people at home for as long as possible' often with inadequate support and reliance on the goodwill and capability of family (often of a similarly older spouse) means we are hugely dependent upon strong, spirited, visiting nurses who are good humoured, respectful of our efforts and believe in genuine shared care. Thankfully my 2 care homes in Devon recieve this. Long may it continue I was a little perturbed, as I always am, about the mention on page 41 of "long term institutional care". I always balk at this. Care homes are NOT institutions, we are safe, fun, energetic, calm, kind places for people to look forward to living in when the time is right. DNs like all members of our society must resist perpetuating the view that going into a care home is somehow a failure and should be resisted almost at all costs! The creates fear and stigma when in fact we need positive regard and reassurance. We are doing a job to be proud of and celebrated. Much like the work of DNs. Great work however I will be sharing the report across my range of roles and networks.

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