District nursing “at breaking point”, says King’s Fund

1 Sep 16

Unmanageable caseloads and staff shortages in district nursing services are compromising care quality among some patients, according to the King’s Fund.

District nurse

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District nurses play an important role in providing healthcare in the community, often spending time in patients’ homes, monitoring and delivering care. But research published by the heath think-tank today found a “profound and growing gap” between capacity and demand.

Although the King’s Fund found it was difficult to make a clear assessment of staffing levels due to the limitations of national data recording, it reported that the number of district nurses working in community services fell by 8% between 2009 and 2014. Moreover, the number of staff recorded as working in district nursing posts has also fallen dramatically, by 48%, between 2000 and 2014.

This is partly due to the new Transforming Community Services policy, which has handed off some community staffing to independent and voluntary providers that do not necessarily provide data. Despite this, the think-tank was confident the number of district nurses had declined steeply in recent years.

Meanwhile, the figures reveal that demand for district nurse services has increased in terms of the number of patients seen and the complexity of care provided.

These dual pressures are “compromising quality of care for some patients”, and could be promoting an increasingly ‘task-focused’ approach to care, whereby staff are more abrupt and rush through appointments. This may also be causing nurse visits to be missed or postponed, and reducing levels of preventative and connected care. 

Services were generally overstretched, and gaps in service were too often reliant on staff goodwill. The researchers found this was having a “deeply negative” impact on morale and staff wellbeing. In some cases, unmanageable caseloads were leading to fatigue, stress and ill health. Interviews conducted for the report recorded accounts of staff being “broken” and “on their knees”, leading to some nurses leaving the service altogether.

The King’s Fund makes three recommendations to improve the situation. First, health leaders must recognise the vital contribution made by district nurses in delivering the aims of transforming the health and social care system. Second, there is an urgent need to reverse the decline in staff numbers by raising the profile of the profession, and making it more attractive as a career. Finally, the report stresses the importance of introducing robust mechanisms to monitor and improve the service. 

Researchers were also sanguine in defending the concept of the district nurse, claiming that at its best, it offers an ideal model of person-centred, preventive, community-based care. They observed that staff, patients and carers all seem to agree on what constitutes good patient care. Based on this, they have devised a framework designed to be used in assessing and assuring the quality of care in the sector.

Anna Charles, policy researcher at the King’s Fund, said: “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.”

The people most likely to be affected were often vulnerable and among those most likely to be affected by cuts in social care and voluntary sector services, she added.

“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.”


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