Pressure on district nursing services is leaving staff “broken”, “exhausted” and “on their knees”, and is compromising the quality of care they are able to provide to patients, according to an influential think-tank.
The problems are being driven by an increase in the number of patients and the complexity of care they require, in addition to a reduction in the number of community nurses in recent years, said the King’s Fund in a new report investigating district nursing for older people.
It was “common” for district nursing staff to have unmanageable caseloads and, as a result, some were leaving the service, warned the report.
“Providing more care in the community cannot be achieved when district nursing is at breaking point”
Because this type of nursing care is provided in people’s homes, there was also a “real danger that serious failures in care could go undetected because they are invisible,” it warned.
In addition, it said the shortage of district nursing staff was having an impact on caseloads in general practice and social care. There was a risk the shortage could mean more older people require hospital admission and that there is an increase in delayed transfers of care for older people in hospital, said the report.
Researchers conducted interviews with 50 patients, carers and staff at three case study sites – in London, a rural area in South East England and a city in North East England.
At one site, staff numbers had halved in the past three years due to a combination of cuts to posts and difficulties with recruitment and retention. This had led to the Care Quality Commission giving the site a poor rating for safety.
“A number of people receiving care commented on reduced frequency of visits and delays to wound care”
King’s Fund report
At another site, one interviewee said they were using an escalation process for staff shortages on a weekly basis. Managers at the third site said they only had a full team for around three months a year due to staff turnover.
Concerns were raised about a lack of training places for nurses wanting to become district nurses and the shortage of experienced staff members with this specialist qualification.
The think-tank noted that these problems were not unique to these regions, as recent reports by NHS England and the Royal College of Nursing had indicated district nursing shortages were widespread.
It said that, although national data was not available on the exact number of nurses working in district nursing due to many services now being run by non-NHS providers, official figures from the Health and Social Care Information Centre did show a 48% drop in NHS district nurses between 2000 and 2014.
At the three sites researchers looked at, staff shortages were often dealt with by employees working longer hours, very intensely and often without breaks.
“To let the decline [in district nurse staffing] continue would be to knowingly deprive patients of care which makes a proven difference”
But despite this, researchers found district nurses sometimes were unable to visit patients as often as they should do and that there were resulting delays to care.
“A number of people receiving care commented on reduced frequency of visits and delays to wound care: one person was confined to her bedroom for several days following a postponed visit as the leakage from her wound was so severe,” said the think-tank.
In its report – called Understanding quality in district nursing services: Learning from patients, carers and staff – the King’s Fund noted it had originally set out to compile evidence for a framework for quality district nursing care.
But after finding the gap between demand and capacity within district nursing had worsened in recent years, it has set out a series of immediate actions to address this problem as well.
It called for action to be taken to reverse the declining number of district nurses by raising the profile of the profession and developing it as an attractive career option.
Robust mechanisms for monitoring resources, activity and workforce must also be developed, it said.
In addition, it urged health and care leaders to recognise the vital importance of community health services in helping to transform the way the whole health and care system was run in the future.
“It’s two years since the RCN warned that the district nurse role was in danger of extinction, yet the situation is at least as bad today”
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.”
Responding to the report, the RCN said it showed problems with district nurse staffing must be tackled immediately.
Dr Crystal Oldman, chief executive of the Queen’s Nursing Institute, welcomed the report’s findings, which she said “closely reflect information gathered from nurses by the QNI in recent years”.
“Nurses, patients and their families, and policy makers all want more care to be delivered closer to home,” she said. “But this will never be a reality while we have growing patient demand, and falling capacity in the workforce.
“Overstretched District Nursing teams lead to staff burnout, exacerbating recruitment and retention problems, which in turn make staffing problems even worse,” said Dr Oldman.
“Therefore, we strongly welcome the key recommendations of the report, and the opportunity to work with all stakeholders at the system and service levels to address these issues urgently and in a sustainable way, to protect patient care now and in the future,” she added.
Kathryn Yates, professional lead for primary and community care for the RCN, said: “District nurses are an essential lifeline to many people…They are highly qualified, skilled and experienced nurses with expertise which includes palliative care, medication and wound management.
“It’s two years since the RCN warned that the district nurse role was in danger of extinction, yet the situation is at least as bad today,” she said.
“There is much to take away from this report. However, the main message is that to meet the level of need for high quality care, the long term problem of staffing has to be tackled now. To let the decline continue would be to knowingly deprive patients of care which makes a proven difference,” she added.
Ruth May, executive director of nursing at NHS Improvement, said: “District nurses play an essential role in delivering community services and we want to support them to make sure they can continue to deliver quality care to patients in their homes across England.
“Today’s report is helpful in defining what good quality care provided by district nurses looks like and NHS Improvement has already been working closely with nursing leaders, royal colleges and our partners to understand what kind of support district nurses need,” she said.
“Alongside our wider safe staffing work, NHS Improvement have commissioned a working group at the Queen’s Nursing Institute to understand what more can be done to improve the quality of community nursing care and ensure consistently safe caseload management,” she added.