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Making the invisible workforce visible again

Rosemary Cook
Queen's Nursing Institute

District nursing is one of the oldest and most familiar roles in community nursing. But familiarity has bred, if not contempt, at least considerable criticism in recent years. Conversely, government policies on extending the roles of nurses and moving care out of hospital and into home settings, and the inexorable rise in the numbers of people living with long-term illnesses, are creating unprecedented demand for nursing in the home.
The "listening exercise" that the Queen's Nursing Institute (QNI) is currently undertaking with district nurses marks the start of an ongoing dialogue, and is a chance for district nurses to lay claim to their central role in primary care, at a time when there is a major new government commitment to moving care out of hospitals and into home and community settings.

Past commentary on district nursing
The Audit Commission report First Assessment, published in 1999, is one of the major landmarks in the critical review of district nursing that has taken place in recent years.(1) Some of its main points are shown in Box 1.


The Queen's Nursing Institute report, The Invisible Workforce, was based on focus groups and questionnaires to district nurses around the country.(2) The report concluded that strategic solutions and nationally focused direction were needed to address low morale in district nursing. It encouraged district nurses to think of themselves as leaders and take control of the agenda.
In 2003, the Community Practitioners' and Health Visitors' Association published District Nursing at the Crossroads, which described district nursing as a "pivotal specialism" and called for the development of a national strategy.(3)
Overall, the picture of district nursing at that time was of a specialism struggling to work proactively rather than being driven by referrals; one that was searching for a clear way forward, and one that lacked visibility in the nursing profession. All reports, however, acknowledged that good practice was often happening at individual and team level.

Policy focus on community nursing and care in the home
In parallel to these reports, the focus of government health policy was expanding the roles of nurses in all settings.

  • Making a Difference, the strategy for nursing, midwifery and health visiting published in 1999, flagged the development of extended nurse prescribing, nurses' roles on PCT boards and executive committees, "first-contact" care and the increasing public health role of community nurses.(4)
  • Subsequent developments in nurse prescribing - the "extended formulary" and the introduction of supplementary prescribing - were built on the experience and evaluation of district nurse and health visitor prescribing.
  • The NHS Plan, published in 2000, set out the CNO's 10 key roles for nurses, including ordering diagnostic tests, making and receiving referrals, admitting and discharging patients, managing caseloads, running clinics and prescribing;(5) all key tasks and skills for community nurses who work with relative autonomy and at a distance from other health professionals and facilities.
  • In 2002, Liberating the Talents set out a new framework for nursing in primary care, with three core functions: first-contact care; continuing care; and public health/health protection.(6) It also stressed the need to value generalists, in addition to developing specialist roles. A follow-up document, Supporting People with Long Term Conditions - liberating the talents of nurses who care for people with long-term conditions,expressly identified the key role that district nurses and other community nurses will have in the home-based care of the increasing numbers of people with chronic conditions.(7)
  • More recently, the introduction of community matrons, and the rollout of practice-based commissioning have increased the opportunities for community nurses to take a role in coordinating, case managing, delivering and commissioning healthcare to vulnerable and ill people in their own homes and communities.(8)

Unfortunately, many of these positive developments were overshadowed by the publication in July 2005 of a letter from Sir Nigel Crisp, Chief Executive of the NHS, that included the direction to primary care trusts to cease the provision of services, including community nursing, by 2008.(9) Although subsequent statements have returned policy on provision to its position before this letter, many district nurses are still distracted from professional developments by concern about future employment prospects.

Following up The Invisible Workforce
So, district nursing has, in recent years, been poised between a rather defensive past and a potentially major role in home care for a growing population of people with long-term conditions, in which they can deploy a wide range of new skills and responsibilities.
It is in this climate that the QNI is producing a follow-up report to The Invisible Workforce. We are holding focus groups of district nurses around the country, and asking each some trigger questions designed to identify future changes and elicit their hopes and beliefs about the core values and potential of district nursing.
Although budget pressures and employment uncertainty are causing a lot of anxiety at present, we believe - and early focus groups are confirming - that there is still a lot of passion, professionalism, commitment and creativity in district nursing.
Our new report will not set out a single vision of the future for district nursing. It will reflect the diverse views of those nurses we heard from in the groups. We see it as the beginning, rather than the end, of a dialogue about the future of this very important service, and we hope it will provide a further impetus for district nurses to lay claim to their central role in caring for patients at home.
The follow-up report to The Invisible Workforce will be published by the QNI in April. To order copies, contact Joanne Moorby on 020 7490 4227, or email
For more information on the QNI, visit


  1. Audit Commission. First assessment: a review of district nursing services in England and Wales. London: Audit Commission; 1999.
  2. The Queen's Nursing Institute and English National Board for Nursing, Midwifery and Health Visiting. District nursing "The Invisible Workforce". A discussion paper. London: QNI/ENB; 2002.
  3. CPHVA. District nursing at the crossroads - a CPHVA perspective. London: Community Practitioners' and Health Visitors' Association; 2003.
  4. Department of Health. Making a difference - strengthening the nursing, midwifery and health visiting contribution to health and healthcare. London: Department of Health; 1999.
  5. Department of Health. The NHS plan - a plan for investment, a plan for reform. London: Department of Health; 2000.
  6. Department of Health. Liberating the talents - helping primary care trusts and nurses to deliver the NHS plan. London: Department of Health; 2002.
  7. Department of Health. Supporting people with long-term conditions - liberating the talents of nurses who care for people with long-term conditions. London: Department of Health; 2005.
  8. Department of Health. Making practice based commissioning a reality - technical guidance. London: Department of Health; 2005.
  9. Department of Health. Commissioning a patient-led NHS. London: Department of Health; 2005.

Queen's Nursing Institute

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