CQC issues warning over shortage of district nurses

A shortage of district nurses is driving ‘task-based’ care and risks undermining the government’s plans to shift care from hospital settings into the community, the healthcare watchdog has warned.

The Care Quality Commission’s (CQC’s) annual report into the state of health care and adult social care in England stressed community services need ‘significant investment’ in both capacity and capability to deliver on the government’s 10 Year Health Plan.

The report spotlighted serious concerns around dwindling district nurse numbers and the impact this was having on care – including that staff shortages and high levels of referrals meant patients were, in some cases, being left to deteriorate.

‘A 50% drop in district nurses per 10,000 people aged 65 and over’

Pointing to NHS England workforce statistics, the CQC said that the monthly average of full-time equivalent (FTE) level 1 qualified district nurses had fallen from 6,745 in 2010/11 to 3,871 in 2024/25 – a 43% drop overall.

While some of the early decline could be attributed to the transfer of some staff to Community Interest Companies (CICs) following the Health and Social Care Act 2012, the CQC said ‘there continues to be significant decline since 2012/13’.

Analysis by the CQC suggested that: ‘In the context of an ageing population that relies on this service, this reduction presents a 50% drop in qualified district nurses per 10,000 people aged 65 and over (from 7 in 2011/12 to 3.5 in 2024/25).’

Further analysis of NHS electronic staff record data found that the total annual numbers of new district nurse trainees were ‘rarely more than half the number of staff leaving the profession’.

The healthcare watchdog stressed that district nurses were an ‘important part of shifting care from hospital settings into the community’ because the services they provide can ‘take pressure off secondary care services by preventing admissions to an acute hospital and facilitating earlier hospital discharges’.

But it warned: ‘A shortage of qualified staff in district nursing is contributing to a shift away from providing holistic care to delivering services in a task-based way.’

Demand for district nursing services was also ‘rising’, added the CQC. The report drew on data which suggested the volume of new referrals to district nursing services for people aged 65 and over has risen by 28% between 2021/22 and 2024/25. This equates to just over 3.4 million referrals – up from 2.7 million.

‘The risk of taking on too many referrals’

During inspections of community healthcare services, the CQC said it had identified the risks of taking on too many referrals.

‘For example, we found that one provider of district nursing services had created lists for people who were prioritised for visits into either a ‘red’ (or ‘critical’) list or a ‘deferred’ list of people who were lower priority,’ the report said.

‘Some people spent many days on the ‘deferred’ list but ended up on the ‘red’ list as their health had deteriorated. We also observed additional problems in relation to a shortage of qualified district nurses.’

Increased demand was mirrored by the findings of a Queen’s Institute of Community Nursing (QICN) survey of more than 1,500 district nurse team leaders.

As noted by the CQC, the survey showed how more teams were carrying bigger caseloads, with the number of district nursing teams working with 600 or more patients having risen to from 12% to 16.2% in 2023. At the same time, those reporting a team caseload of under 200 cases decreased from 32% to 28%.

‘Team leaders commented that the lack of time and resources were driving their services to focus on task-orientated care rather than holistic care for their patients – especially regarding their emotional and social needs,’ the CQC said about the QICN survey.

‘Risk of erosion in care quality’

The CQC warned that unless community services were given additional support, ‘there is real risk of erosion in care quality, with people struggling to get the care they need and the most vulnerable groups likely to be hit hardest through longer waits, reduced access and poorer outcomes’.

CQC interim chief executive Dr Arun Chopra said: ‘The government’s 10-year plan is a real chance to improve care by putting people’s needs first.

‘But for the plan to succeed, community health and care services need more support. Without this, there’s a risk fewer people will be able to access good care, with vulnerable groups hit hardest.’

He said community services had reported ‘struggling because the way care is funded and organised is designed around hospitals’.

Dr Chopra reiterated the CQC’s call for ‘more investment in care outside hospital’ and for ‘more emphasis on measuring quality of care, not just numbers of procedures’.

‘We’ll play our part – with a renewed focus on listening to what people tell us about their care and acting on their feedback,’ he added.

‘When we find poor care, we’ll take steps to protect people. We’ll work with healthcare providers and local systems to make care better, and we’ll find and share examples of good, innovative care that puts people first. And where we see barriers to good care, we’ll work with partners to find solutions.’

District nurse numbers ‘hugely worrying’

Royal College of Nursing (RCN) general secretary and chief executive Professor Nicola Ranger said the report was a ‘stark reminder of just how challenging the government’s shift from hospital to community will be’.

‘Community services need significant investment in staff and an expansion of local treatment centres if the community care vision is to be realised, but we mustn’t forget about the new investment needed in hospital services too,’ she added.

‘It is hugely worrying that, as ministers have a stated ambition of neighbourhood healthcare, the number of district nurses has halved in the last 14 years while demand has continued to surge.

‘These expert nursing roles are key to transforming care, especially for the vulnerable and must see investment.’

The government was urged by the RCN to use its upcoming budget and highly anticipated workforce plan to address the situation.

‘Only new investment to grow the nursing workforce, particularly in community settings, will ease pressures on hospitals, improve care for patients and ensure the government’s reforms are delivered safely,’ said Professor Ranger.

QICN chief executive Steph Lawrence said while the findings were ‘very concerning’ she was pleased to see the CQC reporting on capacity issues in the community.

‘We know there are capacity gaps in all aspects of community services, from community nursing and huge gaps in the district nursing workforce, to adult social care nursing, general practice nursing, children’s community nursing and community mental health and learning disability nursing. Without focus and investment on these crucial areas, the NHS 10-year plan becomes a pipe dream,’ she said.

‘This is very sad as we know that the place for holistic person-centred care is in their own homes – including care homes – but without investment we will see more nurses leave due to the work pressures and sadly more and more people ending up in hospital unnecessarily.’