District nurses ‘under immense pressure’ as end-of-life care gap widens

Hospice funding constraints mean district nursing teams are increasingly caring for more patients who are at end of life and who have complex needs, without hospice services to turn to when in need of support or specialist advice. Madeleine Anderson explores the situation.

Nursing in Practice has heard from district nursing teams across the country who say their already-stretched caseloads are being pushed to breaking point as they care for patients who, until recently, would have received hospice support.

While providing palliative care is a core role of a district nurse – with some choosing to specialise in this area – some among the profession are warning that cuts to hospice services, coupled with staffing issues, mean district nurses are managing larger caseloads and, in some cases, feel they are unable to deliver care at a standard they would like to.

The latest concerns follow long-standing warnings from across the hospice sector, with Nursing in Practice having this year heard from hospice leaders who said longer-term funding was needed to secure the future of the hospice nurse workforce and avoid cuts amid rising staffing costs. And last month, a report from the National Audit Office (NAO) found that almost two-thirds of independent hospices were in deficit in the year 2023-24.

Nurses from across community and hospice settings have told us of examples where hospice services are being reduced or withdrawn altogether and explain the impact this is having on both patients and the workforce. We’ve also been given exclusive data on just how much district nurses are feeling the pressure when it comes to increasing palliative care demands.

Loss of specialist support and longer delays

District nurse and member of the Royal College of Nursing (RCN) District and Community Nursing Forum, Carolyn Fleurat says funding issues have seen a reduced number of hospice step-up beds, meaning district nurses must now manage ‘very complex and unstable patients’ in the community.

This is leading to more emergency admissions and patients not receiving their ‘last dying wish’ to die in a hospice in some regions.

She also warns that reduced hospice services mean district nurses do not always have the option to ask for specialist support.

‘Previously, district nursing teams could call on hospice specialists at weekends for urgent advance care planning or rapid assessment of unstable palliative patients,’ she says.

‘These services have since been removed in some areas, very rapidly.’

Ms Fleurat warns these pressures have left a ‘service gap’ which is adding to already long delays in NHS 111 and out-of-hours GP services.

She explains that these alternative services can also often lack both palliative expertise and the trusted patient relationships that guide complex decision-making. They may also struggle to advise when patients are on complex or off-formulary medication regimes suggests Ms Fleurat.

Only the most complex patients seen

Gail Goddard, chair of the RCN District and Community Nurse Forum and a district nurse team manager, told Nursing in Practice that many district nursing teams are now only able to support ‘really complex’ patients, with respite care becoming ‘really sparse’.

‘District nurses are now also covering larger areas and larger caseloads with less workforce and as a result response times have also increased,’ she says.

Ms Goddard explains that some district nursing teams are also having to recruit end-of-life care specialist nurses or link nurses to manage their rising palliative care patient caseload.

Another issue raised by forum members, she says, is that GPs in some areas are no longer writing palliative medication administration record (MAR) charts, leaving V300 prescribers, including nurses, to complete drug charts routinely.

Speaking earlier this month, Ms Goddard suggested that employers are creating ‘new roles’ at lower pay bands in ‘replacement’ of district nurses and warned there was a ‘widespread lack of understanding’ about the level of expertise that district nurses bring to the community nursing workforce.

**A range of other issues were raised by RCN forum members to Nursing in Practice, including that:**

Hospice support given to district nursing teams is ‘mostly advisory only’
Clinical nurse specialist support is ‘much reduced’
MAR chart issues remain unresolved as GPs step back from producing them
Capacity issues mean less support from charities or night-time care
Community nursing response times are ‘less than ideal’ due to staffing shortages and reduced skill mix.

Significantly reduced services

Nicola Payne, a hospice nurse at Beaumont House, told Nursing in Practice that some hospices have ‘significantly reduced’ their services due to chronic underfunding, with these changes now impacting wider community care provision.

‘District nursing teams are already under an immense amount of pressure,’ she says.

‘Caseloads in the community are ever-growing and they can’t essentially close the door to accepting patients. Because of that, they’re going to have to prioritise, and that’s going to reduce the care they can give to palliative patients.’

Ms Payne says that while local fundraising currently keeps many hospices afloat, relying on communities is no longer sustainable.

‘There needs to be funding from the government,’ she explains.

‘Releasing some of the pressure on fundraising would give hospices more financial sustainability to develop services that would complement district nursing.’

Ms Payne stresses that district nursing also needs extra money to make up for ‘years of underfunding’, alongside increasing demand for services.

‘We need to act now,’ Ms Payne warns. ‘Without proper funding, both hospices and district nursing will struggle to deliver the care that dying patients deserve.’

What does the data say?

The impact of the issue has been spotlighted in a major new survey, with unpublished data being seen by Nursing in Practice for the first time.

The study reveals the scale of end-of-life care being delivered by the UK’s community nursing workforce and the growing pressures preventing them from meeting patients’ needs.

Led by Dr Ben Bowers, assistant professor of primary care and a practicing honorary nurse consultant in palliative care, and conducted between April and May 2025, the research is based on responses from 1,471 community nurses across the UK.

Most respondents worked in community and district nursing teams (1,156), with a further 174 in specialist palliative care.

On their most recent shift, community and district nurses spent an average of 23.5% of their time providing end-of-life care, according to the survey.

Yet almost half of all nurses (49.4%) said they were unable to deliver aspects of this care to the standards they consider professionally acceptable, particularly psychological support and care coordination, respondents said.

The survey also found that 11.6% of nurses had to defer end of life visits during their last shift due to workload pressures.

Respondents pointed to staff shortages, overwhelming demand and systemic barriers as key reasons why essential end-of-life support is increasingly delayed or left undone.

Dr Bowers told Nursing in Practice that the findings highlight an urgent need for renewed investment in both core and specialist community nursing, alongside broader reforms to ensure a sustainable workforce capable of meeting rising demand for timely, home-based palliative care.

‘Dramatic’ increase in palliative care workload

Rachael Norman, district nurse sister with East Northants district nursing team, told Nursing in Practice that her end-of-life care patient workload had risen significantly during her last three years in post.

‘I’ve been in the trust that I work now for three years and even in that short time the workload around palliative patients has increased dramatically,’ she explains.

Ms Norman notes that her area had seen a rise in waiting lists for hospice care, with more people unable to choose whether they can die in a hospice, hospital, or home environment.

Despite the rise in demand for district nurse care, she believes the government is unaware as to the volume and complexity of care that district nurses deliver.

‘I think the government is really not aware at all as to how much palliative care is delivered in the community, I don’t think they have any sense of that at all,’ she says.

‘There’s still a lot of misunderstanding around what community nursing is, so we end up being a bit of a mock up service at times which obviously creates pressures in terms of demand as well as case load pressures.’

Ms Norman explains how her own workload had risen as local specialist palliative care nursing services were increasingly rejecting patients whose condition was not seen as ‘complex enough’.

‘I think the perception is that a lot of people will go to hospice or hospital for end-of-life care, when actually the majority of people are at home, and community nurses are the people delivering quite complex symptom management at home,’ she says.

A new report from the House of Commons Health and Social Care Committee, published this month, describes nurses as the ‘backbone’ of community care for people nearing the end of life, but warns their workforce is ‘decimated’ with poor training and retention.

Last month, Jim Mackey, chief executive of NHS England (NHSE), said the government’s planned transition towards more community-based care should trigger the ‘expansion’ of the district nursing workforce.

Meanwhile, a report by the Nuffield Trust and commissioned by the Queen’s Institute of Community Nursing (QICN) recently revealed that over one in four district nurses are at a lower pay band than the typical starting point for the profession. The report also exposed how the number of district nurses has plummeted by a staggering 43% since 2009.

In the summer, the health and social care secretary said he has ‘never been comfortable’ with how funding for hospices is reliant on public donations and that the government should ‘leverage more support’ for the sector.

Speaking to the Health and Social Care Committee in July, Wes Streeting said he disagreed with how much hospices are reliant on donations, given their ‘integral’ role within the healthcare system.

In the same month, the government released a £75m funding package for hospices in an effort to help deliver upgrades across hospices in England, including specially adapted beds, rooms and other technology.

Join the discussion on this topic via the Nursing in Practice LinkedIn page