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District nursing: ‘undervalued’ but vital

District nurses save the NHS hundreds of millions across the UK by treating patients in their own homes and helping to keep them out of hospital. But cuts mean their numbers have nearly halved in 10 years and the profession is under threat, reports Kathy Oxtoby

‘We are the service that holds everything together – the central hub of wider community services liaising with GPs, hospices and social services,’ Liz Alderton, district nurse team lead at North East London Foundation Trust, told Nursing in Practice.

But that service is under siege. This May, a report by the Queen’s Nursing Institute (QNI) and the Royal College of Nursing (RCN) revealed that the number of district nurses has fallen by almost 43% over the past decade in England. The document, which examines outstanding models of district nursing and is the first joint publication from the two nursing bodies, urgently calls for a commitment to investment and training for district nurses.

The report highlights that there are only 4,031 district nurses providing care for a population of around 55.8 million in England – a drop from 7,055 a decade ago. The fall in numbers combined with a rise in patient demand means many district nurses are working at unsafe levels, the nursing bodies warn. 

The Government’s NHS Long-Term Plan identified the need for more nursing care to be delivered in the community to reduce lengths of hospital stays and prevent unplanned admissions.

But the QNI says this pledge has not been backed by the required investment.

Professor Alison Leary, chair of healthcare and workforce modelling at London South Bank University, says that while district nurses are ‘critical to managing the demand placed on the acute sector by providing complex care in the community’, there seems to have been ‘a devaluation of the specialist practitioner qualification of the role’.

‘For example, many nurses seem to have to accept a drop in salary to take the qualification or they lack support from employers,’ she says.

And those on the service front line also report fears about the future of district nursing.

‘Personally, I think the profession is under threat,’ says Paula Boyer, a community matron in Rotherham, South Yorkshire, and a qualified district nurse who now works closely with a district nursing team.

She says the area used to have smaller district nursing teams that were based within GP surgeries and tended to have one district nursing sister for two GP practices and a district nursing team. ‘Now we’ve got larger locality teams and it seems that as they have merged with smaller teams, district nursing sisters are not being replaced – there’s around one for every four or five surgeries,’ she says.

Julie Green, dean for education at Keele University in Staffordshire, programme lead for its district nurse specialist practice programme and chair of the RCN’s district and community nursing forum, believes district nursing is ‘very under pressure’. ‘There are a lot of merging teams, and some diaries have 350 visits a day co-ordinated across a large team,’ she says.

This increased workload also has an impact on continuity of care for district nurses who, Ms Green says, ‘might be doing 20 to 25 visits a day’.

District nursing under threat

Dr Crystal Oldman, chief executive of the QNI, believes district nursing as a service is under threat because ‘the focus for many years has been on hospital-based nursing’.

‘It’s not about wilful or intentional neglect of district nursing. It just hasn’t been a priority. Hospitals have been the priority,’ she says.

From her experience as a district nurse lead, Ms Alderton believes the profession is under threat because bursary nurse training has been scrapped. ‘If you’ve got a mortgage and are thinking of applying to be a nurse with no bursary, you’re not going to be able to do it,’ she says.

Other reasons for the shortage are the physical demands of the job, a lack of investment in the role, and fewer training posts. Also, many district nurses are approaching retirement. And while there are many vacancies, ‘there aren’t the people to fill them’, Ms Alderton says.

‘It’s a vicious circle. We’re so short staffed, it’s exhausting, morale dips, and then people leave to work somewhere else that will be less stressful,’ she says.

Value of district nursing

The service is being neglected at a cost. By helping to ensure patients can stay at home and out of hospital, district nurses are saving the NHS hundreds of millions. For community matron Ms Boyer, the benefits of the profession are ‘priceless’.

Ms Alderton agrees. That value, she says, is manifested in a multitude of ways, such as giving a daily insulin injection if someone can’t administer it on their own, or giving intravenous antibiotics for wounds to people discharged from hospital within days of having major surgery. District nurses might be managing long-term conditions, nursing people who would otherwise have to be in residential care, or giving end-of-life care and supporting families.

Despite the many skills involved in delivering this type of nursing, Ms Alderton feels the profession is undervalued because ‘people do not understand the complexity of what we do.’

Patients value district nurses ‘immensely’, says Donna Davenport, specialist practice facilitator for district nursing at Hazel Grove Clinic in Stockport, Cheshire. These nurses are ‘highly trained, highly skilled and deliver highly complex care to a diverse patient population while working across health and social care to deliver the integration agenda’, she says.

District nursing training and professional status

This undervaluing of district nursing is reflected in the numbers of nurses who are training for the role. ‘We know that there are around 450 to 500 nurses undertaking the specialist practice qualification in England. But we need three times that number to keep up with the demand,’ Dr Oldman says.

District nurses on the front line of care are concerned about their professional status – Ms Green says the RCN district and community nursing forum, which has 6,700 members, features many posts related to the workforce being ‘demoralised’.

‘Some posts from district nurses are quite positive about the jobs, but they are demoralised by how much hard work it is, how much extra they give in their own time for the service they do,’ she says.

With morale low and the profession under threat, could district nursing disappear from the NHS? Dr Oldman says no. ‘We have the support from the chief nursing officer, Ruth May, and the recognition that this is a specialist practice area that is not going away. It is still regulated by the Nursing and Midwifery Council. Employers have supported the development of apprenticeships, and the Department of Health and Social Care has confirmed its status as a profession from 2020,’ she says.

If the role of district nurse is phased out, nurses say there are no alternatives to replace them. For Ms Green, while there are services for rapid response and end-of-life care at home, it is district nursing that ‘co-ordinates much of that and they are the lynchpins who can provide continuity of care for patients. There is no other service able to do that.’

The way forward

Nurses and nursing bodies told Nursing in Practice what they would like to see to help boost the specialty.

Dr Oldman says the QNI would like a district nurse 10-point plan, following the success of the general practice nursing 10-point plan released by NHS England in partnership with Health Education England in 2017. This plan, she says, was based on many of the nursing body’s recommendations, and raised the specialty’s profile and boosted funding.

The QNI is in the process of looking at the findings of a survey of 3,000 district nurses, which could form the foundation of a 10-point plan for the profession, she says.

Dr Oldman also recommends government ministers spend time shadowing district nurses at work to understand the value of the work they do and spread the word, because when they do, the typical response is, ‘We cannot believe what we have witnessed today – the work district nurses do is amazing.’

Recommendations by the QNI and RCN in their recent combined report include a standardised data set in England, with ‘meaningful data that recognises “value for money”’, to promote a strong economic case for investment into district nursing. In addition, they recommend a strategy to expand understanding of the role among commissioners, health providers and the public.

The report highlighted that district nurses must continue to gain a post-qualifying district nurse specialist practice qualification to create a workforce fit for purpose.

The QNI and RCN also suggested considering the idea of co-locating district nurse teams in primary care networks to enhance continuity of care and working relationships in primary care. The nursing bodies also called for safe staffing and safe caseloads in the community.

Nurses in the front line of care also want to see the value of district nursing recognised. Ms Alderton would like a return of the bursary, ‘so more nurses are able to train more easily’, and for more ‘flexible ways to encourage people to do nurse apprenticeships, and more emphasis on primary care training’, so that more people can be cared for at home.

Ms Boyer agrees it is vital to have ‘robust’ training, funding and support. She also stresses that district nursing as a career should receive the respect it deserves.

And her passion for the profession has no limits. ‘It’s a massive honour to nurse somebody at home and make them feel safe. You can’t put a value on that.’

Kathy Oxtoby is a freelance journalist