Over a quarter of district nurses lower than Band 6, report finds

More than one in four district nurses are at a lower pay band than the typical starting point for the profession, while a growing proportion of staff working within district nursing teams are not registered nurses, a major report has suggested.

The report, commissioned by the Queen’s Institute of Community Nursing (QICN) and carried out by the Nuffield Trust, raises serious concerns about an ‘undervaluation’ of district nursing, as well as skill shortages and widening regional disparities in district nurse access across England.

The findings, based on data from 113 NHS trusts, show that 27% of professionals listed as ‘district nurses’ and employed under Agenda for Change (AfC) are working at Band 5 in England. This is despite the typical starting point for district nurses being a Band 6.

The report suggested those employed at Band 5 were unlikely to have the District Nursing Specialist Practitioner Qualification, adding: ‘In fact, many teams do not require their “district nurses” to have this qualification.’

Report authors suggested this could reflect an ‘undervaluation of the role and limit the level of skills and experience on the frontline’.

But at the same time, the report said there were ‘many’ district nurses working at a higher level than would be typical of their current pay Band.

‘Some of the key differentiators between Band 5 and Band 6 nursing roles include specialist knowledge and frequently caring for terminally ill patients,’ the report said, pointing to recently updated national job profiles.

‘These are key characteristics of the district nursing role, suggesting that employing nurses in district nursing services at Band 5 does not appropriately match the level of skill and knowledge required.’

Earlier this year, the QICN warned that some district nurses felt ‘obliged’ to accept lower paid job roles to achieve changes to their hours, working conditions or to further their education.

The Nuffield Trust report suggested – in line with ongoing calls of the QICN – that the role of a district nurse should be recognised as a Band 7.

‘In fact, district nursing appears to be aligned with some key characteristics of the higher Band 7 nursing job profiles, such as having responsibility for a caseload and the autonomy to decide how expected results are best achieved,’ the report said.

Despite national job profiles including key responsibilities that align with Band 7 roles, the researchers found that many job adverts still list these duties in Band 6 district nurse posts.

Regional pay disparities

The analysis also found major variation in how district nurses are banded across England.

The South West and North West had the highest proportion of district nurses working below Band 6, at 43% and 44% each.

The Midlands and East of England had the lowest proportions of district nurses working below Band 6, at 5% and 6% respectively.

Less registered nurses in district nursing roles

Further analysis by Nuffield Trust revealed that registered nurse numbers were falling as a proportion of the district nursing workforce – accounting for fewer than three in four staff (72%) in 2024 compared to 82% in 2009.

In 2009, all seven NHS regions in England had, on average, a similar proportion of district nursing staff who were nurses, with levels ranging between 78% and 84%.

In the South East, nurses now make up only 62% of the workforce, compared to higher figures like 79% in the North West (as at September 2024).

Meanwhile, the proportion of healthcare assistants working in district nursing has risen sharply in recent years – from 18% in 2009 to 28% in 2024.

Clinical support staff now make up a growing share of the district nursing workforce, increasing from 16% in 2009 to 26% in 2024.

However, this trend varies across regions. The proportion of staff in health care assistant or health care support worker roles ranges from 10% in the North West to 19% in the South East.

The report highlights how these roles can provide valuable support for tasks like rehabilitation and continence care, but points to previous reviews warning that inadequate training and supervision could compromise patient safety and care quality.

The number of clinical support staff, including health care assistants, has risen by 15% since 2009 to 2,905 as of September 2024.

A shrinking workforce under growing pressure

As has previously been reported, the number of district nurses has plummeted by a staggering 43% since 2009.

Between 2009 to 2024 the report estimates that staffing levels relative to need have fallen by over half (55%), which is comparable to losing around 4,200 full-time-equivalent district (FTE) nurses.

Turnover also remains high with an estimated one in four district nurses working at Band 6 and above having left the profession in the year to September 2024.

And fewer than three full-time equivalent (FTE) district nurses were recorded for every 10 registered nurses with a district nursing qualification in 2024.

Falling contacts and rising costs

District nursing contacts, including face to face and telephone appointments, fell from 32 m 2009/10 to 29.2 million in 2023/24, the report also found.

The cost of face-to-face district nursing appointments varied fourfold between the different providers examined in the report.

Costs ranged from £23 to £98, with the report authors finding no clear explanation for the variation.

More funding is needed

Commenting on the report, chief executive of the QICN, Steph Lawrence, said a lack of district nurses was leading to ‘corridor care in the community’ and that rising numbers of coroner’s reports were citing district nurse shortages as a factor in patient’s deaths.

‘More funding to train district nurses is required, alongside ensuring we have continuation of level 7 Apprenticeships and finally ensuring we remunerate at the correct Agenda for Change band for the specialism – a minimum of Band 7 to reflect the advanced and autonomous practice of district nurses today,’ she added.

Her comments come after the government’s decision in May to remove funding for which includes Level 7 apprenticeships for people aged 22. The move was widely criticised by community nursing leaders, who warned the move undermines the government’s own ambition to shift care from hospitals to the community.

The government has since confirmed Level 7 apprenticeship funding for some NHS roles, including specialist community public health nurse (SCPHN) and district nurse (Community Specialist Practice Qualification).

Stark consequences

Nuffield Trust chief executive, Thea Stein, said district nurses make a ‘huge contribution’ to the NHS, and have been neglected by policy makers ‘for too long’.

‘The consequences we have uncovered are stark – far fewer patients are getting crucial support from district nurses, despite the ever-growing need for these services,’ Ms Stein warned.

‘If the government doesn’t begin to address the glaring issues with district nursing and build a workforce plan that better supports this pillar of community care, it will be a core weakness of efforts to shift more care from hospital to home.

‘Urgent action is needed to ensure the training pipeline for district nursing is fit for purpose.’

Royal College of Nursing (RCN) general secretary and chief executive, Professor Nicola Ranger, said: ‘District nursing is among the best investments a government can make.

‘They are key to delivering expert interventions to help people live healthier lives in their communities, their visits are vastly cheaper than expensive hospital admission, and they will be absolute vital in the success of the planned neighbourhood health service.’

Professor Ranger warned the government’s focus on shifting care from hospital to community ‘cannot be delivered on the backs of a depleted district nursing workforce or by damaging acute care provision at the same time’.

She said ministers had ‘a great chance to bring forward new investment’ in the government’s highly anticipated workforce plan.

Last week, the Care Quality Commission (CQC) issued a warning about falling district nurse numbers and said a shortage of the profession was driving ‘task-based’ care and risks undermining the government’s plans to shift care from hospital settings into the community.

In December the health and social care secretary, Wes Streeting, said district nurses were an ‘absolutely vital part’ of the NHS that are often ‘undervalued and understaffed’.

And last September, the Darzi review found that lack of investment in community services and its nursing workforce has left the NHS in a ‘critical condition’.

In the same month, the RCN revealed new analysis suggesting the specialist nurse workforce – including district nurses, health visitors and school nurses – was on track to halve in size over a 20-year period.

Last summer, the QICN published a report showing that district nurses are having to defer end of life care due to rising workloads and increasingly complex patient needs.

A Department of Health and Social spokesperson said: ‘This government is working to turn around the NHS workforce crisis we inherited. Nursing is a skilled, challenging and deeply rewarding profession and district nurses will play a crucial role as we shift more care out of hospital and into the community as part of our 10 Year Health Plan.

‘We are backing nurses with a graduate guarantee that will unlock thousands of new jobs, ensuring newly qualified nurses find roles easier and our Skills for Care strategy will encourage more nursing students to pursue a career in social care.

‘The 10 Year Workforce Plan will also make sure the NHS has the right people in the right places, with the right skills to care for all patients, when they need it.