District nurses need better way to show their value and protect posts

They warned that lack of understanding of the role of a district nurse and the benefits they brought to families and the wider health system had led to “chronic” under-investment.

“It’s the district nurses who do that job day in, day out who are not recognised for that”

Crystal Oldman

The concerns were made in a new joint report released today by the Queen’s Nursing Institute and the Royal College of Nursing called Outstanding Models of District Nursing.

The document revealed how a 46% drop in the number of district nurses in England’s NHS since 2010 meant there were now only 4,000 to provide care to a population of 55.8 million.

This equated to a ratio of only one district nurse for every 14,000 people, compared with one GP for every 1,600 people, it highlighted.

The report warned that greater investment in district nursing was essential if the ambitions laid out in the NHS Long Term Plan for England, were to be achieved.

It called for the creation of a new “meaningful” data collection system that better captured the often-unseen work of district nurses in order to promote a stronger economic case for investment.

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Crystal Oldman

Effectiveness in the NHS was frequently measured on key performance indicators (KPIs) and district nurses should be able to prove their value through ”positive patient outcomes” such as preventing unplanned hospital visits, said the report.

Between 2011-12 and 2017-18 there was a 9% rise in accident and emergency admissions, noted the report, adding: “Clearly this figure is part dependent on the capacity and capability of the district nursing services in the community being able to prevent unplanned admissions and support people to be safely cared for at home.”

Crystal Oldman, chief executive of the QNI, told Nursing Times data should illustrate the work district nurses did around prevention – a key part of the NHS Long Term Plan, which was released in January. 

She said: “When something doesn’t happen, you don’t know that something happened to stop it from happening, so how do you measure that?

“I often say to district nurses: every time you have been to a patient, one of your outcomes is to have avoided unplanned admission.

“That’s what they do day in, day out, but the narrative isn’t avoiding unplanned admissions, the narrative has been unfortunately about – not so much now but in previous years – low-level care, leg ulcers and cups of tea,” she said. “It’s not been about highly complex work.”

Dr Oldman said she believed a marker of success for the country should be if the vast majority of people were being cared for in their own homes at the end of their life.

“That’s when I say we have got a success and it’s the district nurses who do that job day in, day out who are not recognised for that,” she told Nursing Times.

“That would be an indication in terms of statistics as a great outcome,” she added. “If we had that as a goal and an aim that we are going to invest in a district nursing service to improve those statistics around end of life care, and then the next logic of that is okay how many do we need…and that’s when you start to get the investment,” she added.

Other recommendations in the report included:

  • Maintain the post-qualifying district nurse specialist practice qualification (DNSPQ)
  • Develop a strategy to expand commissioners’, providers’ and the public’s understanding and knowledge of the district nurse role
  • Explore the co-location of district nursing teams within primary care networks

The report, which is being launched at the RCN congress in Liverpool today, highlighted how district nurses were being stretched to their limit, working beyond their allocated hours and frequently going their whole shift without a break.

Many community nursing teams had become “task focussed” and unable to deliver the level of holistic and personalised care that they would like to, the report added.

One district nurse interviewed for the project said: “As a group of nurses, we put patients first and would go above and beyond the constraints of our role to deliver high quality care, but we are stretched beyond belief and are only firefighting.”

The document also highlighted how the relocation of district nurse teams away from general practices in many areas had resulted in disjointed care delivery across primary and community services.

Agnes Fanning, author of the report and a Queen’s nurse, told Nursing Times that the report was the result of a year-long project gaining evidence from a wide range of stakeholders including executive nurses, professional and voluntary organisations, nurse students, universities, GPs, carers, patients, and the DNs themselves.

“District nurses provide a lifeline for patients, many of them frail and elderly”

Yinglen Butt

Dr Fanning added: “What was quite interesting was a lot of the views were very similar across all of them – the one key thing that did come out was there weren’t enough; that they were wanting to work as outstanding nurses – they all had the skills but time and resources did not enable them to all the time.”

The NHS Long Term Plan revealed plans to introduce new multi-disciplinary teams into the community to provide faster and more comprehensive care to people in their homes and in the care homes.

Dr Fanning said district nurses were perfectly placed to lead these teams, if they were given the capacity to do so. 

“It would make a lot of sense if the district nurse led the multi-disciplinary teams, because the district nurse is the one professional who does have a really good overview of both physical and mental health,” she told Nursing Times. “This is an ideal time for the district nurse to take on the lead of these teams.”

Yinglen Butt, associate director of nursing at the RCN, said: “Given the fundamental role district nurses play in delivering personalised care close to home, and in reducing the burden on hospital providers, the chronic underfunding of this service is an outrageous false economy.

“District nurses provide a lifeline for patients, many of them frail and elderly, who often can’t leave their own homes to get care elsewhere,” she added.

The NHS Long Term Plan pledged to invest an additional £4.5bn in primary and community services but it not yet known how this money would be spent.

Future plans for the district nurse workforce are due to be set out in the forthcoming NHS People Plan.