No one is a stranger to the pressures exerted on the NHS, least of all its staff. However, one group in particular is overstretched and under intense financial constraints: the district nursing workforce. The problem is both acute and, up to now, almost completely undocumented.
Pressures on the service may be reaching critical mass, with rising demand and static, or falling, budgets placing immense pressures on the service. A recent report from the King’s Fund, Understanding Financial Pressures in the NHS, described district nursing services as ‘under particular strain’. This, in turn, is negatively affecting the quality of patient care, as well as the morale of the workforce itself. According to the report, the structural differences between the community sector and acute and general practice, mean that the workforce experience disproportionate levels of pressure.
‘The findings of the King’s Fund provide unequivocal confirmation that cuts to district nursing services in some areas are having a negative effect on patient care,’ said Crystal Oldman, chief executive of the Queen’s Nursing Institute.
The pressures are not just a concern for district nurses. Several pieces of anecdotal evidence in the report reveal the dependence of other services on the district nursing workforce. These include:
- Examples of hospitals releasing bed capacity by discharging people earlier following admission for acute illness or surgery. This leads to district nurses picking up the ongoing care that would have been carried out in hospital, undertaking tasks such as managing surgical wounds or administering antibiotics.
- The pressures in general practice increasing district nursing workloads. In one case cited by the report, shortages in a general practice out-of-hours service meant that district nurses were completing tasks traditionally undertaken by GP, such as certifying deaths.
- Cuts to publicly funded social care put pressure on district nursing caseloads as they are providing additional support.
‘Our research shows that services like district nursing, where we found evidence that access and quality are deteriorating for some patients, have been hardest hit by the financial pressures facing the NHS but that this is often going unseen,’ said Ruth Robertson, a fellow in Health Policy at The King’s Fund and lead author of the report. ‘This undermines the vision set out in the NHS five year forward view to strengthen community services and focus on prevention.
Additionally, the report highlighted the difficulty in measuring the funding and performance of community-based services. It states that ‘national data on NHS performance mainly covers acute hospital services, with little known about community-based services’.
‘There is strong evidence that services are under pressure and this is negatively affecting the quality of patient care,’ said Kathryn Yates, Royal College of Nursing lead for primary and community care. ‘We know that the demand is growing, while services are faced with funding constraints, and there is a critical shortfall in the workforce. However, there is little data on the level of activity taking place, other than this report.’
The report identifies a number of other concerns for the district nursing workforce. These include recruitment and retention of nurses, disproportionately large workloads, and the difficulty of managing demand for community services.
‘It is a service that is highly networked and highly interdependent with the rest of the health and care system, and therefore how other services are operating or not operating has a major impact,’ said one district nurse.
‘If the rising number of older and more vulnerable people in the population, often with multiple co-morbidities, are unable to access nursing services at home, this has a knock on effect on GP services and on A&E,’ says Ms Oldman. ‘It also means that more patients have to stay in hospital because they cannot be discharged home. This is expensive for the NHS and undesirable for many patients and their families.’
Another issue identified by the report was the challenge of managing the demand for community services, a difficult task in comparison to acute and general practice services. While in general practice and acute settings, there are a finite number of appointments and beds available to patients. However, in district nursing, the only way to rationalise demand for services is by raising access criteria. This is undesirable as it risks patients’ conditions being more severe before they are seen. For example, if patients are able to visit their general practice (even if doing so is challenging), they will not be eligible to receive care from district nurses in some areas.
‘If a ward is full, a ward is full, but within district nursing caseloads there’s no way of doing that,’ said a district nurse cited in the report. ‘The referrals keep coming, and providing they are appropriate in terms of clinical requirements, then those patients will be accepted… The demands increase exponentially and it’s not easy to control.’
The situation is being exacerbated by a shortage of district nurses. Data cited in the report indicates that the total number of nurses working in community health services has declined over recent years, and the number working in ‘district nurse’ posts has dropped by almost half since 2000. Monthly workforce data released by NHS Digital last year suggested that this decline is continuing: the number of full‑time equivalent district nurses fell by a further 14.8% between September 2014 and September 2016.
Some of these falls are a result of deliberate policies by CCGs to reduce costs by holding back from filling vacancies or recruiting less senior staff, but in many areas where posts are available, services are unable to recruit due to a lack of qualified applicants. ‘It’s not just that there isn’t the money, there actually aren’t the nursing staff’, said one team manager.
To minimise the impact of the shortfall in staff and rise in demands on patients, many district nurses are working intensely over long hours. This presents issues for patient care, with the King’s Fund identifying an increase in task-focused approach, with staff being rushed and abrupt, along with reductions in preventive care, visits being postponed, and a lack of continuity of care for the patient.
Additionally, the situation is having a negative impact on staff wellbeing, often leading to low morale and high levels of stress, which in some cases seems unsustainable. This in turn, has led to a vicious cycle of significant retention problems, with nurses moving into other roles or leaving the service altogether. Additionally, senior roles often remain vacant or are filled with less experienced staff.
According to the report, ‘The service seems to be depending on goodwill to a large extent’, but one interviewee reported that ‘more and more, the staff goodwill is running out’.
District nursing is also beset by a visibility problem, meaning that it is not treated with the priority a crisis in the acute sector would be. Ms Oldman says that the care provided by these services often takes place ‘behind-closed-doors’ and ‘away from the eyes of public, media and commissioners, it has historically had a low profile compared to hospital or GP services’.
However, despite the significant problems identified with district nursing, the report also indicated that many areas were working on innovative projects to relieve the pressures on the workforce.
The most prominent of these included the using of digital technologies. Many services now provide staff with tablets, allowing remote access to patient lists and notes and enabling staff to go straight to patient visits at the start of their shift. While there is variation in the extent to which services are utilising these technologies, the report showed evidence of ‘striking efficiencies’ where implementation has been successful; one interviewee gave an example of a service that had saved an average of one hour per nurse per day by introducing tablets.
Upgrading and streamlining the use of clinical equipment was also found to be a potential solution to pressures. The report cites services using new wound dressings that allow less frequent visits and promote more rapid healing, while services are changing the way they order equipment. For example, this can be done by ordering a supply to keep in stock rather than prescribing and ordering it for individual patients, where it would be wasted if it were not used by that individual. One frontline district nurse reported that their service had reduced the number of different dressings used so that cheaper, larger-volume orders could be made.
In the meantime, the district nursing workforce continues to prop up many other sectors of the health service. If the financial and professional pressures on the role become too great, it’s not far-fetched to see how this will have having a catastrophic impact on the wider health services.
A hospice manager quoted in the report cited the ‘tsunami effect’ of large increases in patients requiring their services as the provision of district nursing waned. ‘We neglect district nursing services at our peril,’ says Ms Oldman.