1 in 4 District Nurses Leave NHS, Putting Care Shift Plans in Jeopardy
Government plans to move more NHS care into the community and out of hospitals won’t be achievable unless action is taken to address the dire state of district nursing, with an estimated one in four district nurses having left the workforce in the year to September 2024.
Ahead of the government’s new NHS Workforce Plan, a Nuffield Trust report published today details the consequences of a failure to invest in district nursing, just when it is needed as a cornerstone of community health care.
The authors set out how district nursing services, which are intended to provide care for patients and support for their families at home, in clinical settings and in care homes – 24 hours a day, 365 days a year – are in a state of crisis. The supply of nurses is plummeting while demand for care has risen, and is set to rise further. From 2009/10 to 2023/24, the number of district nurses fell by 43% (an estimated 55% when taking into account growing patient need), while the need for the service is estimated to have risen by 24%.
It is projected that, as more people live for longer and with more complex health needs, demand will increase by another 34% over the next 15 years to 2040. The Nuffield Trust says this trend must be urgently addressed, and restoring the service to 2009 levels, relative to current population, could cost £376 million.
The analysis also found concerning variation in patient access to services across the country, with the number of staff recorded in district nurse roles significantly higher in the North West (13.7 nurses per 100,000 needs-weighted population) but lower in the East (2.8), South East (3.3) and South West (4.4).
Further findings include:
• There were 2.8 million fewer recorded district nursing contacts (such as face-to-face or telephone appointments) in 2023/24 (29.2 million) than in 2009/10 (32.0 million).
• There was a fourfold unexplained variation in reported average cost of a face-to-face appointment between providers of district nursing services in 2023-24 (ranging from £23 to £98).
• In 2023/24, fewer than half of training places led to qualified district nurses.
• District nurses are expected to typically start at NHS pay Band 6, but the analysis found that over one in four (27%) of staff recorded as ‘district nurses’ are at a lower pay band. This could represent an undervaluation of the role and limit the level of skills and experience on the frontline.
• An increasing proportion of the staff working within the district nursing workforce are not nurses – the proportion of staff employed in other roles, including as healthcare assistants, has risen from 18% in 2009 to 28% in 2024.
Previous studies have highlighted issues with district nurses’ experience of work. Up to a fifth (19%) of district nurses’ time is spent on administrative tasks, and in a 2023 survey, a quarter of the workforce reported that they are carrying out more than seven hours a week of unpaid work. The heavy workload is regularly cited as a factor by those leaving the workforce, while the lack of senior roles and access to professional training and development also impacts retention.
The Nuffield Trust report sets out a range of clear recommendations to reverse these trends and improve the supply and retention of district nurses. This includes calling for the Department of Health and Social Care and NHS England to work with employer representatives to ensure there is a mechanism and funding in place, so all newly qualified district nurses have an appropriate role available to them.
Nuffield Trust Chief Executive, Thea Stein said: “District nurses make a huge contribution to the NHS through managing long-term conditions, supporting patients with severe illness, and providing palliative care, but for too long this staff group has been neglected by policymakers. 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.
“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.”
