Demand on district nursing services leaving staff ‘on their knees,’ says King’s Fund

Adobe Spark (4)A growing gap between capacity and demand in district nursing services has led to staff feeling ‘broken’, ‘exhausted’ and ‘on their knees’, the King’s Fund has said.

A new report (Maybin et al, 2016) published by the think tank has examined the care for older people who receive district nursing services in their own homes. It considered what good-quality care looks like from the perspective of people receiving care, their carers and district nursing staff. This was done by conducting a review of existing policy and research literature, having scoping conversations with national stakeholders, conducting focus groups with senior district nursing staff, and carrying out interviews with patients, carers and staff in three case study sites.

By seeing how patients’ preconceptions of good-quality compared with their actual experiences, the think tank sought to establish what factors support ‘good care’, and figure out what is getting in the way.

Their research indicated that activity has increased significantly over recent years. This applies both to the number of patients seen and the complexity of care provided. From 2005–2014 the number of people living in England has increased by almost 20%, with the most substantial growth seen in the oldest age groups. Additionally, the population aged 85 years and above has increased by just under a third.

It is anticipated that that is set to increase, with the number of people aged 65 years and over expected to rise by almost a half and those aged 85 years and over set to almost double (Mortimer and Green, 2015; Office for National Statistics, 2015). With this increase in age, the likelihood this population will live with chronic disease, multiple health conditions, disability and frailty also rises (Health and Social Care Information Centre, 2014; Oliver et al, 2014).

While demand for services has been increasing, available data on the healthcare workforce suggests a decline in the number of nurses working in community health services over recent years. Additionally, the number working in senior ‘district nurse’ posts has fallen dramatically over a sustained period.

Compromise in quality of care

The result of these pressures is that quality of care is being compromised. Examples highlighted in the report indicate an increasingly task-focused approach to care, staff being rushed and abrupt with patients, reductions in preventive care, visits being postponed and lack of continuity of care. This in turn has caused a deeply negative impact on staff wellbeing, with unmanageable caseloads being increasingly reported. In many cases, staff are leaving the service as a result. Additionally, the King’s Fund has argued that if the ability of district nursing services to deliver appropriate care continues to be undermined, there will be consequences in terms of additional hospital admissions, delayed discharges and dependence on social care.

The King’s Fund have warned that those most likely to be affected by the pressure faced by district nursing staff are often the most vulnerable members of society, who will therefore most likely be affected by cuts in social care and voluntary sectors. They warn that what is more concerning is that this is happening ‘behind closed doors in people’s homes, creating a real danger that serious failures in care could go undetected because they are invisible’ (Maybin et al, 2016).

Recommendations outlined in report

As a result of the issues identified in the report, the King’s Fund have issued the following recommendations as immediate priorities:

Match the stated intention to move care into community settings with greater attention to this service area. Despite intentions by policy makers and regulators to deliver ‘care closer to home’, the direction of resources, monitoring and oversight remains distinctly focused on the hospital sector. The report therefore recommends that community services must be involved in, and central to, the development of new care models and Sustainability and Transformation Plans.

Involve district nursing service leaders in local plans for service redesign. Too often the voice of district nursing service leaders is absent at the system level. The report highlights the valuable role of district nursing and how it is of central importance to the wider health system. The service enhances the health and wellbeing of people living in their own homes, often caring for people with complex and multiple health needs, and helps prevent deteriorations in health and the need for additional services. Therefore now, more than ever, this important but pressured service needs to be part of discussions about future service redesign.

Respond to the issues facing community health and care services, and the needs of people who depend on these, in the round. To address the wide-reaching problems faced by all services, not just district nursing, the report recommends NHS England and Health Education England, together with local commissioners and providers, look in the round at the staffing and resourcing of community health and care services for the older population, taking into account the capacity of people receiving care, their unpaid carers and local communities.

Renew efforts to establish robust national data on capacity and demand in district nursing services. This would include establishing a standard for demand–capacity and workload planning tools in this area, as is currently being undertaken by The Queen’s Nursing Institute and NHS Improvement. The report highlights that the absence of robust national data on activity levels in district nursing services and of a clear dataset on trends in staffing numbers, makes it very difficult to demonstrate, understand and monitor the demand–capacity gap within this service area.

Accelerate the uptake of digital technologies and support implementation. The report argues that adopting new technologies should remain high on the agenda of providers and local service leaders as a strategic area for development, as district nursing stands to benefit significantly from enhanced digital support, if it is designed and works well. Technologies that enable remote working, such as iPads and other tablets, have the potential to improve efficiency and productivity, as well as enhancing quality and safety through timely access to notes at the point of care and supporting communication between professionals.

Develop a meaningful form of oversight for care delivered in people’s own homes, which is sensitive to the unique characteristics of this care. The report stresses the need for national oversight systems to be developed in order for their frameworks to meaningfully capture and reflect care quality. Current national mechanisms of quality assurance and accountability, which are largely designed to assess hospital care, are poorly suited to measuring quality in the community.

Develop a sustainable district nursing workforce. Undoubtedly the most important recommendation, the King’s Fund warns the shortage of suitably trained staff to fill roles in district nursing services is a major cause for concern. Services are increasingly unable to recruit and retain staff. With many of the current district nursing workforce approach retirement age, and others choose to leave due to service pressures, it is understood that this situation will likely worsen.


District nursing services have a key role to play in the national health system, allowing patients to be treated in their own homes and avoid unnecessary hospital admissions. They allow patients to maintain their independence, maintain long-term conditions and manage acute conditions. However, this is only possible through a sustainable workforce. Insufficient staff numbers place unmanageable pressures on the existing workforce as well as other areas of the health service. This report highlights a dissonance between the policy drive to move more care out of hospitals into community settings, and the capacity problems being experienced in district nursing services. It presents a number of recommendations for addressing these issues and calls for the need to develop a robust framework for assessing and assuring the quality of care in the community.


Health and Social Care Information Centre (2014) Focus on the health and care of older people. NHS Digital, Leeds. (accessed 23 September 2016)

Maybin J, Charles A, Honeyman M (2016) Understanding Quality in District Nursing Services. The King’s Fund, London. (accessed 22 September 2016)

Mortimer J, Green M (2015) Briefing: The Health and Care of Older People in England 2015. Age UK, London. (accessed 22 September 2016)

Office for National Statistics (2015) Population estimates for UK, England and Wales, Northern Ireland: Mid-2014. Office for National Statistics, Newport. (accessed 22 September 2016)

Oliver D, Foot C, Humphries R (2014) Making our health and care systems fit for an ageing population. The King’s Fund, London. (accessed 23 September 2016)

Taken from British Journal of Community Nursing, published 3 October 2016.

Emergency calls increase by 6.1%

In June, annual performance data for ambulance services in England were published by the Health and Social Care Information Centre (Workforce and Facilities Team, Health and Social Care Information Centre, 2015). It revealed that the number of emergency 999 calls presented to ambulance switchboards over the past year was 9 million. This represents an increase of 515 506 (6.1%) over last year’s 8.49 million calls. To break this down, this is an average of 24 661 calls per day or 17.1 calls per minute.

Of these calls, 3.14 million (48.5%) were classified as category A (most urgent) and resulted in a response from an emergency vehicle. Of these, 5.2% (164 478) were classed as Red 1 (most serious) and 94.8% (2.98 million) were classed as Red 2 (serious but less urgent). The response rates within 8 minutes were as follows: Red 1—71.9% nationally with 5 of the 11 ambulance Trusts achieving 75% or more (compared to 75.6% for 2013–14); Red 2—69.1% nationally with 1 of the 11 ambulance Trusts achieving 75% or more.

It is worth noting that the national Red 2 data needs to be treated with caution, as a result of the Secretary of State for Health introducing the Dispatch on Disposition (DoD) pilot in February 2015 (Hunt, 2015), rolled out within London Ambulance Service NHS Trust and South Western Ambulance Service NHS Foundation Trust. The pilot increased the time call handlers have to assess patients before the ‘clock starts’ from 60 seconds to a maximum of 180 seconds for all 999 calls, except those categorised as Red 1. The aim was to allow more time to triage and therefore improve the overall outcomes for ambulance patients.

However, the pilot caused notable sensationalism within the media when the proposed recommendations for change were leaked by a whistleblower in December 2014 (BBC, 2014). Although the clinical advice claimed a change to response times would improve overall outcomes for ambulance patients, concerns were raised as to whether this would in fact be the case.
Factors thought to have affected response times for 2014–15 included the increase in demand for ambulance services, which in turn has put pressure on resources; the location of incidents; patient handover and turnaround time; and staffing numbers.

Perhaps one of the most interesting findings was that the proportion of incidents managed without need for transport to A&E has risen slightly from 36% last year to 37% this year (two years ago this was 35.1%). This figure concerns patients discharged after treatment at the scene or onward referral to an alternative care pathway, and those with a patient journey to a destination other than Type 1 or 2 A&E.

Given the introduction of the DoD pilot, it is difficult to gain an accurate gauge of how Red 2 response times have changed over the last year. However, what is evident is that the number of emergency calls to ambulance services has increased. Assuming this will continue to rise, new initiatives will be required to meet this demand.


BBC (2014) Ambulance Targets: Plan for longer times in England revealed. BBC. (accessed 21 December 2014)

Hunt J (2015) The ambulance service in England. HCWS201. The Stationery Office, London

Workforce and Facilities Team, Health and Social Care Information Centre (2015) Ambulance Services, England 2014–15. HSCIC, Leeds. (accessed 29 June)

Taken from Journal of Paramedic Practice, published 3 July 2015.

Paramedic views wanted for development of new standards for ambulance patient records

The Royal College of Physicians (RCP) is encouraging paramedics to participate in a survey as part of an important project for clinical care of patients in ambulance services.

New standards for ambulance patient records are being developed in the national project initiated by NHS England. The standards must reflect the needs of patients, paramedics and other care professionals in delivering patient care.

The information that ambulance clinicians, care assistants and volunteers record about the patients with whom they are working is an important clinical record. As the development and implementation of electronic health records gathers pace across the health service, the ability to integrate ambulance information with secondary and primary care patient clinical records becomes increasingly important.

The standards will be designed to meet the needs of patients, reflecting the way the care professionals work across the four nations of the United Kingdom. The aim is to develop standards that support optimal care and enable integration with other electronic health record systems, including hospital and primary care systems. This is a vital step in the creation of the unified patient-focused record.

The project is led by the ambulance services and relevant professional bodies, supported by the Health Informatics Unit (HIU) of the Royal College of Physicians (RCP) and the Health and Social Care Information Centre (HSCIC). It will engage widely with pre-hospital professionals, patients and other identified stakeholders, including primary and secondary care clinicians.

Taken from Journal of Paramedic Practice, published 16 December 2013.