The Royal College of Nursing projects that in a decade we might see the complete demise of district nurse services, but how can this be happening in tandem with calls to care for more patients at home, asks Tony Yeaman

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Is a crucial part of the nursing profession truly facing extinction?

Workforce figures show that the number of district nurses – generally female and profiled more towards the upper end of the working age – have dropped from 12,620 in 2003 to 6,656 in 2013.

‘Another decade could see the complete demise of the district nurse’

The Royal College of Nursing suggests that if we continue on a similar linear projection, another decade will see their complete demise altogether.

This reduction in numbers is coupled with a narrative that district nurses are often pressed for time, do not feel that they have the time they need to talk to patients, and that the majority of their patients are frail, elderly and may have communication needs.

The complexities of community care

How can this be happening in tandem with the calls for integration of health and social care; the demand to keep patients and service users in their own homes; the drive to maintain older people in their own homes rather than a hospital bed or a nursing or residential home for life; and the pressure to drive down the number and use of expensive hospital beds while at the same time improving patient safety and care?

What is happening in community services is a complex tapestry, characterised by a number of huge changes in health and social care, as well as the drivers of new technology, changing demography, patterns of demand and austerity.

‘The district nurse has a toolkit of social and interpersonal skills required for providing care in a patient’s home’

In addition to nursing skills, the district nurse has a toolkit of social and interpersonal skills required for providing care in a patient’s home. How many clinicians have to deal with a cat deciding to walk over your sterile dressing area? District nurses have to cope with these sorts of problems every day.

Big machinery pushing out district nurses

Some areas are investing in district nursing services, setting up rapid response services that are staffed by highly skilled nurses who will usually be contracted to begin a complex assessment within an hour of referral.

In combination with high intensity nursing services, they are able to maintain patients through sub-acute episodes in their own homes with the aim to avoid hospital admission. 

Combined with integration with other clinical disciplines and in many areas of social care, this kind of care requires a highly trained and specialised but smaller district nurse service where other traditional nursing tasks are carried out by other members of the care team.

‘This kind of care requires a highly trained, specialised and smaller district nurse service’

How does district nursing fare in the face of the big bits of machinery that are being moved into place in care services now: the Care Quality Commission chief inspector regime; safer staffing, which is probably the main manifestation of post-Francis concerns; and the move to seven day working?

Some initial new style inspections have been undertaken in community services and anecdotal evidence suggests that, not surprisingly, inspectors are happier in a community hospital than they are in a district nurse’s car.

Safe staffing levels are impossible

Although no absolute minimums have been imposed, it was commonly expected that safer staffing models would be based on one registered nurse to eight patients except in specialised situations such as intensive therapy units.  

Safer staffing is almost impossible to define in district nursing services unless there is an agreed capacity and workload model in place. Its absence is one of the many reasons that attempts to generate community tariffs have foundered on the rocks of poor, absent or meaningless data. 

‘The extinction of the services the average district nurse provides would be a sad loss indeed’

Many services are investing in mobile working, new patient administration systems and alternative shift patterns to improve efficiency and maintain patients at home, supporting a move to seven day working, which has always been there to some extent but will be now less variable at weekends. 

The additional information available through these new approaches, which is not universally welcomed by the nurse on the ground, will provide the evidence needed to define the capacity of the system and shoot the fox of unlimited capacity to take on referrals.

These changes are being introduced through training and investment but also through taking fortuitous opportunities to reduce the workforce when individuals leave or retire.

The face of district nursing may well be changing, but extinction of the services the average district nurse provides would be a sad loss indeed.

Tony Yeaman is national head of healthcare at Weightmans LLP