District nursing: How to reverse the decline and rebuild capacity?

Background: District nurses are specialty qualified nurses in the NHS that provide care and support to patients and their families in their own homes. Intended to be universal, services cover every community, town and city in England and operate most, if not all, hours of the day, 365 days a year. These services will be fundamental in achieving the UK government’s ambition to better integrate services and shift more care into community settings.

This research describes the current situation of district nursing in England and sets out a case for change, defining the core components of establishing a high-quality, sustainable district nursing service. While rooted in the English context, this analysis offers lessons to other countries seeking to strengthen community-based care, particularly around workforce planning and service integration.

 

Approach: This study used a rapid mixed-methods approach including a review of twenty-seven international and UK-based papers, a comprehensive job advert review to understand entry requirements and responsibilities and analysis of published and bespoke datasets covering training, workforce and financial costs.

 

We also engaged with approximately thirty key experts and stakeholders through shadowing of district nurses, conducting interviews and the delivery of two focus groups - one focused on local barriers and enablers and the other on broader policy perspectives. A rapid research design was chosen to maximise the opportunity to influence key policy strategies such as the updated NHS Workforce Plan.

 

Results: Our analysis shows that the NHS has failed to invest adequately in district nursing, and that the role is often undervalued and misunderstood. The number of staff in district nursing roles has fallen by 43% between 2009 and 2024. This decline has happened while the estimated need for services has risen by 24% meaning that workloads are becoming increasingly unmanageable and the gap between demand and capacity is widening. Key barriers to building capacity and sustainability in the district nursing workforce include:

1. Changing skill mix: The proportion of registered nurses within district nursing teams is falling and clinical support staff now represent an increasingly large proportion of the district nursing workforce.
2. Falling participation and retention: The NHS has not maintained a pipeline of qualified district nurses, with course places limited and more than one in four district nursing staff working at lower pay bands and therefore unlikely to have a specialist qualification.
3. Efficiency and productivity challenges: Outdated technology, excessive administrative tasks, and inconsistent referral policies all continue to limit efficiency.

 

Implications:  Our findings highlight the contributions of district nurses in providing holistic, person-centred care closer to home, supporting wider under-pressure services and helping avoid hospital attendances. Ensuring these benefits are sustained and available across all communities will require concerted action to strengthen and support the workforce.

We set out recommendations for policy makers, providers and commissioners to increase the supply of qualified district nurses and better manage demand and workload management. While focused on England, these challenges and trends are likely to be relevant to other health systems and offer important insights for international contexts.