Ahead of the government's new NHS Workforce Plan, the Nuffield Trust report reveals that 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%.

The Nuffield Trust says this trend must be urgently addressed, and restoring the service to 2009 levels, relative to current population, could cost £376m.

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 DHSC 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: ‘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.'

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Stephen Lawrence, chief executive of QICN, who was involved in facilitating early input into the research, said: ‘There are many things that have contributed to this, but the District Nursing workforce has been overlooked by policy makers for too long. If the 10-year plan and shift of care from hospital to community is to be realised, urgent action is required, as it will not happen without a robust district nursing workforce.

He added: ‘The QICN has been calling on Government and NHS England to ensure we train adequate numbers of district nurses for a number of years. We now say this has to be seen by Government as a critically urgent issue. More funding to train district nurses is required, alongside ensuring we have continuation of level 7 apprenticeships and finally ensuring we remunerate at the correct Agenda for Change band for the specialism – a minimum of band 7 to reflect the advanced and autonomous practice of district nurses today.'

RCN general secretary and chief executive, Professor Nicola Ranger, said: ‘District nursing is among the best investments a government can make. They are key to delivering expert interventions to help people live healthier lives in their communities, their visits are vastly cheaper than expensive hospital admission, and they will be absolute vital in the success of the planned neighbourhood health service.  

‘The government's focus on shifting care from hospital to community and from sickness to prevention is the right one, but it's time for a reality check. It cannot be delivered on the backs of a depleted district nursing workforce or by damaging acute care provision at the same time. Ministers have a great chance to bring forward new investment in the forthcoming ten-year workforce plan or risk those very reforms becoming unachievable.'

Rory Deighton, acute and community director at the NHS Confederation, said: ‘District nurses are the bedrock of NHS community services and their importance will only grow as the NHS works towards the government's ambition to shift care away from hospitals and closer to people's homes. But it is clear from this report that these services are under immense pressure from a combination of growing patient need and fewer staff.

‘NHS England's recent Medium-Term Planning Framework predicts a 3% annual growth in community services' activities will be needed to keep pace with rising demand. This will require more district nurses, not fewer – both to keep existing services running and to bring more care closer or into patients' homes. We look forward to feeding into the upcoming workforce plan about how to achieve this across the NHS over the next 10 years.'