District nursing: Understanding the decline and mapping the future

District nursing services provide care for patients and support for family members in the community, including at home, in clinical settings and in care homes. Services are intended to be universal – covering every community, village, town and city in England – and operate most, if not all, hours of the day, 365 days a year. Typical nursing care includes wound management, diabetes management, leg and pressure ulcer treatment and end-of-life care. 

As well as supporting the shift towards more person-centred, preventative care closer to home, district nursing services have the potential to save the NHS money. The estimated mean average cost to the NHS of a face-to-face district nurse visit – at £57 – is half that of an Accident & Emergency (A&E) attendance and around a 40th of the cost of an average emergency short-term hospital admission. While the formal evidence on the cost-effectiveness of district nursing interventions is sparse, with some studies suggesting mixed results, various international studies have identified positive effects around, for example, improved quality of life and reduced referrals.

This report, the result of rapid mixed-methods research, describes the current situation in district nursing – including the size and structure of services, how these have evolved over time and how they vary across England. It also explores the case for investment in district nursing and defines some of the core components of high-quality, sustainable district nursing services.

Underinvestment in district nursing

In 2023/24, there were 29.2 million recorded contacts with NHS district nursing services in England across all providers. However, this represents a fall in activity since 2009/10 (32.0 million contacts), despite increasing need for care among the population. In that 14-year timeframe, the population increased in size by 11% and estimated need – accounting for older people using services more frequently – increased by 24%.

The NHS’s failure to invest in the district nursing workforce has significant implications for patients and the wider NHS in England. Previous research has suggested that capacity and workload issues within district nursing services have a particular impact on psychological care and support, assessments and continence care – with these types of care increasingly being performed unsatisfactorily, not being done or falling on already overstretched services elsewhere.

A falling and geographically imbalanced workforce

Between 2009 and 2024, the number of staff recorded in district nurse roles in NHS hospital and community services fell by 43%, from 7,643 to 4,322. Put another way, for every five district nurses in 2009, there are now just three. Factoring in the increasing and ageing population, the trend is worse still: we estimate that staffing levels relative to need have fallen by more than a half (55%), which is comparable to losing around 4,200 full-time-equivalent district nurses.

There also appears to be a postcode lottery in relation to access to district nursing, with the distribution of district nurses varying across England in a way that is inconsistent with measured patient need. Specifically, the relative number of staff recorded in district nurse roles is significantly higher in the North West (13.7 nurses per 100,000 needs-weighted population) but lower in the East of England (2.8), the South East (3.3) and the South West (4.4).

Unexplained variation in the mix of staff

The district nursing workforce comprises a range of staff groups and professions, with registered nurses accounting for fewer than three in four staff in 2024 (72%), compared to 82% in 2009. Conversely, the number of clinical support staff (for example, health care assistants) in district nursing teams has grown and now contributes a quarter (26%) of the workforce.

More than one in four staff recorded as ‘district nurses’ (27%) are actually at a lower pay level (Agenda for Change pay framework, band 5, £35,004 average) than the typical starting point for qualified district nurses (band 6, £41,626 average ¹ ) and so are unlikely to have the District Nursing Specialist Practitioner Qualification – a degree-level training programme for registered nurses. In fact, many teams do not require their ‘district nurses’ to have this qualification. 

On seniority and pay, many district nurses are working at a higher level than would be typical for their current pay band. The national job profiles for (all) nurses, updated in 2025, describe the level of work for different pay bands. Some of the key differentiators between band 5 and band 6 nursing roles include specialist knowledge and frequently caring for terminally ill patients. These are key characteristics of the district nursing role, suggesting that employing nurses in district nursing services at band 5 does not appropriately match the level of skill and knowledge required. In fact, district nursing appears to be aligned with some key characteristics of the higher band 7 nursing job profiles, such as having responsibility for a caseload and the autonomy to decide how expected results are best achieved.

These markers of the (im)balance of the district nursing workforce also all vary significantly between the seven NHS regions in England. For example, we found a growing disparity in the proportion of the workforce who are registered nurses (from 62% in the South East to 79% in the North West) and a nine-fold variation in the proportion of ‘district nurses’ at band 5 (from 5% in the Midlands to 44% in the North West), as at September 2024. ²

Lack of a sustainable supply of district nurses

The NHS in England has failed to develop a sufficient pipeline of new district nurses. Key issues include the following:

• The number of district nursing course places is restricted by, for example:
  • a lack of practice assessors and supervisors
  • cuts to training budgets
  • service pressures, which are restricting opportunities to release staff to
    undertake the training.
• The proposed removal of postgraduate-level apprenticeships for those over 21 years old would have blocked one of the key routes to a district nursing qualification. A total of 360 nurses achieved the qualification through an apprenticeship in 2023/24, equivalent to around three-quarters of all recorded qualifications in the same period. While NHS England and the Department of Health and Social Care have announced funding for the district nurse apprenticeship until 2029, at the time of writing the details were sparse.
• Across the centrally funded training places (excluding apprenticeships), a failure to fill and complete training has led to a leaky pipeline, with an estimated one registered qualification for every three-and-a-half planned places.

There is a clear issue with the participation of district nurses in NHS district nursing services. For every 10 registered nurses with the District Nursing Specialist Practitioner Qualification in 2024, there were fewer than three full-time-equivalent NHS district nurses, excluding those in a district nursing role but paid below the typical starting salary for the qualification. Retention rates are also a concern, with the data we had access to suggesting that an estimated one in four district nurses (at band 6 or above) (25%) left that staff group in the year to September 2024.

Poor pay and career progression are likely compounding retention issues, with district nurses four times less likely to be paid at band 8a (£54,470 average) than across all nurses. Challenging workloads are also contributing to leaver rates, with almost a quarter of district nurses working an additional seven or more unpaid hours a week. Moreover, district nursing has an ageing workforce, with one survey from 2019 reporting that 25% of district nurse team leaders planned to retire in the following six years.

Supporting the sustainability and productivity of services

Commissioners and health care professionals frequently misunderstand district nursing services. Existing methods of activity recording exacerbate this, as they often fail to reflect the breadth of work that district nurses undertake – including the support and advice they give to families and carers after a patient’s death, which cannot be coded. There also appear to be issues with the consistency and appropriateness of many referrals to district nursing services, from both hospitals and general practice, in part due to a lack of formalised referral policies and methods in some areas. And with the gap between demand and capacity widening, workloads are increasingly difficult to manage.

While still low, the real-terms unit cost of a face-to-face district nursing contact has been increasing since 2016, with variation in reported average costs increasing substantially since around 2020. The trend of increasing costs is evident in most of the NHS regions in England, although average costs appear to have fallen in the North East and Yorkshire, and the South West. An array of factors are likely to be driving the trend, such as the rising complexity of patients’ needs and wider cost pressures. Previous research has also pointed towards various inefficiencies that could be increasing costs, including:

• the heavy burden of administrative tasks, which account for up to a fifth of district nurses’ time
• non-optimised travel and challenges finding suitable parking
• a lack of technological systems and support.

That said, as we highlight in this report, there have been some promising examples of ways to overcome these inefficiencies.

Challenges in relation to commissioning and integration are also hindering efforts to ensure sustainable, productive district nursing services. NHS England has sought to improve the standardisation of community health services to help remove unwarranted variation in the commissioning of services. However, community health care is complex and fragmented, covering a vast array of service types and providers, from the NHS to non-NHS providers such as independent community interest companies and voluntary, community and social enterprises. And district nursing services exist within this web of community health services. This represents a challenge not only for commissioners – with integrated care boards also currently having to halve their running costs, meaning they will likely have less capacity to support the needed coordination – but also for effective communication between district nurses and other services, such as general practitioners, hospital discharge teams, social services and voluntary agencies.

Conclusion

District nurses are fundamental to the government’s plans to shift more care from hospital to the community, as well as contributing to more preventative care and supporting under-pressure GP and social care services. District nursing services are already making a huge contribution in managing long-term conditions, supporting patients with acute illness and providing palliative care, all while helping people maintain their independence. However, there are clear challenges to managing the demand on district nursing services, providing an appropriate workforce to meet the demand and supporting the efficiency and productivity of services.

Importantly, the challenges are amenable to policy intervention. To that end, in this report we set out key recommendations in Chapter 4 – covering the supply of new district nurses, skill mix, participation and retention, demand and workload mangement, and integration and coordination. These recommendations include developing baseline or indicative service specifications, and job guarantees for newly qualified district nurses. Certainly, with rising demand for services, the government needs to act urgently to put in place a funded, sustainable strategy to deliver universal, high-quality district nursing services. But the buck does not stop there. Team leaders and directors of nursing, working with – and challenging – their senior colleagues within NHS providers, have a key role in implementing the required changes, alongside the education sector and local and regional commissioners.