Palliative care commission flags district nurse shortages

The Commission on Palliative Care and End-of-Life Care also raised concern about the “failure” of nursing schools and employers to train all nurses in palliative care.

“It’s no surprise, but it is also deeply worrying”

Crystal Oldman

The commission was set up with the support of the health and social care secretary in the wake of the assisted dying bills in England, Wales and Scotland.

The assisted dying debate has brought recognition of the current gaps in high-quality palliative and end-of-life care. The aim of the commission is to analyse and come up with recommendations for addressing these gaps.

In its first report, published last week, the commission – which has previously faced criticism over a lack of nurse representation – noted that many people die in hospital when they would prefer to die at home.

It warned that out-of-hours care in the community was “often unavailable” and that access to specialist palliative care was “patchy”.

The commission found that there was a “workforce crisis in specialist palliative care” as well as “severe shortages of highly trained district nurses and of community nurses”.

A decline in district nurses meant there was now only one district nurse for every 14,000 people in England, compared to one GP for every 1,600 people.

The report went on to warn: “There are not enough hospice nurses to meet this shortfall in community nursing.”

Meanwhile, the commission found that many health and social care professionals receive “little or no training in palliative or end-of-life care”.

It noted that among internationally educated nurses, undergraduate training in these topics was also lacking and that palliative care may be “culturally a different concept” to them.

It found employers were failing to address gaps in training when recruiting staff either domestically or from overseas.

Data from hospitals in England, Wales and Northern Ireland suggested that only 64% included end-of-life care in staff induction programmes and only 51% included it in mandatory or priority training.

“The failure of schools of nursing and induction programmes for nurses to ensure knowledge, skills and attitudes towards palliative care patients are exemplary flies in the face of the Nursing and Midwifery Council standards of proficiency for registered nurses, which lists several relevant core requirements of nurses at the point of registration,” warned the report.

“We are determined to shift more healthcare out of hospitals and into the community”

Government spokesperson

The report’s findings were set within the context of the government’s three shifts for the NHS that it is aiming to achieve through its upcoming 10-year plan for the health service.

One of the three shifts is to move more care from hospitals into the community.

However, the commission warned:  “Without a nursing workforce in the community, it will not be feasible to make the shift of care out of hospital.”

Among the recommendations made by the report was for palliative care to be a “core part” of undergraduate programmes for nursing, medicine and allied health professionals.

In addition, there should be training modules available to all staff in practice in health and social care, the report stated.

The commission also called on the government to “mandate and fund 24/7 specialist palliative care” as well as improve access to community services more generally.

Overarchingly, the commission demanded a new national strategy for palliative and end-of-life care that included a framework for the commissioning and delivery of these services and the workforce requirements for this.

Crystal Oldman

Dr Crystal Oldman, chief executive of the Queen’s Institute of Community Nursing (QICN), said the shortage of district nurses was a “significant problem”.

She told Nursing Times that palliative and end-of-life care were a “core part” of district nurses’ skillset and yet the workforce had been “depleted by significant numbers” over the past decade.

The decline came at a time when there was an ageing population and more people wanting to die at home, she noted.

“So, there is a significant problem,” warned Dr Oldman.

To the QICN – formerly the Queen’s Nursing Institute – the commission’s findings around district nursing were “not a surprise”, she added.

“We’ve been highlighting this for years, so it’s no surprise, but it is also deeply worrying, because we need a significant investment into the district nursing service and into district nurse education,” she urged.

Dr Oldman further noted that hospice nurses often came from a district nursing background, so the lack of district nurses also affected the provision of specialist palliative and end-of-life care.

She called for a workforce plan that boosted the district nursing workforce in line with population need.

“What we need is target numbers that are based on demand,” she told Nursing Times.

“This is a needs-led service so let’s have a workforce plan with numbers that works out how many district nurses we need to be trained in order to meet the needs of the population, to reduce the number of unplanned [hospital] admissions at end of life for people who could be beautifully cared for at home, if only we had a district nursing service.”

A Department of Health and Social Care spokesperson said it would review the commission’s findings and issue a formal response in the coming weeks.

They highlighted the investment the government had made into hospices and added:  “We are determined to shift more healthcare out of hospitals and into the community through our Plan for Change, and we are working to make sure this vital palliative and end-of-life care is sustainable in the long term.”