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Insufficient staffing is leading to care being missed

8 August 2025

QICN Chief Executive Steph Lawrence writes about risk in community services.

This piece was originally published in the Health Service Journal.

Risk in community services is rarely discussed. But up and down the country, on a daily basis, the NHS fails to deliver the community services it should. This trend even has a name: “care not done due to capacity”. The lack of capacity is due to services not having enough staff and the rising complexity of patients requiring care in their own homes.

As an organisation, we absolutely support the shift of care from hospital to home, but this cannot be at the detriment to patient safety. Just this week, a learning from death notice has been issued to a community trust where a patient died of sepsis, as care could not be undertaken in the community as a result of insufficient staffing.

The inquest report into the death of Susan Clissold attributed the cause of her death in part to understaffing of district nurses. As an ex-chief nurse of a large community trust in this country, I can say categorically this is not the first time this has happened and sadly will not be the last.

Since I started working at the Queen’s Institute of Community Nursing in October 2024, initially as deputy chief executive and now as chief executive, I have been raising concerns about hidden risks in community nursing.

We know at a glance what is happening in our hospitals – how many patients are waiting for a bed, how many patients are being cared for in a corridor or other inappropriate non-clinical spaces, how many patient discharges are delayed in the hospital, and how many ambulance handover delays there are.

However, there is absolutely no oversight at a national level of what care is not being undertaken in the community. Some trusts will have very good local oversight of this, especially those where community care is their main focus; others will have no idea, and therefore the board and possibly the accountable executive director, likely to be the nurse, will have no idea of how much care is being deferred on a daily basis and the risk this causes to patient safety.

There have been several learning from death notices, and I suspect there will be many more to come. We urgently need an overhaul of how we monitor care not able to be delivered in the community. This will include, as in Susan Clissold’s case, wound care and sepsis management. In my experience, it will also include other routine care, such as catheter care, but perhaps more worryingly, it will include elements of end-of-life care as well.

Hospital nursing for many years has had safer staffing tools, which help to an extent, but in the community we still do not have a reliable tool. This is something that has to be addressed urgently, as well as an investment in community nursing services.

We cannot achieve the shift from hospital to community without adequate community nursing services and oversight of patient care to ensure patient safety. I make reference specifically to adult community nursing, but there are issues around staffing levels and capacity for all elements of community nursing, including children’s, homeless and health inclusion services, health and justice services, end-of-life and palliative care services, health visiting, school nursing, and adult social care nursing.

Patients deserve high-quality care wherever they are cared for, and whilst we completely agree that corridor care in a hospital is totally unacceptable, we have to urgently consider what is happening in the hidden community nursing services to avoid further deaths like the one referred to above.

England has lost more than half of its district nurses in the past 10 years. There has been a 43 per cent drop in NHS district nurse roles between 2009 and 2024, falling from 7,643 to 4,322 full-time equivalents.

For every five district nurses in 2009, there are now only three. When adjusted for population need, staffing levels have fallen by more than 55 per cent, equivalent to losing around 4,200 nurses. In an independent 2023 study of UK community nurses, 50 per cent reported missing care on their last shift — even though 78 per cent had worked unpaid overtime.

There have been several coroners’ Prevention of Future Deaths notices citing a lack of community nursing, and I suspect there will be many more to come. We urgently need an overhaul of how we monitor care not able to be delivered in community.

Our own research indicates that the current workforce has to defer these vital visits, often to vulnerable people, on a daily basis, with the remaining district nurses working on average 10 hours a week unpaid overtime (reference below).

There is rightly concern about corridor care in hospitals, but the situation is just as acute in the community. Vulnerable patients such as Mrs Clissold are going without care, with tragic consequences.

If government wants to achieve a meaningful shift out of hospital and into the community, this issue must be addressed.

This piece was originally published in the Health Service Journal.