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.

Background: Over the last decade the role of Care Worker has grown in complexity and scope. With the recent publication of the NHS ten year plan, the independent commission to transform social care and the implementation of The Care Workforce Pathway for Social Care, an accessible structured approach to planned Continuing Professional Development (CPD) needs to be offered to Social Care workers that takes this scope and complexity into account.

Approach: An iterative four round, mixed methods Delphi study was conducted between January 2025 to August 2025. The researcher participant group consisted of front-line care workers, managers, specialists, and training staff. Round one used open questions to explore the necessary steps for Social Care Workers to develop effective CPD plans and the characteristics of a good plan. Content analysis was used to identify key themes. In round two, research participants were asked to rank the themes. In round three, the previous rankings were used to develop four models which participants were asked to rank. The models were based on 1) the participants’ ranking, 2) the researchers’ previous research, 3) Skills for Care code of conduct standard, and 4) the Northern Irish CORU CPD model. In round four the highest ranked model was sent out to participants and they were asked to agree or disagree, with the model. There was 100% agreement by the remaining seventeen participants at the conclusion of the study.

Results: The final model consisted of five key areas or stages that built on one another.
Stage one: Identify your strengths and gaps in skills and experience and how you learn best.
Stage two: Reflect on your practice, client needs, and code of conduct.
Stage Three: Consider feedback, job description, resources, career development, and interests.
Stage Four: Include organisations policies and procedures, goals, new developments in sector, and mandatory training.
Stage Five: Plan goals to support your development.
Front line workers in the study reported that they experienced CPD as something that was instructed by others while the group of managers and other professionals felt the locus of control was held by the front-line worker.
Implications: The model developed through this research offers an accessible, coproduced structured approach to planned CPD, that considers the scope, complexity, resources, learning methods and interests of the individual worker. This is central to the wider intention of the sector to integrate care and health interventions leading to improved client outcomes and a reduction of pressure on inpatient services. However, a shift in the paradigm is needed within the sector to see front line workers as professionals who can develop and direct their own CPD
This research provides important insights for policymakers, sector skills councils, social care providers, and educational institutes on the development of CPD and illustrates the importance of the need to view social care workers as being at the centre of their own plan and masters of it. Furthermore, the findings have broader applicability, to other registered professions in how CPD is conducted and reviewed.

Background
Delivering high-quality integrated care requires leaders to step outside silos, collaborate across organisational boundaries, and engage the collective intelligence of diverse teams and communities. Yet, few have received training in cross-system improvement. Drawing on the Health Foundation’s Improving Across Health and Care Systems work—developed with national improvement leaders from the UK and Ireland—we designed a leadership course to address this gap, aiming to be the first in the UK to offer training based on its recommendations.
Approach
The Coaching for System Improvement programme was co-designed by system improvement leaders at One Gloucestershire ICS and Rubis QI, Northumbria Health and Care Trust.
It equips senior leaders with coaching skills to enhance collaborative leadership and accelerate transformational change. Drawing on improvement science, coaching theory, co-production principles, and frameworks such as the Health Foundation’s Improving Across Systems, the curriculum blends theory with practical application.
It follows the lifecycle of a system improvement project, with sessions on diagnosing needs, building conditions for change, designing aims and measures, managing change, and sustaining improvement. Peer-to-peer learning and safe spaces for reflection are central, facilitated by a teaching faculty with expertise in quality improvement, coaching, and systems thinking. Case studies and live system challenges help develop practical coaching skills.
The target audience includes senior leaders navigating complex system change, from diverse professional backgrounds across health and care organisations in Gloucestershire. The initial cohort included six participants, with later cohorts expanding to thirteen. Sessions were delivered as full or half days, spaced to allow integration of learning into practice.
Our ambition is to build a cohort of leaders who appreciate the relational aspects of transformation, think systemically, support each other, and spread this approach. A community of practice was established to consolidate skills and foster networks.
Evaluation and reflection were embedded, with structured reviews after each session and at programme end to support iterative improvement.
Results
We have trained 21 leaders (rising to 34 by end of 2025), with bi-monthly community of practice meetings. Satisfaction surveys showed an average rating of 9.14, with 93% recommending the programme.
Evaluation used mixed methods across two cohorts. Findings show increased confidence in relational leadership, psychological safety, and use of improvement tools. Participants valued the cross-organisational cohort, which fostered stronger relationships, broader perspectives, and a shared language of improvement. Protected time for reflection was highly valued, and many reported sustained engagement with coaching practices. Embedding these approaches within organisational cultures remains challenging. Executive sponsorship and strategies for sustaining behavioural change were identified as essential for long-term impact.
Implications
Following two successful cohorts, we are confident the programme meets the needs of health and care leaders seeking to enable collaborative system improvement. Case studies show encouraging changes in practice. Our third cohort is oversubscribed, and we plan to embed a local ongoing programme while exploring regional and national expansion.
The approach is being applied across initiatives including virtual wards, neighbourhood-based falls prevention, and weight management services. In Gloucestershire, it will underpin leadership capability for the continued development of Neighbourhood Health.

Background
Canada’s health workforce is under strain. Health care delivery and related health workforce planning has not kept pace with the needs of an aging population and growing demand for services, resulting in fragmented care and persistent access challenges. Planning has traditionally occurred in professional or jurisdictional silos, disconnected from broader health system transformation. A new, integrated approach is needed to align health workforce planning with population health needs and system goals.
Approach
The Canadian Medical Association (CMA) led a multi-year, evidence-informed, and highly consultative initiative to develop Canada’s first Integrated Health Workforce Planning Policy. The process engaged interprofessional partners alongside health system leaders, researchers, unions, regulators, ministries, Indigenous leaders, and persons with lived and living experience. Foundational work included evidence briefs, interprofessional dialogues, key informant interviews, and a health workforce co-creation event, the finding from the latter were shared at ICIC 2024. The policy’s five core pillars were refined through a series of five sector-specific invitational dialogues with 62 key informants representing persons with lived experience, researchers, medicine, health professions, and health system leaders. These robust dialogues help to shape the content of the policy, which further refined through a targeted consultation involving 176 invited participants representing a wide range of health care interest and rights holders in Canada. These consultations included stand-alone Indigenous-led town halls and patient voice sessions. Feedback from 66 submissions representing 47 organizations affirmed the policy’s relevance.
Results
The development of the policy outlines an innovative, evidence-based approach to integrated health workforce planning that aligns workforce development and deployment with the goals of the health care system and the needs of the population. It emphasizes long-term, inclusive strategies, patient-partnered planning, and data-driven decision-making. A dedicated Indigenous-led section addresses the unique needs of First Nations, Inuit, and Métis health workforce planning, woven throughout the policy as a cross-cutting principle. The consultation process yielded robust feedback, leading to refinements in language, partner and interest-holder inclusion, and clarity of recommendations. The policy has been recognized for fostering trust, collaboration, and constructive discourse across the health system.
Implications
This policy offers a replicable model for jurisdictions seeking to strengthen workforce capacity, inclusivity, and resilience through integrated planning. It aligns with multiple pillars of integrated care—particularly workforce capacity and capability, system-wide governance and leadership, people as partners in health and care, and resilient communities and new alliances. The policy supports the Quintuple Aim by promoting equitable access to care, optimizing scopes of practice, and sustaining health care workers. It signals a long-term commitment to health system transformation and the importance of building relationships across sectors to co-create solutions that meet the evolving needs of communities.

Since Autumn 2024, partners in Hounslow have been developing an integrated model of primary and community care for people with frailty and others with multiple health and social needs.

Reviews of our system had revealed a number of weakness in our current services: a lack of good generalist, ongoing care for people with complex needs, meaning that the system fails to intervene proactively to keep people well and avoid hospital care; a fragmented landscape of small services; and increasing costs.

From Autumn 2024, we brought together staff from across our system to address these challenges. Patients, carers and the voluntary sector played a key role in helping us understand the problems and think creatively about solutions. We agreed to test a model of small, full-time integrated teams sitting in primary care centres.

Our ambition was to restore relationships and continuity, reduce the loss of information and transaction costs that come with transferring people between services, and make better use of staff than possible when staff work in separate silos. We also wanted to restore accountability, through small teams delivering holistic care for defined panels of patients.

We argued that this could also lay the foundations for longer term restructuring. If we build a coherent model of team-based primary and community care, this should provide a basis for simplifying services and moving more staff out of hospitals and service silos into neighbourhoods.

In mid 2025, we brought together staff and patient representatives to co-design the model. We learned from high performing systems in England and other countries. Over three months, we developed our service specification and operating procedures, as well as clarifying our philosophy of care, model of team working and desired culture.

In September, the partnership launched its first two prototype Hounslow Care Together teams. Each team sits together full time at a health centre and serves patients registered at three GP practices. The teams include GPs from the practices, a nurse case manager, social support worker, community health worker and care coordinator. A social worker, housing officer, occupational therapist and pharmacist spend a day a week in each team supporting patients or upskilling staff. Hospital consultants will participate in monthly multi-disciplinary discussions.

In their first month, the teams assessed their first forty patients. In a workshop after the first month, one team member asked :“Shouldn’t we have done this years ago?” Others described being liberated from paperwork, now that they could turn to a social worker or housing officer for help rather than writing a referral letter. The teams received their first thank you letter from the family of a frail couple.

By April 2026, we will be able to share evidence on patient reported health outcomes, staff feedback on working in the new team structure, and evidence of the impact on use of GP services, A&E and hospital services. We will also be able to share learning on the co-design process, mobilisation of the teams, refinement of the team model and plans for applying this model at scale.