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The district nursing service in England is at "breaking point" as unmanageable workloads have left patients at risk, a report suggests.

The King's Fund review found there had been a big drop in nurse numbers, causing delays and fewer visits.

And it described a service where staff had been left "broken and exhausted" by the pressures being placed on them caring for the frail and vulnerable.

But NHS bosses said attempts were being made to increase staffing.

District nursing plays a key role in caring for the elderly, those with disabilities and long-term illnesses, by providing support in their own homes.

As well as district nurses, the service includes community matrons and other nurses.

The King's Fund identified official figures showing that district nurse numbers had fallen by 28% in the past five years to just under 6,000, while the wider community nurse workforce had shrunk by 8% to 36,600.

It acknowledged some of this was down to services being contracted out to the private and voluntary sectors - nurses working in those sectors are not counted in the official figures. But it said this would not account for the entire drop.

Researchers spoke to nurses and patients during their review as well as analysing official data.

They were told that the service was being "propped up" by agency staff as managers struggled to fill vacancies.

Staff they spoke to complained they were being left exhausted and stressed out by the extra hours they were being required to do.

And it meant they were not always able to spend the time they wanted to with patients, with delays being experienced and the frequency of visits being cut.

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Anna Charles, of the King's Fund, said: "For years health service leaders have talked about the importance of providing more care in the community, but this objective cannot be achieved when district nursing is at breaking point.

"It is even more troubling that this is happening 'behind closed doors' in people's homes, creating a real danger that serious failures in care could go undetected because they are invisible."

Kathryn Yates, of the Royal College of Nursing, said the findings were "very worrying".

"To let the decline continue would be to knowingly deprive patients of care which makes a proven difference," she said.

But NHS England said attempts were being made to attract nurses back into the community and training places for district nurses were increasing.

A spokeswoman added: "We recognise the hard work of district and community nurses and the pressures many are feeling as they continue to provide valued and high quality care for patients."

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