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The gold standards framework (GSF), which is a key part of the government's end-of-life care programme, develops tools for those involved in end-of-life care in the community.

The aim is to provide patients with more choice about where they die.

However, the GSF's nursing and clinical leads said only a large and well-trained workforce of district nurses would enable them to achieve those aims. They are concerned this is being eaten away in the rush to recruit community matrons who may or may not look after end-of-life needs.

They are worried that a shift to locality-based community nursing teams could affect progress in end-of-life care.

GSF clinical lead and Birmingham GP Dr Kerri Thomas said the basic job of the district nurse was being undervalued because PCTs failed to replace nurses who moved on to become community matrons.

'The work is not going away. This, and the move to shift district nurses out of GP surgeries, is really undermining all of the constructive work done with GPs on end-of-life care,' she said.

Dr Thomas said if the district nursing workforce was reduced too much it would severely hamper the capacity of the service to move people out of hospitals and care for them at home in their final months.

GSF nursing lead Helen Meehan said that the reorganisation of district and community nursing services into localities could have a damaging effect on patient care.

'District nurses are pivotal to end-of-life care and they need to be recognised as a key part of the primary healthcare team,' she said.

'The majority of GSF coordinators for practices are district nurses.

If they are not attached to practices it would be difficult for them to be consistent members of the primary healthcare team, which could affect coordination and continuity of care.'

The comments follow a progress report showing that about a third of GP practices are now using the GSF. Dr Thomas said she expected the inclusion of more points specifically relating to palliative care in the quality framework to dramatically increase that number.

'I think this will move palliative care from being thought of as a specialist area into the mainstream of general practice care,' she said.

'We are expecting about 90 per cent of GPs to start taking on the GSF.'

She added that practice audits indicated that practices using the GSF could double home death rates.