Doctor Substitution by Advanced Practitioners in UK Hospitals

A Freedom-of-Information request covering roughly half of NHS organisations shows that doctor shortages have prompted many trusts to place advanced practitioners (senior nurses with postgraduate training) on medical rotas. The reliance on APs raises concerns about patient safety and care quality. Forty-three of 86 responding trusts (?50%) assign APs to doctor-level duties; 41 allow them to fill rota gaps, and 55 grant “crash bleeps” for emergencies. Eighty-two trusts permit APs to order investigations, while only six prohibit this. The practice is reported in emergency, neonatal and critical-care units across England, Scotland, Wales and Northern Ireland. The data span England, Scotland, Wales and Northern Ireland, reflecting a UK-wide pattern.

The Guardian

The British Medical Association (BMA) and its doctor-substitution lead, paediatric registrar Dr. Mel Ryan, warn that employing “non-doctors” in medical roles is unsafe and may stem from cost-saving pressures. NHS England stresses that APs are valued team members but should not replace doctors, urging adherence to competence limits. The Royal College of Nursing (RCN) counters that advanced nursing practice is underpinned by master-level education and is essential to safe, multidisciplinary care. Trusts cited include Birmingham Women’s and Children’s NHS Trust, Barking, Havering and Redbridge NHS Trust, Dumfries and Galloway Health Board, Forth Valley Health Board, and Rotherham General Hospital.

The Guardian

Dr. Ryan called the substitution “scandalous,” urging recruitment of more doctors. An inquest into the July 2024 death of David Almond found an advanced nurse practitioner missed a pulmonary embolism risk, contributing to his death. A separate inquiry revealed that a consultant nurse’s unsupervised endoscopy work at Rotherham General Hospital (2016-2021) caused serious harm or death to at least 68 patients. The BMA deems AP use unsafe, the RCN highlights master-level training, while NHS England adopts a middle stance. No comprehensive outcome data exist for patients treated by APs, limiting safety assessment.

The Guardian

• “The extent of doctor substitution shown by these figures is very concerning.” — Dr. Mel Ryan, Paediatric Registrar, BMA lead

The Guardian

• “A RCN spokesperson said: “Advanced nursing practice is highly skilled, delivered by expert registered nurses and is underpinned by a masters level education and a comprehensive range of knowledge, skills and capabilities.” — RCN spokesperson

The Guardian

• “ An NHS England spokesperson said: “NHS guidance is clear – advanced practitioners are highly skilled practitioners and are valued members of NHS teams alongside doctors.” — NHS England spokesperson

The Guardian

• “simply not safe” — BMA statement

The Guardian

• “ A union source added: “This dangerous game is the BMA at its most obnoxious.” — Union source, RCN

The Guardian

The BMA has called for a national review of staffing policies and accelerated doctor recruitment. NHS England plans audits of compliance with AP guidance. Ongoing investigations into the Rotherham and Manchester incidents may shape future regulatory reforms.

The Guardian