UK hospitals are increasingly using nurses to cover for doctors due to an NHS-wide shortage of medics, raising fears that “substitute doctors” may provide inferior care. Health professionals known as advanced practitioners (APs) – mainly senior nurses – are undertaking roles usually performed by doctors in A&E, neonatal units, critical care, and other areas.
Widespread Use of Advanced Practitioners
Almost half of hospitals in the UK are deploying APs to cover gaps in doctors’ rotas, according to figures obtained by the British Medical Association (BMA) under freedom of information laws from NHS trusts in England and health boards in Scotland, Wales, and Northern Ireland. The BMA warned that the widespread use of “non-doctors” in medical roles is “simply not safe” and may be driven by hospitals using staff who are cheaper than doctors to save money.
Breach of NHS Guidelines
“Doctor substitution” appears to be in breach of NHS guidelines in England. NHS England stated that while advanced practitioners have valuable skills, they “should not replace the roles of doctors” to ensure patient safety. Despite this rule, some NHS trusts made clear in their responses to the BMA that they do use experienced non-medical staff with specialist skills in roles that doctors would usually perform.
For example, Birmingham Women’s and Children’s NHS trust said: “Advanced practitioners are trained and employed to work in the same role as their medical colleagues. This means that they do work on medical rotas, which can be SHO [senior house officer] or registrar [level] depending on the specialty and level of training.” Barking, Havering and Redbridge NHS trust in east London – where many of health secretary Wes Streeting’s constituents get their care – said that in its two acute hospitals, advanced practitioners’ “coverage typically aligns to junior or middle grade [doctors’ roles]”.
Incidents of Harm and Death
The BMA’s revelations follow a number of cases in which mistakes in diagnosis or treatment by APs led to patients being harmed or dying. An inquest in Manchester in July 2024 concluded that David Almond died in January that year after an advanced nurse practitioner acting as a doctor at his GP practice did not realize that he was at risk of blood clots, despite his history of the condition. The coroner found that when Almond was investigated for breathlessness, “he did not see a doctor ... he was seen by an advanced nursing practitioner.” The possible risk of an embolism was not recognized, and he was sent for an X-ray, which would not diagnose a pulmonary embolism. Four months later, Almond died of a “massive” blood clot.
Another official inquiry found that a consultant nurse had provided dangerously poor care at Rotherham general hospital when performing a complex form of endoscopy between 2016 and 2021, during which time at least 68 patients suffered serious harm or died as a result. The nurse carried out the procedure because the consultant gastroenterologists who had previously performed it had all left the hospital and no replacements were recruited.
BMA and RCN Clash
The BMA’s findings provoked a furious response from the Royal College of Nursing (RCN). An 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. These nurses are central to the delivery of safe and effective care across many services. They are not substitutes for other professions.” A union source added: “This dangerous game is the BMA at its most obnoxious. Pushing nursing down will not help doctors and they need to avoid this getting more ugly.”
An NHS England spokesperson said: “NHS guidance is clear – advanced practitioners are highly skilled practitioners and are valued members of NHS teams alongside doctors. These roles should not replace the role of doctors and should only be used in line with their competence and qualifications, and all staff are able to raise concerns where they are worried about patient and staff safety.”
