UK hospitals are increasingly using advanced practitioners—mainly senior nurses—to fill gaps in doctor rotas, raising concerns about patient safety. Figures obtained by the British Medical Association (BMA) under freedom of information laws show that nearly half of NHS trusts and health boards across the UK deploy these staff in roles traditionally performed by doctors, including in A&E, neonatal units, and critical care.
The BMA has warned that this 'doctor substitution' is 'simply not safe' and may be driven by cost-cutting, as advanced practitioners (APs) are cheaper than doctors. The practice appears to breach NHS England guidelines, which state that APs 'should not replace the roles of doctors'. Despite this, some trusts openly confirmed they use APs on medical rotas, with Birmingham Women’s and Children’s NHS trust stating that APs 'work in the same role as their medical colleagues'.
Examples of substitution include APs holding emergency crash bleeps—traditionally a doctor's role—at 55 NHS bodies, and routinely referring patients for tests and treatment at 82 bodies. In Scotland, Dumfries and Galloway health board includes APs on medical rotas in critical care and out-of-hours GP services, while Forth Valley uses them in children’s and neonatal services.
Dr Mel Ryan, a BMA lead on preventing doctor substitution, said: 'The extent of doctor substitution shown by these figures is very concerning. There is a vast difference in the level of education and training between doctors and APs.' She called the practice 'scandalous' and urged the NHS to hire more doctors instead.
The concerns follow cases where mistakes by APs led to patient harm. An inquest in Manchester in July 2024 found that David Almond died after an advanced nurse practitioner at his GP practice failed to recognise his risk of blood clots, despite his history. The coroner noted that Almond 'did not see a doctor' and that the risk of an embolism was missed.
