Safety fears as UK hospitals use nurses to cover for doctors due to shortage of medics

Exclusive: Advanced practitioners are being deployed to cover doctor rota gaps across the NHS, figures show

UK hospitals are using nurses to cover for doctors because of an NHS-wide shortage of medics, raising fears that “substitute doctors” may provide inferior care.

Health professionals known as advanced practitioners – who are mainly senior nurses – are undertaking roles usually performed by doctors in A&E, neonatal units, critical care and other areas.

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 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.

Its revelations follow a number of cases in which mistakes in either diagnosis or treatment by APs led to patients being harmed or dying.

“Doctor substitution” appears to be in breach of NHS guidelines in England. NHS England said that while advanced practitioners have very valuable skills, in order to ensure patient safety, such staff “should not replace the roles of doctors”.

Despite that 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]”.

In Scotland, Dumfries and Galloway health board includes APs alongside doctors on medical rotas in its critical care unit and also as part of its out-of-hours GP service. And Forth Valley health board uses them in its inpatient children’s and neonatal services.

In a further formalisation of APs’ role providing care usually done by doctors, 55 of the NHS bodies across the UK that responded to the BMA’s request for information said they allow APs to hold crash bleeps, so they can be called if an emergency arises, which traditionally only doctors have. Only 32 said they did not do that.

“The extent of doctor substitution shown by these figures is very concerning. It is startling to see close to half of NHS organisations reporting that they use APs in doctor staffing, holding the emergency bleeps and making referrals to different specialities,” said Dr Mel Ryan, a paediatric registrar in Nottingham and a BMA lead on preventing doctor substitution.

“There is a vast difference in the level of education and training between doctors and APs. APs cannot substitute for doctors, yet alarmingly many employers are doing just that.

“I think it is scandalous that the NHS is allowing the substitution of doctors by individuals without sufficient medical knowledge instead of the obvious response to doctor shortages: hiring more doctors,” she said.

About half of all NHS organisations across the UK took part in the BMA’s survey. Almost half – 43 – said they deploy APs on medical rotas; 45 said they do not. Similarly, 41 said APs are allowed to cover doctor rota gaps; 44 do not permit that.

APs are routinely referring patients for tests and treatment. That happens at 82 NHS bodies and only six said they do not allow APs to do that.

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 realise that he was at risk of blood clots, despite his history of the condition.

In the prevention of future deaths report issued afterwards by the coroner, Alison Mutch, she found that when Almond was investigated for breathlessness in September 2023 at his GP surgery “he did not see a doctor ... he was seen by an advanced nursing practitioner.”

“The possible risk of an embolism was not recognised and he was sent for an X-ray, which would not diagnose a pulmonary embolism,” she said in the report. The X-ray was clear, so he was not seen again. The ANP did not recognise that Almond should have a follow-up appointment, even if the X-ray showed nothing wrong, the coroner added.

Four months after the fateful appointment with the ANP, Almond died of what Mutch called a “massive” blood clot.

An official inquiry found that another AP – 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 combination of an endoscopy and an X-ray – which is known to be challenging and risky – because the consultant gastroenterologists (doctors) who had previously performed it had all left the hospital and no replacements were recruited.

The nurse was dismissed and the hospital apologised for the “substandard” care, which led to “a cluster of adverse incidents and complications”, including deaths.

The BMA’s findings provoked a furious response from the Royal College of Nursing. 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.

“These nurses are central to the delivery of safe and effective care across many services. They are not substitutes for other professions. They are autonomous professionals, delivering complex care as part of multi-disciplinary teams.”

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.”