UK hospitals are using nurses to cover for doctors because of an NHS-wide shortage of medics, raising fears that \u201csubstitute doctors\u201d may provide inferior care.<\/p>\n
Health professionals known as advanced practitioners \u2013 who are mainly senior nurses \u2013 are undertaking roles usually performed by doctors in A&E, neonatal units, critical care and other areas.<\/p>\n
Almost half of hospitals in the UK are deploying APs to cover gaps in doctors\u2019 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.<\/p>\n
The BMA warned that the widespread use of \u201cnon-doctors\u201d in medical roles is \u201csimply not safe\u201d and may be driven by hospitals using staff who are cheaper than doctors to save money.<\/p>\n
Its revelations follow a number of cases in which mistakes in either diagnosis or treatment by APs led to patients being harmed or dying.<\/p>\n
\u201cDoctor substitution\u201d 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 \u201cshould not replace the roles of doctors\u201d.<\/p>\n
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.<\/p>\n
For example, Birmingham Women\u2019s and Children\u2019s NHS trust said: \u201cAdvanced practitioners are trained and employed to work in the same role as their medical colleagues.<\/p>\n
\u201cThis 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.\u201d<\/p>\n
Barking, Havering and Redbridge NHS trust in east London \u2013 where many of health secretary Wes Streeting\u2019s constituents get their care \u2013 said that in its two acute hospitals advanced practitioners\u2019 \u201ccoverage typically aligns to junior or middle grade [doctors\u2019 roles]\u201d.<\/p>\n
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\u2019s and neonatal services.<\/p>\n
In a further formalisation of APs\u2019 role providing care usually done by doctors, 55 of the NHS bodies across the UK that responded to the BMA\u2019s 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.<\/p>\n
\u201cThe 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,\u201d said Dr Mel Ryan, a paediatric registrar in Nottingham and a BMA lead on preventing doctor substitution.<\/p>\n
\u201cThere 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.<\/p>\n
\u201cI 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,\u201d she said.<\/p>\n
About half of all NHS organisations across the UK took part in the BMA\u2019s survey. Almost half \u2013 43 \u2013 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.<\/p>\n
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.<\/p>\n
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.<\/p>\n
In the prevention of future deaths report issued afterwards by the coroner, Alison Mutch, she found<\/a> that when Almond was investigated for breathlessness in September 2023 at his GP surgery \u201che did not see a doctor … he was seen by an advanced nursing practitioner.\u201d<\/p>\n \u201cThe possible risk of an embolism was not recognised and he was sent for an X-ray, which would not diagnose a pulmonary embolism,\u201d 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.<\/p>\n Four months after the fateful appointment with the ANP, Almond died of what Mutch called a \u201cmassive\u201d blood clot.<\/p>\n