Advanced practitioners are not unsafe substitutes, but vital parts of the NHS workforce – a role backed by evidence and professional governance, yet increasingly caught in a political battle over who should deliver care.
BMA’s concerns over ‘substitute doctors’
The British Medical Association, the trade union representing doctors, has claimed that nearly half of NHS trusts (48%) use advanced clinical practitioners (ACPs) to cover rota gaps, characterising such staff as unsafe “substitute doctors”. The BMA has warned that encouraging non-medical clinicians to work outside their competency or without adequate supervision risks patient safety and undermines the training of medical students and junior doctors. It says it supports multidisciplinary working, but argues that the current use of ACPs blurs professional lines in a way that endangers patients.
These concerns have been amplified by specific cases, including an incident at Rotherham General Hospital and a GP practice, where failures attributed to advanced practitioners were reported.
Evidence supports advanced practice
Advanced clinical practitioners and their supporters have pushed back strongly. One letter writer, an advanced clinical practitioner in acute respiratory medicine, told this website that every shift she assesses and manages patients with severe chronic obstructive pulmonary disease exacerbations, pulmonary embolisms, pneumonia and acute respiratory failure. She takes clinical responsibility within a consultant-led multidisciplinary team, underpinned by a master’s-level qualification and more than a decade of specialist experience. “This is not doctor substitution,” she wrote. “This is advanced practice: a distinct, evidence-based clinical role that enhances patient care rather than compromising it.”
Another letter, from Helena Scott of Dumfries, highlighted what she called a “critical conflict of interest” in the BMA’s position. “The British Medical Association is the trade union for doctors. It has a direct financial and professional interest in limiting the expansion of advanced practitioner roles.” Under the BMA’s own conflict of interest policy, members are required to declare potential conflicts in advance, especially when speaking in debates or making decisions where a secondary interest – such as financial gain or professional reputation – may influence judgment. Critics argue the BMA’s campaign against ACPs amounts to professional boundary protection dressed as patient safety.
The evidence, Scott continues, does not support the claim of a safety gap. A Cochrane systematic review published in February examined 82 randomised studies involving more than 28,000 patients across 20 countries. It found little to no difference between nurse-led and doctor-led care on critical outcomes including mortality, patient safety events and clinical outcomes. On some measures, nurses performed marginally better. The review noted that patients are likely to have similar or better outcomes and may be slightly more satisfied with their care when treated by nurses. “Context matters,” the review cautioned, but the overall conclusion is clear: nurse-led care is as good as doctor-led care in many settings.
Advanced practice itself is defined as a level of practice, not a specific role or title, requiring additional post-graduate education – typically a master’s qualification – and experience beyond initial registration. It is built on four pillars: clinical practice, education, research, and leadership or management. ACPs work across nursing, pharmacy, physiotherapy, paramedicine and occupational therapy, and their roles are often tailored to the needs of a specific service. The Nursing and Midwifery Council has set out principles for advanced practice, emphasising that ACPs work alongside doctors, not as substitutes.
A third letter, from Lynn Malloy of Crouch End, London, described her experience of advanced nurse practitioners in stroke services as “exemplary”. She noted that many doctors acknowledge how much they have learned from other professions, particularly in their formative years, and that the NHS functions best through cooperative, respectful teamwork – “something the BMA seems hesitant to fully acknowledge”.
Systemic failures behind the safety debate
The cases at Rotherham General Hospital and the GP practice cited by the BMA are seen by practitioners as failures of organisational governance, not evidence that advanced practitioners are inherently unsafe. Past reports into Rotherham have highlighted governance issues, including inadequate oversight of patient safety and repeated identification of problems without consistent action. “Poorly supervised practice causes harm, regardless of whether the practitioner holds a medical degree,” the respiratory medicine ACP wrote. The real question, according to Helena Scott, is “why clinicians of any background are being deployed in roles without adequate supervision and governance. That is a workforce and management failure.”
That workforce failure is compounded by the NHS’s chronic staffing crisis. Years of inadequate workforce planning, lack of investment, and difficulties with staff retention have left the health service struggling to fill rotas. The government has promised a refreshed workforce plan to increase staff numbers and improve retention, but meanwhile, industrial action has added to the strain. Since the end of 2022, at least 1.7 million healthcare appointments have been rescheduled due to strikes by doctors and other staff. The ACP letter pointed to the “striking irony” of the BMA raising patient safety concerns while “sustained industrial action has resulted in hundreds of thousands of cancelled appointments and procedures, placing the NHS under extraordinary strain”.
Missed or delayed diagnoses by doctors are also a significant but largely invisible problem. Estimates suggest diagnostic errors occur in 10% to 15% of all medical cases. Between 2017 and 2021, there were 8,718 claims made to the NHS for failure or delay in diagnosis, costing more than £1.14 billion. Around one-third of UK patients believe they have experienced a misdiagnosis. The conditions most frequently involved include cancer, stroke, sepsis, heart attacks and fractures. Over half (58%) of diagnostic errors in general practice occur during GP consultations. “Missed diagnoses by doctors are endemic and largely invisible,” Scott wrote. “The same clinical failure carries a different narrative weight depending on who commits it.”
The amplification of advanced practitioner errors, while equivalent failures by doctors pass unremarked, is not a patient safety campaign, she argued. “It is a professional boundary dispute dressed as one.” Attributing systemic workforce and management failures to a single professional group is a convenient distraction – one that the evidence does not support.