Nearly half of NHS hospital trusts are using non-doctors to fill doctors’ roles, new research reveals, prompting the British Medical Association to issue a stark warning about patient safety.
The doctors’ union described the practice as “haphazard” and said it risked a “potential disaster”, with under-qualified staff being pushed beyond their training to plug rota gaps. Dr Tom Dolphin, chair of the BMA council, said the approach meant “where you live determines whether you will be seen by a doctor or by someone else for the same condition”.
The findings come from freedom of information requests sent to hospital trusts and boards across the UK. Of those that responded, 41 said they were using Advanced Practitioners – a category that includes physician associates and specialist clinicians drawn from nursing, paramedic and pharmacy backgrounds – to fill doctors’ rotas, while 44 said they were not. The BMA said the near-even split exposed a “postcode lottery” in patient care.
Blurred professional lines and safety fears
At the heart of the union’s concerns is what it calls a systematic blurring of professional boundaries. Dr Dolphin stressed that Advanced Practitioners (APs) and physician associates (PAs) are “valued members of our multidisciplinary teams” but accused NHS managers of using them as “spare capacity to fill up understaffed doctors’ rotas”.
“While other healthcare roles can be enhanced within safe limits, this must never encroach into areas where a doctor’s specific training and expertise is required,” he said. The BMA has warned that patients are being left confused about who is treating them and what level of care they should expect, while doctors themselves are unclear on where the lines are drawn.
The union also points to potential cost-saving motives, suggesting trusts may be using cheaper staff to substitute for doctors – a practice it condemns as “doctor substitution”. Critics argue that the rapid expansion of PA and AP roles has outstripped proper regulation, leaving unclear boundaries around what these professionals can and cannot do. Although physician associates have been regulated by the General Medical Council since December 2024, with a two-year transition period before registration becomes mandatory, the BMA says nationally agreed limits on responsibilities are still urgently needed.
“An NHS stretched to breaking point is no excuse,” Dr Dolphin added. “Better regulation and clear, uniform scopes of practice to stop this blurring of professional lines are needed, so no patient comes to harm.”
Tragic cases highlight the risks
The warning is underscored by several high-profile cases where misdiagnosis by non-doctor clinicians has been linked to patient deaths. In October 2022, Emily Chesterton, 30, visited a GP practice in north London with calf pain. She was seen by a physician associate and repeatedly told she had a sprain. In fact she had a blood clot. She died days later from a pulmonary embolism. Her family believes her death could have been prevented had she been seen by a doctor. The physician associate was dismissed, and the practice later removed all its PAs.
In another case, a coroner issued a formal warning about the role of PAs after the death of 77-year-old Pamela Marking. She was sent home from an A&E department with a diagnosis of a nosebleed despite severe abdominal pain and vomiting blood-stained fluid. The coroner noted that the term “physician associate” was misleading to the public and that the PA who treated her had been unsupervised. A similar coroner’s warning was issued in the case of Nathan Blackburn, who died after multiple contacts with a PA who allegedly failed to refer him for a suspected pulmonary embolism.
Separately, Susan Pollitt died after a drain was mistakenly left in her abdomen for 21 hours at Royal Oldham Hospital, causing an infection. Coroners have issued Prevention of Future Deaths reports in several cases, raising wider concerns about decision-making, supervision and the level of clinical expertise on the front line.
Professional bodies divided
The BMA is not alone in voicing concerns. The Royal College of Nursing emphasised that advanced nursing practice is “highly-skilled, delivered by expert registered nurses” with master’s-level education, but stressed that these nurses are “not substitutes for other professions”. The RCN added: “They are autonomous professionals, delivering complex care as part of multi-disciplinary teams.”
NHS England, however, defended the use of Advanced Practitioners, saying its guidance is “clear – advanced practitioners are highly skilled practitioners and valued members of NHS teams alongside doctors”. An NHS England spokesman said the roles “should not replace the role of doctors and should only be used in line with their competence and qualifications”. He added that all staff are able to raise concerns where they are worried about patient and staff safety.
The debate takes place against a backdrop of severe pressure on the NHS, with staff shortages, record waiting lists and rising demand. The NHS Long Term Workforce Plan includes expanding the roles of PAs and APs as part of its strategy. But the BMA argues that expansion has been too fast, and that the lack of clear scope of practice for these roles leaves patients vulnerable. Training for physician associates typically involves a postgraduate course of around 3,200 hours (half theory, half clinical) but does not require prior registration as a healthcare professional – a “direct entry” route the BMA views as inadequate for unsupervised clinical decision-making.
“Patients deserve a consistent standard of care whichever hospital they happen to live near,” Dr Dolphin said. “They shouldn’t have to worry about whether the local managers have asked non-doctors to deliver care that only uniquely-qualified doctors can safely deliver.”