The BMA has today published a series of “disturbing” reports warning that patient safety is being repeatedly put at risk when those patients are looked after by less-qualified advanced practitioners (APs,) rather than doctors.
Earlier this year the BMA revealed that nearly three quarters of doctors reported that advanced practitioners, staff who originally trained as nurses, paramedics, pharmacists, midwives or other professional roles, are routinely replacing doctors in their workplaces. In FOI responses to the BMA, half of hospitals in the UK admitted to using advanced practitioners to cover doctor rota gaps and including these staff on doctors’ rotas. The BMA believes this places staff without the necessary medical training in difficult and inappropriate positions with clear risks to patient safety.
With concerns rising over the deployment of advanced practitioner roles, the BMA launched a new tool in January for doctors to share their experiences directly. Doctors have since reported hundreds of patient safety incidents. These include a case where an advanced practitioner failed to arrange vital testing and referral for a child with meningitis and another in which advanced practitioners missed a cancer diagnosis, resulting in a patient “losing out on 6 weeks of time to get her affairs in order before dying.”
“My daughter was seen by an ACP in Paeds Emergency Department. I took her with concerns that she had meningitis… The ACP discharged her with no bloods or referral. Daughter readmitted within 36 hours and diagnosed with meningitis, however delay in diagnosis resulted in Lemierre’s syndrome, surgery and 2 CT heads. On that evening, the ACP was the most senior clinician in paeds ED due to a rota gap for the paeds ED consultant.” - Consultant, East Midlands
Responding to the accounts now made public, Dr Tom Dolphin, chair of BMA council, said:
“These are shocking accounts of patients being let down by the system. Patients are being put at risk of harm or even death because hospital managers are putting advanced practitioners and others into roles that should be filled by doctors, as this report and multiple inquests suggest.
"We have made clear, over and over, that there are times when patients must be seen by a doctor and this testimony lays out why in extensive, excruciating detail. Patients with missed diagnoses, patients with severe conditions given nothing but mild pain relief and sent on their way, and patients facing end of life conditions being offered totally substandard care: they all deserved so much better.
“One patient was lucky their mother was a doctor, as otherwise a potentially fatal case of meningitis would have been missed. But you should not need to have a qualified doctor as a parent to get the right treatment in the NHS, and it is disturbing to think how many other similar cases might be out there.
“Advanced practitioners are not to blame for this systemic failure. They are NHS colleagues who are hardworking, talented individuals trying to make the best of a situation one doctor described as a ‘farce’: management pressuring non-doctors to plug gaps in doctor rotas and do things only doctors should be doing. This is not fair on them.
“Again and again we see accounts of hospitals in chaos where leadership has totally failed to draw appropriate boundaries around who should be doing what. When we requested information about this practice via the Freedom of Information process, every trust has admitted that it should not happen, for reasons that are very apparent reading this report. Yet despite stating that they are against it, the reality is that this is a practice bizarrely condemned and condoned by the very same people. One trust, Arrowe Park, shockingly told us that this has become standard practice across the NHS. These leaders appear to be either asleep at the wheel or actively supporting the unsafe substitution of doctors.
“We need NHS leadership to wake up. NHS England’s suggestion that hospitals should rely less on doctors, in order to cover for their lack of workforce planning, is a real threat to patient safety. We need a prohibition on the use of non-doctors on doctors’ rotas, and new training posts so that doctors can fill these gaps instead. We need an urgent review of advanced practitioners’ scopes of practice, backed by national standards, so that only doctors are able to carry out work that requires a doctor’s unique training, skills and expertise.”
Notes to editors
The BMA is calling for:
- A prohibition on the use of non-doctors on doctors’ rotas
- An urgent review of AP scopes of practice, with the adoption of national standards
- An end to the “taskification” of medicine – the shifting of more and more tasks to non-doctor professions
- Improved statutory regulation of advanced practice roles, including through the introduction of revalidation
- The ‘first right of refusal’ for doctors over any clinical training opportunity to ensure that the senior decision-makers of the future are adequately trained
Examples of accounts from doctors in the report include:
My daughter was seen by an ACP in Paeds ED. I took her with concerns that she had meningitis with symptoms of fever not resolving with weight doses paracetamol and ibuprofen, headache and neck stiffness with no focus. The ACP discharged her with no bloods or referral. Daughter readmitted within 36 hours and diagnosed with meningitis, however delay in diagnosis resulted in Lemierre’s syndrome, surgery and 2 CT heads. Having not done an ED post in this trust or worked in ED for over a decade, I assumed ACPs required senior sign off in a similar way to FY 1/2. On that evening, the ACP was the most senior clinician in paeds ED due to a rota gap for the paeds ED consultant.
Consultant, East Midlands
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Saw a 60 something year old patient in ED, background of smoking. 8 week history of cough, weight loss and then facial swelling. Had been seen 3x by ANP in primary care over period of 6 weeks, without any input from a doctor. Had been prescribed 3x courses of antibiotics with no improvement. Facial and arm swelling had been put down to her ?long term statin which had been stopped (not in BNF). She'd self presented to ED due to ongoing symptoms and inability to see an actual Dr. Within 5 minutes of seeing her, I highly suspected lung cancer with SVC obstruction, which is what she was diagnosed with around 90 minutes later. She died within a few weeks. She had every red flag - new persistent cough in smoker, unintentional weight loss and facial swelling. She hadn't even been sent for an CXR by the ANP as per NICE guidelines which would have showed large lung mass. She was seen by a non-dr despite recurrent presentations to GP practise with same problem, never reviewed by a dr. She lost out on 6 weeks of time to get her affairs in order before dying. It makes me really angry. This was not a difficult diagnosis to make.
Can't remember exact date this happened but was in 2024.
When raised concerns locally: Raised concern to own consultant at time who said they'd raise with GP practice. Don't know the outcome of this.
Not in training, Scotland
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- A lady had a consult with a pharmacist ACP regarding unintentional weight loss and vomiting. There was a strong FH type 1 diabetes but she had been labelled as type 2 diabetes at age 40 despite weight loss. She was acutely unwell but the pharmacist ACP did not recognise this - instead he referred her to fast track service for suspected cancer. Her husband contacted one of the GPs at the practice as he had his personal number as he was concerned and the GP advised to take her to A&E - she was diagnosed and treated for diabetic ketoacidosis. At no point did the ACP acknowledge that this was a complex case and there was no discussion with a GP and if there was it did not iterate /press on the supervising GP how sick this patient was.
- A patient was referred to a community service for a visit to avoid hospital admission with 10/10 severity abdominal pain and vomiting by a pharmacist ACP … there was minimal history taken and the ACP did not acknowledge that this patient needed an emergency ambulance. There was no differential in the notes either and no discussion with a supervising GP at the practice. The patient had a large hernia and possibly had a strangulated or obstructed hernia
- A paramedic ACP had visited an elderly patient with back pain and reassured him that pain is due to arthritis and offered analgesia. A few days later I consulted the patient via tel triage and he had a history of malignancy and signs and symptoms of cauda equina syndrome which the ACP had missed /dismissed. I arranged emergency admission.
GP, Urgent Community Response
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ACP reviewed a cancer patient who had opted for best supportive care. Determined that she was at the end of life and admitted her to end of life care room. Patient confused and agitated and subsequently found to have hypercalcaemia, which was treatable and clinical condition improved with treatment and was discharged. ACP inappropriately deemed patient to be dying without considering reversible causes. This occurred during a CQC inspection so should be captured in the report.
When raised concerns locally: Was escalated by others and CQC also saw some of what had happened, however I don't know what the response was.
Medical student, Yorkshire
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The ACCPs are technically on a different rota but essentially do the same job as the resident doctors and overnight when there is not an ACCP there will be an additional doctor.
On this day an ACCP diagnosed someone with necrotising pneumonia and massively climbing ECMO requirements with constipation. The patient actually had a tension pneumothorax. The only reason they survived overnight was the ECMO cannula was splinting their mediastinum. The ACCP didn't perform a respiratory examination nor did they request a chest x ray.
Registrar, East Midlands
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