Advanced practitioners are not unsafe substitutes, but essential, qualified professionals who play a distinct and evidence-based role in patient care, a group of senior clinicians has argued in response to British Medical Association (BMA) warnings about the growing use of nurses and other non-medical staff to cover doctor rotas.
In letters to this news organisation, an advanced clinical practitioner in acute respiratory medicine, a stroke services patient and a healthcare professional from Dumfries all challenged the BMA’s characterisation of advanced practitioners as a safety risk. They pointed to robust research, including a Cochrane systematic review published in February 2026, which examined 82 randomised studies involving more than 28,000 patients across 20 countries and found little to no difference between nurse-led and doctor-led care on critical outcomes such as mortality, patient safety events and clinical outcomes. On some measures, the review found, nurses performed marginally better, including in diabetes control, cancer follow‑up and dermatology, while doctor‑led care performed slightly better in a small number of sexual health and medical abortion follow‑up services. A separate Cochrane review from July 2018 on nurse‑led primary care reported similar or better health outcomes, with patients potentially experiencing slightly fewer deaths in certain groups and reporting higher satisfaction, although consultation times were sometimes longer.
Advanced practice: a distinct, qualified profession
The advanced clinical practitioner who wrote from an address supplied to this news organisation described a typical shift assessing and managing patients with severe chronic obstructive pulmonary disease exacerbations, pulmonary embolisms, pneumonia and acute respiratory failure, taking clinical responsibility within a consultant‑led multidisciplinary team. The role, they said, is underpinned by a master’s‑level qualification and more than a decade of specialist experience. “This is not doctor substitution,” they wrote. “This is advanced practice: a distinct, evidence‑based clinical role that enhances patient care rather than compromising it.”
The Nursing and Midwifery Council (NMC) has published principles for advanced practice that describe the role as encompassing four pillars: clinical practice, leadership and management, education, and research. Advanced nurse practitioners (ANPs) and advanced clinical practitioners (ACPs) are educated to master’s degree level and operate across healthcare settings, with the ability to assess, diagnose, prescribe and manage treatment plans. The Royal College of Nursing (RCN) has strongly defended advanced nursing practice, emphasising that these are autonomous professionals delivering complex care as part of multidisciplinary teams, not as substitutes for other professions.
Lynn Malloy, a patient from Crouch End in London, described her experience of ANPs in stroke services as “exemplary”. She noted that ANPs in stroke services assess acute stroke patients, facilitate early imaging and treatment, and coordinate patient journeys, and are considered the lynchpin of the acute stroke service. “The more humble medical doctors acknowledge how key, particularly in their formative years, the role of staff from other professions has been in developing their clinical skills,” she wrote. “Indeed the most candid will acknowledge how, on occasion, these more experienced clinicians have stepped in to avert mistakes being made. The NHS functions at its best through cooperative, respectful and complementary teamwork – something the BMA seems hesitant to fully acknowledge.”
BMA claims under scrutiny
The BMA has warned that the increasing use of advanced practitioners to fill gaps in medical rotas poses a risk to patient safety, arguing that this constitutes “doctor substitution” and is a “haphazard” approach by NHS management potentially driven by cost‑saving measures. A BMA survey indicated that nearly half of NHS trusts (48%) permit advanced practitioners to cover doctors’ rota gaps, with some trusts stating explicitly that they work in the same role as medical colleagues, including on senior house officer or registrar rotas. The union warns that this blurs professional lines, creates a “postcode lottery” depending on where patients are treated, and can impact the education and training of medical students and junior doctors.
Helena Scott, from Dumfries, argued that the BMA’s position must be seen in the context of its role as a trade union for doctors. “It has a direct financial and professional interest in limiting the expansion of advanced practitioner roles,” she wrote. “The claim of a safety gap is not supported by evidence.” She noted that missed diagnoses by doctors are “endemic and largely invisible” and do not generate freedom of information requests, coroners’ prevention of future deaths reports directed at professional bodies or media front pages. “The same clinical failure carries a different narrative weight depending on who commits it,” she added. “The amplification of advanced practitioner errors, while equivalent failures by doctors pass unremarked, is not a patient safety campaign. It is a professional boundary dispute dressed as one.”
The advanced clinical practitioner who wrote the first letter also pointed to the irony of the BMA raising patient safety concerns at a time when its own members’ industrial action has placed extraordinary strain on the NHS. Sustained strike action, largely by junior doctors, has led to the rescheduling of at least 1.7 million healthcare appointments since the end of 2022, placing greater demand on the very practitioners being dismissed as a safety risk. “It is a curious position to simultaneously argue that fewer clinical staff should fill the gaps that the disruption creates,” they wrote.
An NHS spokesperson has stated that guidance is clear: advanced practitioners are highly skilled and valued members of NHS teams working alongside doctors, and their roles should not replace doctors but be used in line with their competence and qualifications. NHS England guidance explicitly states that advanced practitioners should not replace doctors to ensure patient safety. The BMA, however, points to the 48% of trusts that do allow the practice as evidence of a systematic problem.
Workforce solutions: governance, supervision and collaboration
The clinicians who wrote to this news organisation were united in arguing that the real problem is not the inherent capability of advanced practitioners but the way they are deployed. “The cases cited in your article – at Rotherham General Hospital and a GP practice – represent failures of organisational governance, not evidence that advanced practitioners are inherently unsafe,” the advanced clinical practitioner wrote. “Poorly supervised practice causes harm, regardless of whether the practitioner holds a medical degree.”
A nationwide evaluation of advanced practitioner roles in England has found significant variation in role titles, practice scopes, job descriptions and governance structures. Recommendations have been made for more standardised roles, improved governance and consistent competency frameworks. The NMC’s principles for advanced practice emphasise that advanced practitioners work alongside doctors, not as substitutes.
This debate is set against an NHS workforce crisis that will not be solved by doctors alone. In March 2023, the health service had more than 112,000 vacancies across all disciplines, including nurses, midwives, GPs and hospital doctors. Projections suggest a potential shortfall of 260,000 to 360,000 staff by 2036-37. The same advanced clinical practitioner wrote: “The NHS workforce crisis will not be solved by doctors alone. It will be solved by a properly governed, collaborative workforce. Advanced practitioners are part of that and we deserve better than to be used as a political instrument.”
Helena Scott put it more bluntly: “The real question is not whether advanced practitioners are dangerous. It is why clinicians of any background are being deployed in roles without adequate supervision and governance. That is a workforce and management failure. Attributing it to a professional group is a convenient distraction.”
