‘This substitution must stop.’

Melissa Ryan, a resident doctor in paediatrics, made a plea – firmly rooted in evidence – for doctors to protect themselves and their patients by putting a stop to employers asking APs (advanced practitioners) to work on medical rotas without the requisite qualifications.

Members of the BMA’s representative body voted overwhelmingly to back the motion, which said APs pose ‘unquantified patient safety risks’ because of a variability in regulation, training and scope of practice.

The motion called on governments in each UK nation to quantify the current use of APs, develop a nationally agreed scope of practice, protect medical training and introduce mechanisms to ensure APs complement rather than substitute for doctors on medical rotas.

It also calls for safeguards that require that APs do not diagnose or manage undifferentiated patients, and for specific regulation of APs.

Dr Ryan pointed to a recent statement by the World Medical Association which ‘denounced’ what she called the ‘taskification’ of medicine and said there was no proof that it is a viable cost-saving measure.

She said it seemed instead that cost-saving instead had become the ‘main goal’ of the NHS with ‘decades of underfunding’ and workforce planning that reduces the reliance on resident doctors.

Dr Ryan noted a recent BMA investigation into the scale of NHS employers using APs to work on medical rotas despite having no medical degree, providing evidence of the extent of the issue.

GP Samuel Parker, who proposed the motion, said: ‘Examples continue to emerge of non-doctor roles being expanded to undertake increasingly complex roles and responsibilities.’

He said that only the ‘depth and breadth’ of the medical training of doctors equips them for this specialist role, including the treatment of undifferentiated patients and continuity of care.

‘This expertise, and the many years of training simply cannot, and should not, be substituted. Patient safety depends on the right clinician, with the right training, seeing the right patient.’

He highlighted the ‘numerous’ PFD (prevention of future death) reports issued by coroners which raise concerns about role confusion, substitution, and patient safety, saying ‘we ignore these warnings at our peril’.

Dr Parker also called out the ‘paradox’ of doctor under-employment at the same time as NHS doctor shortages, saying the ‘absurd’ state of affairs – where roles are instead going to non-doctors – ‘should trouble every one of us’.

‘Something has gone profoundly wrong with workforce planning,’ he said, adding that there is no available evidence to back up NHS claims that doctor substitution would offer better value for money.'

In contrast, he pointed to Health Foundation research that shows GPs provide substantially more appointments per full-time clinician than many of the additional roles introduced into general practice and noted that the European Union of General Practitioners recognises family medicine as a specialist discipline.

‘Patients want to see a doctor and they should be able to,’ he told the conference. ‘However, patients in a deprived community appear increasingly likely to find substitution.

‘Tragically, the UK risks creating a two-tier health system where those who can afford private healthcare will spend thousands of pounds to see a GP or consultant instead of seeing the NHS doctor substitute. When it comes to healthcare, inequality should not condemn the poorest to receive the lowest standard of expertise.’

Speaking in support of the motion, Molly Nobes, a resident doctor in emergency medicine, said she asked an AP in her team what their scope of practice was and was told ‘there isn’t one’.

‘That should terrify every single one of us,’ she said. ‘Managing uncertainty is what we are trained to do. Undifferentiated and critically unwell patients should never be seen by somebody who hasn’t had the years of training we have, the training needed for that responsibility.

‘Our profession has compromised for long enough. APs should not be quietly substituted into roles designed for doctors, and yet that is exactly what many of us are seeing.

‘We recognise both what we are trained to do, and our limitations, but these roles do not have the same insight. Different professions bring different strengths, but multi-disciplinary working only works when everyone has a defined role and currently that is not happening. Substitution is not equivalent to expansion of our workforce.

‘Patients deserve better, doctors deserve better.’

Calling for the supervision aspect of the motion to be taken as a reference, GP partner Tilo Scheel said: ‘I’ve always believed that a doctor’s work is best done by a doctor.

‘Years ago, I was laughed at by a CCG chair for still taking on doctors when for the same amount of money I could have had three ANPs [advanced nurse practitioners]. Around the same time, we invited NHS Improvement to visit, and the main comment was that we were doctor and partner heavy and would do better employ advanced practitioners’ – a remark which went against the general direction of the debate.

But he noted: ‘GP partners also run businesses.’

‘In general practice, most of the patients are to a degree undifferentiated and while good supervision is key for the safety of our patients, it would not be practical for every patient to be discussed before being allowed to go home.’

‘If we are confident about the abilities of our advanced practitioners, we also must be able to trust their judgement to an extent.’

The issue of doctor substitution was highlighted in the opening speech of the conference by deputy chair of BMA council Emma Runswick.

She said the NHS is ‘being tempted by a factory model of care’ where it would ‘break medicine into tasks, assign each task to the cheapest available worker, and call it reform’.

But she insisted: ‘Medicine is not a car assembly line.’

After the motion was carried, in full, Dr Runswick said: ‘Recent investigation by BMA into the use of APs on medical rotas and into the strength of feeling from the medical workforce has uncovered a potentially disastrous abdication of safety responsibilities by NHS management, with widespread and frequent blurring of the lines between doctors and non-doctors.

‘We value our AP colleagues and what they can bring to multi-disciplinary teams but we are clear that some tasks must only be done by uniquely trained doctors. 

‘If Government can ensure there are clear scopes of practice defining what APs can and can’t do, and enforce them, then the risks of safety errors will reduce considerably.

‘Workforce planning must not count on staff who are not appropriately qualified for the tasks they are being deployed to carry out – patient safety must be prioritised through a commitment to supporting the unique training of doctors. The conference has today supported this policy in very clear terms.’