‘Doctor substitution’ concerns prompt RCN response on advanced practice nursing
Nurses working at an advanced level are autonomous professionals and are ‘not substitutes for any other profession’, the Royal College of Nursing (RCN) has stated following concerns about a survey focused on ‘preventing doctor substitution’.
The British Medical Association (BMA) has been surveying its members on concerns around ‘unhelpful and inappropriate blurring of the distinction between doctors and non-medically qualified staff’.
It states that concerns have been raised about clinicians being used as a substitute for doctors, ‘particularly those working at the advanced practice level’.
Claims were also made by the BMA that patient safety concerns had been raised around non-medical clinicians working outside of their competency or without sufficient supervision.
The RCN has addressed the survey by publishing a position statement on advanced nursing practice, noting that the poll had ‘prompted questions and concerns from nursing staff, medical professionals and other health and care professionals’.
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‘The RCN position is clear. Advanced level nursing describes a level of practice which can only be delivered by registered nurses with additional knowledge and expertise,’ the RCN said.
‘It is underpinned by a comprehensive range of knowledge, skills and capabilities within each of the four pillars of nursing: clinical practice, education, research and leadership.’
The college added that advanced practice nursing is provided by district nurses, clinical nurse specialists, nurse practitioners, consultant nurses and other roles, spotlighting that district nursing in particular has been ‘established for 150 years’.
‘It is differentiated from other levels of nursing by the nurse’s expertise in applying highly developed theoretical and practical knowledge to complex, unfamiliar and unpredictable situations,’ the RCN said.
Last year, the RCN set out a definition for advanced practice nursing and midwifery as part of its ongoing work to bring ‘clarity and consistency’ to the roles. The professional definition stated a registered nurse or midwife working at an advanced level is an ‘expert professional’, using their ‘evidence-informed knowledge, skills and capability to influence, shape, deliver and lead safe and effective care, while managing risk, uncertainty and complexity.’
As part of this work, the RCN helped universities across the UK sign on as ‘early adopters’ of the principles outlined by the colleague.
The BMA survey, which has now closed, was open for all doctors to complete. When describing why the research matters, the BMA said patient health could be at risk if non-medical clinicians or non-doctor health personnel were performing tasks above their accepted level.
It said: ‘If cohorts of non-medical clinicians are enabled and encouraged by their employers to perform tasks above their accepted level of competence, or within their competence but without supervision from a doctor where necessary, this risks decreasing the safety and quality of care.
‘It also risks delayed, incorrect or overdiagnosis, incorrect treatment and inability to deal with complications, fragmented and inefficient service and lack of proper follow up.
‘It may also increase the overall cost of care, as non-doctor health personnel are more likely to rely on consultations, and diagnostic and other tests, to compensate for their lesser education and training compared to doctors.’
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The RCN said that ‘role definition is vital in all spheres of professional practice’ and that it is ‘essential’ that patients using services understand the difference between the roles of the professionals caring for them.
The college said it will continue to make a ‘strong defence’ in this area of nursing work and added the issue will be debated at its annual Congress in May 2026, at the request of members. A similar discussion was held at the RCN’s Congress in 2024, with concerns raised about the ongoing issue of registered nurse substitution.
It concluded: ‘Nurses working at an advanced level are not substitutes for any other profession. They are autonomous professionals.’
BMA council chair Dr Tom Dolphin responded: ‘Nurses do exceptional work across the NHS and are immensely valued colleagues to doctors. The health service simply couldn’t function without their dedication and expertise.
‘We believe that the public deserves the best care delivered by the right professionals. Following concerns raised by our members, we need to gain a deeper understanding from doctors on the extent to which employers are blurring the distinction between doctors and non-doctors in the workplace.
‘Doctors have a unique level of medical training, and there are things that only doctors should be doing, to protect patient safety.
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‘It is positive that we are in agreement with the RCN on the importance of clearly defined professional roles, and they have been clear that advanced nursing roles should not replace the work of doctors.
‘We share the understanding that patient clarity on who is caring for them is vital for safe and effective practice.’
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