Evidence for replacing doctors with advanced practitioners remains weak, review finds

Advanced Clinical Practitioners (ACPs) are increasingly taking on work traditionally carried out by doctors, despite evidence that substitution may be detrimental to patient-care with no real cost-savings, a new University of Leicester-led review has found.

The literature review, published in the Journal of the Royal Society of Medicine, found scant evidence that they can replace doctors when diagnosing and treating patients with complex conditions or symptoms where the cause is not yet known. 

It also identified studies reporting differences in investigation and prescribing rates, referrals, productivity and use of specialist services, prompting the author, Dr Jatinder Hayre, Public Health Researcher and Honorary Fellow at the University of Leicester who conducted the narrative review,  to call for much stronger evaluation of diagnostic quality, patient safety and the wider impact on the NHS. 

Dr Hayre is calling for an immediate halt on ACP recruitment and a re-evaluation of the role, as comparative evidence shows inferior patient-care where the cause of illness is unknown with greater cost burden to an already overstretched NHS. 

He states that workforce shortages, rising demand, increasing multimorbidity, and growing financial pressures, mean that policymakers have increasingly turned to non-physician clinicians as a means of expanding healthcare capacity, by undertaking clinical activities that were historically the remit of doctors and passing it to ACPs.

Dr Hayre also cautions against savings from employing lower-paid ACPs, suggesting this could be wiped out by additional costs elsewhere in the NHS through longer consultations, additional investigations and referrals, repeat appointments and the need for doctors to provide supervision or reassess patients.

He said: “Advanced Clinical Practitioners can make an important contribution to patient care, but contribution should not be confused with substitution. Our review found that the expansion of these roles has moved faster than the evidence needed to show that replacing doctors delivers the same standards of diagnosis, patient safety and cost-effectiveness.

“Some studies we looked at as part of this identified important differences in areas such as investigations, prescribing, referrals and the use of other healthcare services. This does not mean ACPs cannot provide safe and effective care, but it does mean we need much stronger evidence before assuming they can replace doctors across increasingly complex areas of medicine.

“Ultimately, this is about making sure workforce changes are driven not simply by the need to fill gaps, but by evidence about what provides the safest and most effective care for patients.

At present, there is no convincing evidence that ACPs can substitute medical doctors without compromising patient-safety and the health service. An immediate halt of recruitment of ACPs and urgent review of expansion is needed.”