Recommendations - external second opinions in paediatrics

Healthcare professionals, external stakeholders and families were consulted during the development of this work to understand what challenges may prevent this guidance from being adopted locally. Recommendations have been shaped to address and suggest ways of unlocking these issues.
Last modified
26 May 2022
This document forms part of the Seeking and Providing External Second Opinion in Paediatrics guidance. For the full guidance, see our landing page.

The Royal College of Paediatrics and Child Health will review this work with the Paediatric Critical Care Society in three years and monitor its recommendations to understand whether the work should be updated.

Supporting children and their families

Children with complex care needs are often under the care of multiple specialist teams, which can mean that families have difficulty navigating the decision-making process.

It is always important to hear the voice of the child. Sometimes families report that their experience of their child’s life is not given sufficient weight in informing treatment decisions.

  • Trusts and Health Boards should provide information on how decisions are made in relation to the specialist care that is provided.
  • Trusts and Health Boards should provide families with the guide for families (PDF).
  • Trusts and Health Boards should support the role of a family advocate and make this clear in information and resources provided to families. The family advocate should have good communication skills, form a trusted relationship with the family, and be able to work closely with the clinical team.
  • When an ESO is sought from an individual clinician at another hospital, the child and their family should be involved in the process and their questions and concerns should inform the detail of the request.


There are workforce shortages across every paediatric specialty; ESO work can require a significant time commitment, is variably remunerated and has no formally recognised commissioning arrangement. Given that high profile cases have attracted adverse attention, it is a challenge to recruit enough paediatricians to support these processes.

  • The RCPCH and paediatric specialty groups should consider how they can support as well as increase the number of paediatricians who undertake ESO work.
  • Paediatric specialties should explore setting up National Advisory Panels and inter-hospital MDT meetings to provide objective, peer-supported second opinions to inform decision making processes in complex cases.
  • Paediatric specialties should consider establishing subgroups for colleagues interested in ESO work. Such groups would provide a focal point for training, audit and peer review of cases, and encourage trainees to develop an interest. Membership might also be drawn from other representative specialties, for example medical ethics or law. Senior colleagues could support junior colleagues or develop a ‘buddy’ system. Systems of mentorship would enable succession planning to occur within the specialty as senior colleagues retire.

Caring for children with significantly complex conditions and/or life-limiting illnesses will become more frequent in the future. Workforce planning should ensure there is an appropriately trained paediatric workforce to deliver safe and sustainable services for this cohort of patients.

  • The bodies responsible for workforce planning across the UK (Health Education England; NHS Education Scotland; Health Education and Improvement Wales; and the Northern Ireland Medical and Dental Training Agency) must plan now for an appropriate child health workforce that meet the needs of an evolving patient population.

Healthcare professionals who undertake ESO work may also undertake expert witness work. There is a national shortage of expert witnesses which impedes the work of the coroners, and the family and criminal courts. While the ESO and expert witness work are separate processes, they share similar themes and common challenges, and it is argued that increasing the pool of professionals undertaking ESO work will in tandem increase those prepared to do expert witness work.

  • Recommendations from The President of the Family Division Working Group on Medical Experts in the Family Courts Final Report should be implemented, including: 
    • engagement at senior level between Department of Health, Ministry of Justice, as well as the NHS, to agree common solutions
    • Royal Colleges/Specialist Societies to create online resources to increase awareness of training in the field provided by organisations such as the Academy of Experts and the Expert Witness Institute
    • Royal Colleges/professional bodies and the Family Court to engage with NHS England and clinical commissioning groups to seek changes to contracting arrangements to enable healthcare professionals to undertake expert witness work within the parameters of their employment contracts.
    • create greater training opportunities for medical professionals/allied health professionals including mini-pupillages with judges, cross-disciplinary training courses with medical and legal professionals and mentoring, peer review and feedback opportunities.

Education and training

Paediatricians in training will need to acquire the relevant clinical and non-clinical skills to look after a growing population of patients with significantly complex conditions and/or life-limiting illnesses. Some clinicians often feel they do not have the right skills, knowledge, or experience to undertake ESO work, as well as the time needed to step out of local clinical service. There is also a shortage of experts available to undertake this work in many paediatric subspecialties. Paediatricians are keen to be signposted to helpful resources and supported with using this document.

  • RCPCH should consider whether this report can inform training in relation to parallel planning and the care of children with complex care needs in anticipation of the next GMC review of the Progress+ curriculum.
  • RCPCH should explore funding opportunities that prioritise support for its membership with education and professional development activities, in relation to parallel planning, the care of children with complex care needs and ESO processes in general.
  • RCPCH should review and update its revalidation framework so that acquiring the skills for ESO work is considered as continuing professional development enabling those who undertake ESO work to record it within their annual appraisal documentation.

Service planning

ESOs are not formally recognised in national specialised service specifications, yet occur routinely and underpin good practice and shared decision making across paediatrics. 

  • Service planners should acknowledge ESO work within service specifications.

Supporting the ESO process locally

Second opinion work needs to be recognised as usual practice. It is currently carried out in an informal manner in a variety of formats across all paediatric sub-specialties and is not recognised by service planners. Trusts and Health Boards need to recognise that this work is essential to patient care. When conducted well, it supports patient choice and may reduce complaints and litigation. Raising awareness and standardising and supporting practice will support paediatricians and families alike.

  • Paediatric Clinical Directors should notify Trust/Health Board executives when an ESO is sought from a paediatric health team. 
  • Trusts and Health Boards should acknowledge and monitor the activity of its National Advisory panels and inter-hospital ESOs. 
  • Trusts and Health Boards should recognise and remunerate ESO work within annualised team-based job plans and establish local policies to enable remuneration in a timely fashion (to include time spent travelling to/from seeing the child, report writing, and sustenance).
  • Trusts and Health Boards requesting ESOs from individual clinicians should ensure that there is administrative/ managerial assistance to help arrange the logistics of the visit, ready access to patient notes, and a private space made available to meet with the family and local professionals. 
  • Trusts and Health Boards should ensure that families and clinicians have access to a paediatric-focused Clinical Ethics Advisory Committee that may provide objective transparent ethical advice in complex cases.

Key terms and definitions

List of key terms and definitions
Child or children Babies, children and young people under the age of 18 across the UK.
Critical friend A trusted professional, usually within the same organisation, who is requested to offer a critique of a colleague’s management of a challenging situation; for example, either to advise on treatment decisions or to help navigate circumstances where the child’s family and clinical team disagree on the correct course of action.
Clinical Ethics Advisory Committee (CEAC)  A group consisting of health and other relevant professionals who provide advice and support to clinicians and families on ethical issues that have arisen during clinical practice.
Expert witness A healthcare professional, generally appointed by a solicitor, whose skills and experience qualify them to testify on a particular medical area in a court or tribunal setting.
External second opinion (ESO)   An external medical opinion on the patient’s proposed course of treatment from a second independent health professional/MDT within an appropriate specialty. The initial suggestion to get an ESO may come from a patient/family, or from the child’s health care team. This is for children facing significant life changing decisions, and the second opinion should come from a separate Trust or Health Board.
Family Parent, carer or guardian identified as the person with parental responsibility of the child. This could include the local authority. 
Family advocate A named point of contact who can provide information to the family on the ESO process, and who can signpost to sources of support. See this section for more information.
Health organisations   NHS Trusts and NHS Health Boards across the UK.
Healthcare professional  A clinically qualified person who is working within the scope of practice as determined by their relevant professional body and who is registered with that body as competent to practice.
Mediation  An impartial service designed to support patients, families and NHS staff work together towards resolution of disagreements.
Multi-disciplinary team (MDT) A group of professionals from one or more clinical disciplines from hospital and community settings who together make decisions regarding recommended treatment of individual patients. 
Named consultant A named consultant taking on overall clinical responsibility for the child.
National Advisory Panel  A multi-disciplinary team of experts organised at national level to support decision making around treatment options in complex and rare diseases. Such panels may enhance consistency and transparency around care pathways and aim to ultimately improve survival outcomes.
Parallel planning Parallel planning offers an opportunity for children with life limiting conditions to live their lives to the full while plans are made for managing their ongoing care and end of life.
Referral for second opinion The administration and paperwork that is required to support the process of requesting an external second opinion. 
Service planner Organisations responsible for planning, commissioning, or providing health services.
Team around the child  The professionals that contribute to the wider health and wellbeing of the child.  This would include the child’s named consultant, the MDT, GP and any professional in an advocate role.