Written evidence submitted by Dr Cliona Ni Bhrolchain (RTR0029)

There are 3 points I would like to make to the Committee.  While I have focused on the subspecialty I know best, the same principles will apply to other specialties:

  1. There is an urgent need to develop formal re-entry programmes for secondary care doctors who wish to return to work after a long break.  Due to a system anomaly, re-entry to general practice has always been supported by postgraduate deaneries (now HEE) and there is a funded programme for GPs to be able to re-enter work after an extended breakNo system exists for secondary care doctors.  HEE has finally recognised this, thanks to the Covid pandemic, but the response to date has been limited to providing some online resources and a few days trainingThis is nowhere near enough.


I have personally advised and/or supported up to a dozen doctors through this process, only some of whom succeeded in returning to work.  Others were simply put off by the challenges of having to find and fund their own training placement and gave up.  These doctors are a huge loss to the profession and the current situation needs to be addressed. 


This is the experience of only one doctor in a small subspecialty.  If replicated across all specialties it represents a significant potential workforce that is prevented from returning to useful work due to the barriers to re-entryI would be happy to provide further information to the committee if it would be helpful


  1.                 The NHS needs to recognise and fund community services to meet demandThough the example I use is community child health (CCH), known informally as community paediatrics, it also applies to areas like community psychiatry and community geriatrics. 


Community paediatrics is a true ‘Cinderella’ specialty, often ignored even by inspectors 1.  Despite this lack of attention, community paediatrics is the key medical specialty managing vulnerable and disabled children and young people (CYP).  It also provides statutory support to Local Authorities (LAs) in the key areas of safeguarding, Looked After Children, adoption and in Special Educational Needs and Disability (SEND), including current high profile areas like autism spectrum disorder (ASD) and ADHD 2.  All CYP going through these statutory service areas will see a community paediatrician for medical assessment, diagnosis and treatment of their condition(s) and the paediatrician will then advise the LA on their needsThis makes it a fairly unique NHS service, already working in an integrated way with Education, Social Care and Third Sector services.  It could be an excellent model for other specialties


But, unfortunately, it is also well recognised that there are unacceptable delays in accessing community paediatrics across the UK.  Delays of 9 months, up to twice the 18-week standard, between referral and diagnosis were not uncommon even before the pandemic 3The pandemic has intensified these delays. 


The Parliamentary Committee on Human Rights, and the Government itself, recognised the problems this lack of access can cause, leading to family stress, escalating care needs and resulting in high cost residential placements that could have been avoided 4 with better, earlier, access.  They state:


In her evidence to us the Minister for Care, Caroline Dinenage MP accepted that failure to support young people and their families at an early stage was often a reason for detention [in residential hospitals] later on:  All too often, what you have heard is right: young people end up in an in-patient setting as a result of a number of failed opportunities to intervene earlier, provide the right support and maybe diagnose them from an early stage.” 


Focused support e.g. pump priming and ‘invest to save’ funding for community services will be necessary to reverse decades of neglect and deteriorating services.


  1.            Opportunities to target investment


One example is the lack of specialist nurses, and for their training, in CCH.  Such roles have been developed, and are now standard, in other areas of paediatrics including neonatal medicine, urgent care and chronic physical illnesses such as epilepsy, diabetes and cystic fibrosis, and in other medical specialties.


However children and young people with neurodevelopmental conditions have been forgotten and excluded from these developments.  Thus CYP with autism, ADHD, cerebral palsy and similar neurodevelopmental conditions (all of them life-long) miss out on the support that CYP with physical illness get as a matter of course from their named specialist nurse.


Individual departments are responding to this need by developing ad hoc services 5 and training programmes 6However there is no co-ordinated central training curriculum and no agreement on what these extended roles should do.  This inevitably results in a postcode lottery.


The HEE and RCPCH has started to develop a curricular framework for Advanced Clinical Practice in Paediatrics, including a pathway for those working in community settings. However if the potential benefit of these extended roles are to be realised, practitioners will need funded training places for the university courses required (usually a 2 year course leading to a MSc) and backfill for the clinical posts they have vacated to pursue such training.  It is telling that funding in paediatrics to date has focused on acute, hospital-based specialties like neonatology and urgent care.  This needs to change.



CCH has risen in popularity with paediatric trainees in recent years, with increasing applications for subspecialty training.  However there is a mismatch between local training schemes, with some areas oversubscribed while others cannot fill posts.  The constraints on how training post numbers are allocated makes it very difficult to move posts around to meet demand.  This prevents some trainees from training where they wish to train and means trainees must move home to access training or, if that is not possible, decide to train in another subspecialty instead.  This makes no sense in a shortage specialty.


HEE should work with the College to re-assess the number of training places in CCH to ensure that the overall number and their geographical distribution meet the demand. 



Medical training in CCH could be shortened but it would require a change in philosophy and in the current CCT.  It is DHSC/NHS policy that as many practitioners as possible retain generic skills alongside any subspecialist skills they develop. This means that community paediatrician must maintain their skills in general and neonatal paediatrics until they obtain their CCT.  This takes up about 1/3rd of their training time in ST6-8, while they are also learning CCH.  If this requirement were reduced or removed, training could be shortened, but this would require a change in policy.



January 2022


  1.                 Ni Bhrolchain C.  CQC inspections overlook community child health services.  Archives of Disease in Childhood 2021;106:619-620http://dx.doi.org/10.1136/archdischild-2020-320245
  2.                 RCPCH Covering All Bases.  Community Child Health: a paediatric workforce guide. https://www.rcpch.ac.uk/resources/covering-all-bases-community-child-health-paediatric-workforce-guide
  3.                 RCPCH Covering All Bases Community Child Health survey results https://www.rcpch.ac.uk/resources/covering-all-bases-community-child-health-paediatric-workforce-guide
  4.                 House of Commons & House of Lords Joint Committee on Human Rights.  The detention of young people with learning disabilities and/or autism.  London 2019https://publications.parliament.uk/pa/jt201919/jtselect/jtrights/121/121.pdf
  5.                 RCPCH Covering All Bases - Online directory of innovative practice models or pathways https://www.rcpch.ac.uk/resources/covering-all-bases-community-child-health-paediatric-workforce-guide
  6.                 Ni Bhrolchain C. The role of paediatricians in specialist nurse training: a community child health example.  Arch Dis Child Educ Pract Ed Online First 3rd August 2021. doi:10.1136/archdischild-2020-320797
  7.                 British Association for Community Child Health.  A workforce strategy for community paediatrics.  London 2019.  https://www.bacch.org.uk/resources/43-bacch-workforce-strategy


My background

I am a retired consultant community paediatrician with a particular interest in training and workforce.  I chaired the RCPCH College Specialty Advisory Committee (training committee) for community child health from 2010 - 2015 and was the first Workforce Officer for the British Association for Community Child Health (BACCH) from 2018 - 2021.  I have published numerous articles on training and workforce issues.  I was a key participant in the RCPCH/BACCH review of the community paediatrics workforce (Covering All Bases) which led to the establishment of a BACCH workforce officer post and an implementation strategy for workforce development.  I have supported several re-entry programmes for doctors returning to work after prolonged absence and have devised a training programme for specialist nurses in community paediatrics.  The views expressed do not necessarily represent the organisations I have mentioned.