13th February 2019

The Neurological Alliance responds to proposed changes to specialised commissioning

NHS England has set out a number of proposed changes to how specialised commissioning is organised:


  • Greater flexibility in the number of patient and public voice (PPV) members per Clinical Reference Group (CRG) (with continued active PPV involvement at Programme of Care Board, CRG and working group level)
  • A reduction in the number of clinical members, who will no longer need to represent a specific geographical region
  • Piloting three ‘whole pathway’ CRGs for lung cancer, child & adolescent mental health services and cardiac medicine – bringing together the perspective of both specialised services and those health services commissioned locally by Clinical Commissioning Groups (CCGs)
  • Cessation of the stand-alone Specialised Pain CRG, with pain services to be incorporated within the wider perspective of the Neurosciences CRG
  • A formal clinical leadership development programme
  • Re-alignment of the CRGs to 8 programmes of care (Blood & Infection, Cancer, Gender Services, Genomic Medicine, Internal Medicine, Specialised Mental Health, Trauma and Women & Children)

Our response to the incorporation of Specialised Pain into the Neuroscience CRG


NHS England ran a short formal consultation on the proposal to incorporate the Specialised Pain CRG into the Neuroscience CRG.  As a patient public voice (PPV) member of the Neuroscience CRG, The Neurological Alliance has a particular interest in the proposed changes and responded to this consultation.  In our response we outlined a number of concerns with the proposal to bring specialised pain and neuroscience together:


  • Adding to the complexity of neurosciences
  • Dilution of patient voice – particularly given the wider proposals to take a more flexible approach to PPV representation on the CRGs
  • Reduction in clinical input to both neurosciences and specialised pain – particularly given the reduction in clinical representation on CRGs more generally.
  • Adding to the overall workload of the Chair and members – in ensuring appropriate cross CRG working between pain and other relevant clinical areas (women, mental health, cancer and others)
  • Meeting agendas and commissioner workload will be unmanageable

An alternative proposal for the specialised pain restructure


In our response we proposed what we believe is a more sensible and pragmatic approach: to disperse the clinicians on the pain CRG across relevant CRGs (pain has relevance to cancer, women and children, mental health, neurosciences, rehabilitation and others). A designated ‘pain’ clinical representative would be added to the list of CRG members on relevant CRGs. This would have the effect of ensuring appropriate input from pain specialists in many relevant disease areas, ensuring services are appropriate commissioned.


There are a few patient organisations that have pain as a specific focus – Pain UK (the umbrella body) and Pain Concern being the most well known. Where there is a specific pain focus to an agenda, we propose that these patient organisations are consulted or invited to sit on working groups.


There are also many patient organisations representing specific conditions which have pain associated with them. These patient organisations sit as PPVs on a range of CRGs across different programmes of care and therefore bring patient input in relation to pain when relevant to the agenda.

Piloting a whole pathway approach to commissioning


In parallel, as NHS England has not formally consulted on the wider changes to the CRG structure, we have written to James Palmer, Medical Director for Specialised Commissioning to encourage him to consider including neurosciences in the CRGs that will pilot a whole pathway approach to commissioning.


Our reasons for proposing the inclusion of neurosciences are as follows:


  • One of the challenges for the current neuroscience transformation programme is focussing solely on those aspects of neuroscience services that are specialised. The routes into and out of a specialised service require appropriately commissioned local services.
  • There is a long standing issue with developing a service specification for neurology given the specialised/local split in this clinical area is not an easy one to define.
  • Through the National Neuro Advisory Group (NNAG) we are already piloting a ‘whole pathway’ approach although progress would be expedited should this be given a formal role within NHS England’s CRG structure.
  • NNAG is also undermined by a lack of formal resource to support its programme – programme management is currently funded one day a week by The Neurological Alliance and our charity partners.

What is the role of specialised commissioning?


You can read more about specialised commissioning in the commissioning section of our website.