A small group of clinical commissioning groups remain under legal direction by NHS England, largely because of concerns about governance and leadership, following a review of authorisation conditions.

The national commissioning body on Thursday published the outcome of a review of all the conditions which were placed on CCGs under the authorisation process which took place before April.

Forty-six clinical commissioning groups had conditions lifted, leaving 59 out of the total 211 now with at least one condition.

The process, nearly four months after CCGs took on formal powers, shows those which are still considered to have problems, despite having more time to develop.

Depending on the severity of the conditions, NHS England can offer CCGs additional support, suspend some of their responsibilities, require them to make governance changes, or appoint senior staff.

The number subject to legal directions – meaning NHS England can remove their powers and have more control over them – has reduced from 14 to eight. Those which still have directions are Barnet, Basildon and Brentwood, Croydon, Herefordshire, Scarborough and Ryedale, Thurrock, Vale of York, and Waltham Forest.

The two with the most serious requirements remaining – limiting their functions and requiring them to replace their accountable officer – are Waltham Forest and Thurrock CCGs.

Their most serious problems appear to be related to the skills and capability of their governing body and management, although exact details have not been published.

Among all CCGs’ conditions, the most common are related to problems with service change and finance plans, governing body skills, oversight of safety, and constitutions (see table).

Top five reasons for conditions

TypeProportion of conditions 
Service change and finance plans43%
Governing body skills11%
Oversight, including of safety10%
Addressing inherited problems5%
Constitution and size and shape4%


Regionally, the north of England has the largest proportion of fully authorised CCGs, while the south has the most with conditions (see below). London has the largest proportion with legal directions.

The size of CCGs appears to have little bearing. The average population for CCGs fully authorised is nearly the same as those with conditions or legal directions, at 256,000, 251,000 and 258,000 respectively.

CCGs’ conditions will be reviewed again each quarter in 2013-14, then as part of an ongoing assurance and capability regime for CCGs.

NHS England deputy chief executive Dame Barbara Hakin says in the report of the conditions review: “The safe establishment of autonomous CCGs is the cornerstone of the new clinical commissioning system and, for this reason, the authorisation of CCGs has been of central importance to NHS England and the wider NHS.”

Authorisation by region

 Full authorisationConditionalDirections
Midlands and East72%23%5%