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National guidance issued in January 2020 said there should “typically” be only one clinical commissioning group for each of the 42 “integrated care systems” in England, which implied there could be flexibility for larger areas such as Cheshire and Merseyside.

This encouraged four Merseyside CCGs to press ahead with a merger plan this year, with a view to this transaction taking place by April 2021, while four CCGs in Cheshire completed their long-planned coming together in April 2020.

But then came coronavirus, which led to CCGs being effectively stood down from their key roles and even more decision making concentrated within NHS England’s regional directorates. The new emergency powers made CCGs look even more unnecessary in the eyes of the regulators, and NHSE have now said there must be a single commissioner for the whole of Cheshire and Merseyside.

This is understood to have caused huge frustration among commissioning leaders, who had been working on the assumption that more than one would be permitted. Cheshire and Merseyside is the third largest health system in England.

The decision — if applied elsewhere — could have ramifications for multiple areas of England, as there are still more than 130 CCGs, and just 42 system footprints. Other large systems like the North East and Cumbria, Greater Manchester and South Yorkshire and Bassetlaw have also been looking to retain more than one CCG.