The most pernicious legacy of the Lansley reforms is that the very nature of their genesis created an environment in which it remains almost impossible to act in the most logical ways to solve the problems they created.

As HSJ commented in its unprecedented joint editorial with the British Medical Journal and Nursing Times in January 2012, the chaotic nature of the reforms meant they needed remedial action to make them workable even before they came into effect.

However, such was the controversy created by legislation, which seemed to run in the face of pre-election pledges, that embarking on “top-down re-organisation” became the biggest health policy crime. As a result, endless workarounds were (and continue to be) created to achieve progress.

The irony, of course, is that the vision of the Five Year Forward View is driving a “re-organisation” much more significant and far reaching than that caused by the Health and Social Care Act. The lack of cash in the NHS making its urgent implementation necessarily and increasingly “top down”.

The most recent workaround developed to accelerate the NHS’s latest transmutation are the Sustainability and Transformation Plans. These have metamorphosed very quickly from a way of thinking about service redesign and financial robustness on a regional basis to, effectively, the mechanism for delivering that change.

Financial abyss

Exactly how they will do this is uncertain and will vary significantly. What is not in doubt is that the creation of STPs stems from a clear eyed recognition by NHS England that clinical commissioning groups are unable to fix the underlying problems affecting most health economies.

In other words, the bodies created at great expense and even greater opportunity cost four years ago are not fit for purpose in the eyes of those responsible for their stewardship. That the creation of STPs is deemed necessary is also a comment on the effectiveness of NHS England’s own regional operations.

As the NHS’s provider sector has plunged into the financial abyss, what limited influence CCGs had on hospitals has virtually disappeared. They have been warned not to impose performance penalties, while trusts’ negotiations with NHS Improvement over control totals are trumping the outdated local contractual deals.

As time has passed, finding good quality chairs, accountable officers and finance directors has become more and more challenging

Signing off STP plans halfway through 2016-17 will effectively create the cost envelope in which providers will have to operate in 2017-18. This in turn will determine the providers’ control totals for next year. This new national process is set to bypass the annual contracting round. Transactional commissioning – which has been the core function of CCGs and their predecessors – is becoming a thing of the past before our eyes, and with it the sovereignty and agency of local commissioners.

But CCGs do still have a job to do, beyond being a conduit for nationally agreed local budgets. They remain the organisations most likely to improve primary care quality and the strongest among them have an important part to play in supporting the work of the STPs, especially where they work together. This focus was reinforced in the CCG rating system released earlier this month.

But many CCGs are not strong. As time has passed, finding good quality chairs, accountable officers and finance directors has become more and more challenging – which is why you end up with a tiny and struggling CCG spending £500,000 on two interim directors.

Many CCGs are also very often subscale – indeed the entire south east coast is full of CCGs struggling for any kind of impact because of their size.

Delays on the road

When Simon Stevens arrived as NHS England chief executive he sent a strong message that CCG mergers were not on the cards. He did not want leadership time consumed by thoughts of organisational structure and career prospects.

Mr Stevens was right to do this – but the situation has changed. For the reasons set out above, organisational change is in the air now, as it was not two years ago. CCG leaders’ thoughts are full of it, and their attentions are turning to their own teams and what they will be doing in the future.

The NHS England chief also said from the start that he wanted he and his colleagues to “think like a patient and act like a taxpayer”. It is hard to imagine that the situation at East Surrey or the use of interims at many other CCGs fits the latter part of that pledge.

The senior leadership of NHS England knows what must be done, as do the most far sighted of CCG leaders. But the former are nervous of sending the wrong messages and starting a domino effect of time-wasting mergers – especially as they have not yet assessed the strength of STPs. As a result the long anticipated NHS England “CCG roadmap” may not now see the light of day until the autumn.

But when it is published there must be an unambiguous recognition that CCG “merger”, formal or otherwise, will now often speed the introduction of new care models and other reforms.

Rapid progress

A series of common sense tests should drive decisions.

For example, when a CCG is assessed as inadequate because of poor quality or under-strength leadership the default solution should be to look for existing organisations to take over. That could be a neighbouring CCG or, as might well be the case in areas like the south east, a local authority. In a phrase increasingly heard in Skipton House CCGs must “take leadership where they can find it”.

If, under another scenario, a number of CCGs have already merged the majority of their functions and their governing bodies want to formalise their partnership then NHS England, after the appropriate due diligence, should not stand in the way of the union.

Finally, health economies such as Northumbria, Nottinghamshire and Salford are making rapid progress towards the development of accountable care organisations or other approaches in which commissioners assume a more strategic function. Under these “place-based” models CCGs should be allowed to rethink and rationalise their role and, inevitably, their structure and governance.

Updated: CCG must ‘make the case’ for GPs to take up co-commissioning