Clinical commissioning group mergers must create footprints that help deliver sustainability and transformation plans, and which are “future proofed” for the emergence of accountable care providers, under new NHS England guidance.

Six new criteria include that the new CCG will “provide a more logical footprint for delivery of the local STPs” and have the “right critical mass to discharge” a “more strategic commissioning function” given the “likely” emergence of new provider structures accountable for the health of populations. They must also save a fifth of management costs.

The revised guidance, published on Thursday, is also a clear signal that some CCGs will now be allowed to join together.

Only one CCG merger has so far been allowed since they were created in 2013 – Gateshead, Newcastle North and East, and Newcastle West CCGs in April 2014. Simon Stevens became NHS England chief executive in the same month and introduced an informal ban on mergers.

This summer, however, NHS England leaders indicated that some mergers would be permitted, and CCGs in several areas, including Manchester, Birmingham and Buckinghamshire, have said they want to join.

NHS England said in a statement “there remains a general presumption against mergers unless they can be shown to release staff and resource to support local STP implementation while further cutting administrative costs”.

However, the guidance says the organisation “does not rule out a very limited number of potential mergers occurring in time for 2017-18”.

It is likely there will be substantially more instances of CCGs moving to shared leadership, management and governance, rather than merging. The guidance also revises how NHS England will consider CCG applications for changes to their constitution – this will include the “fit with” STPs, as well as their performance on the CCG assessment framework.

Graham Jackson, co-chair of NHS Clinical Commissioners and chair of Aylesbury Vale CCG – which is considering a merger with Chiltern CCG – said: “We welcome this guidance which should be seen as a way of supporting and enhancing the strategic evolution of commissioning.

“Where there is a case for a formal merger of CCGs it must be driven by the local area who have decided it’s the right thing to do.”

The six new factors to be considered before mergers

  • Strategic purpose: to provide a more logical footprint for delivery of the local STP.
  • Prior progress: the relevant CCGs must have already demonstrated progress in systematically implementing shared functions; and there is evidence of a willingness to work together. Ideally, we want mergers to be a natural next step rather than a major organisational upheaval. Where no formal joint working is already in place, we would want the CCGs to demonstrate how they will implement the change simply and quickly, without the merger distracting both organisations from the more important task of implementing the Five Year Forward View, achieving financial balance and delivering core performance standards.
  • Leadership support: the merger proposal enjoys the support of the STP leadership; the support of constituent CCG governing bodies; or it forms a necessary part of an agreed turnaround plan for a CCG under directions.
  • Future-proofed: the merger proposal provides the right footprint for oversight of likely local multispecialty community providers and primary and acute care systems and to have the right critical mass to discharge the new, more strategic commissioning function. This also includes looking at alignment with existing or likely devolution arrangements.
  • Ability to engage with local communities: we would want assurance that the move to a larger geographical footprint is not at the expense the new CCG’s ability to engage with GPs and local communities at locality level.
  • Optimising use of administrative resources: the merger should show how 20 per cent in ongoing running costs will be released to supporting local system transformation, including how the changes are commissioned.

Pre-existing factors to be considered

  • Coterminosity with local authorities: there is a presumption in favour of CCGs being coterminous with one or more upper-tier or unitary local authorities. If it is not, and a local authority objects, NHS England must consider both the views of the local authority and of the proposed CCG.
  • Clinically led: the new CCG should demonstrate that it will remain a clinically-led organisation, and that members of the new CCG will participate in decision- making in the new CCG.
  • Financial management: NHS England will consider whether the new CCG will have financial arrangements and controls for proper stewardship and accountability for public funds. 
  • Arrangements with other CCGs: the new CCG will have appropriate arrangements with others, for example lead commissioning arrangements.
  • Commissioning support: NHS England can take into account whether the new CCG has good arrangements for commissioning support services.

Source: NHS England guidance

Topics