September 30 is the deadline for applications to merge Clinical Commissioning Groups into much larger bodies from next April, as required by NHS England.

Way back before Covid, in January 2019, NHS England’s Long Term Plan charted a course towards a further reorganisation of the NHS, unpicking some of the fragmentation inflicted by Andrew Lansley’s disastrous 2012 Health and Social Care Act, but at the expense of reduced accountability and increased reliance on private consultancies and companies.

The transition from over 180 surviving CCGs to the new ambition of just 42 so-called “Integrated Care Systems” (ICSs) involves a complex combination of mergers of CCGs … and legislation to lend retrospective legitimacy to the ICSs that NHS England had begun setting up in the aftermath of “Sustainability and Transformation Plans” in 2016.

At present the ICSs stand outside the law, with no authority to decide policy or enforce financial discipline. And despite a vague commitment in December’s Conservative manifesto and in the notes to the Queen’s Speech, there has been no sign so far of the draft legislation to change this status.

The statutory bodies, CCGs, are still public bodies: their governing bodies are required to meet in public and publish board papers. They are required to consult local communities on major changes, and can be held to account by local authority Health Oversight and Scrutiny Committees, which retain powers to block controversial changes and refer them to the Secretary of State for review. None of this is true of ICSs.

In a bid to escape from this level of accountability, the Long Term Plan laid down the principle that there should “typically” be only one CCG for each ICS, and the pressure was on to steamroller through mergers of CCGs across large populations and geographical areas, destroying the flimsy pretence of any genuine local links or accountability to local communities.

With an apparent government commitment to legislate to dismantle some of the Lansley Act and give powers to ICS bodies, NHS England began early last year to crank up the pressure for mergers of CCGs in readiness for a new system that seemed almost certain to end up with the CCGs becoming redundant additional layers of bureaucracy, and facing the axe.

NHSE’s pressure paid off in some areas: April 2020 saw a massive wave of mergers that reduced 76 CCGs to just 18, compared with just two mergers involving six CCGs in 2019.

However in many other areas there was stubborn resistance to the pressure to merge CCGs – in many cases driven by local government, but in Staffordshire GPs led the resistance, voting by a massive 107 practices to 24 against the merger of the county’s six CCGs, with a majority of GPs in only one CCG voting in favour.

There was also resistance in areas that had forged ahead and proclaimed themselves ‘Integrated Care Systems’, even though they were far from integrated and the law meant they were not really systems.

In South Yorkshire and Bassetlaw, which notionally launched an ICS in October 2018, all five CCGs clung on to their status for fear that their area might be disadvantaged – and having gone through the process laid down by NHS England, reported to them that they had decided merger was not the way forward for their population. As a result the ICS exists pretty much in name only, with the CCGs making all decisions and controlling finance.

In Bedfordshire, Luton and Milton Keynes, another early implementer of “Integrated Care,” the ICS Partnership Board in July heard three of the four councils in the patch, Milton Keynes, Bedford and Central Bedfordshire all make clear their continuing opposition to merging into a single CCG:

“Milton Keynes Council had scrutinised the proposals and unanimously raised concerns regarding the merger as there is no detail as to what would be commissioned at scale, local authority level and local/parish level. … Bedford Borough Council Executive is opposed to the proposed merger as it is believed the restructure is at the expense of health outcomes. … Central Bedfordshire Council accepted that this is a national ask to have one CCG but believed the proposals required more consultation…”.

In the giant “footprint” of West Yorkshire and Harrogate, where again there has been understandable resistance to merging into a single CCG that would be accountable to nobody, North Kirklees and Greater Huddersfield CCGs held a summer event to inform their publics that the opposition of GPs in both areas was the reason they were unwilling to merge.

In the North West of England, NHS England has intervened to block moves to merge four North Merseyside CCGs into one, following the merger of Cheshire CCGs in April: instead the order has gone out that all of the remaining Cheshire and Merseyside CCGs must merge into one joint CCG, covering a large ramshackle area and 2.7 million people, to form the basis for an ICS. There is no appeal against an NHS England veto on the more limited merger proposal, but it’s clear that CCG chiefs as well as councillors are concerned at the massive erosion of local accountability

In North West London, attempts last year to push through a merger of the 8 CCGs into one were eventually postponed in the face of determined opposition led by Hammersmith & Fulham council and supported by local campaigners. Now the plan has been revived, with a consultation run mainly through the holiday month of August, Hammersmith & Fulham has once again rejected the arguments put forward for the merger in a letter from its chief executive which notes:

“A basic element of any consultation must be to make the case why the proposed arrangement would be better than the existing one. However, the proposal does not attempt this justification.

“Economies of scale are claimed but not costed. There is a singular lack of evidence in terms of patient outcomes (which are what matter most) for why a single CCG serving 2.2 million people would be better than having eight CCGs now.”

In North East London, where health bosses are also trying again to push through a merger of seven CCGs (City & Hackney, Waltham Forest, Tower Hamlets, Redbridge, Newham, Barking & Dagenham and Havering), the “managing director” of City & Hackney CCG has left it to the evening of September 30 – the final day for submission of applications for merger – to explain to Hackney Healthwatch what the proposed changes will mean.

The notice of the meeting claimed that “the public are sought as key partners in this work” – despite them having been kept deliberately in the dark, not least on the fact that the plan is now for an “Integrated Care Partnership” – rather than the ICS which had been proposed before.

However it’s clear that the process of forcing through more CCG mergers is not as simple as NHS England might have imagined, and the next step – from merger to creating ICSs that are any more than an empty phrase – is likely to be even harder.

* Meanwhile in South West London, where six CCGs tamely merged in April, opposition is growing to the plans to build a new, but much smaller acute hospital on the old Sutton Hospital site, alongside  the downsizing and downgrading of the existing hospitals at Epsom and St Helier, bringing a near-halving of numbers of acute beds. Croydon council has now joined with Merton in referring the £400m plan to the secretary of state for review – leaving the LibDem-led Sutton council sitting on the fence.

* The next Lowdown will follow up our round-up in June and further update the progress on establishing ICSs, and the extent to which this is accompanied by a huge expansion of private sector consultancy and involvement.

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