What is an Accountable Care Organisation (ACO) and how do we get there?

ACOs are integrated care systems bringing together all providers of care end-to-end across the whole health system usually within a specified geography. In the US ACOs are set up to deliver all elements of care end-to-end by design, and individuals are insured for care at any point along the pathway with the same provider.

For the NHS, ACOs are being set up as partnerships (ACPs) and include primary, secondary and specialist care as well as community and social care. This structure of shared responsibility for a capitated budget (a fixed budget for the whole local population) drives collaboration across the partnership to look at mechanisms of reducing costs, introducing innovation, generating more value from services, improving outcomes, and keeping the population healthy so as to reduce intensity of service use.

One pre-requisite for this structure is that primary care set up provider networks called Federations. This need springs from the fact that GPs who want to deliver community contracts need to compete for those services and obviously would have an unfair disadvantage if they were to commission themselves internally. The resultant GP Federations are being set up for that purpose but are fledgling organisations at the moment and must grow in strength to be serious contenders for contracts.

Most of the Federations mirror the geographies of the CCGs they wish to serve i.e. made up of the same doctors, but despite pairing up to bid on community contracts with large acute providers, few have come to fruition. One of the biggest issues is that despite funding being available, most of the resources and people capable of supporting Federation growth sit within CCGs and most Federations have therefore stayed as one or two man bands (clear exceptions include Camden and City & Hackney’s Federations). This will change, not least because the 2018 deadline (likely to slip to 2020) for the formation of ACOs as set by the NHS is looming, and unless these primary care providers grow up quickly there will be a gap in the continuum of care at the most critical level.

This change is even more fundamentally needed for other reasons. The commissioner-provider split has pushed innovation to the back burner; business cases demonstrating in-year savings have risen as the modus operandi of choice for CCGs, with quick wins fast running out and innovations often needing a significant runway to prove their worth. ACOs provides the NHS with a timely opportunity to hit its targets of patient centred care, supported-self management, digital enablement and wellness in general; focus on setting them up properly over the next two years to deliver on these goals is now the key!