NHS integration: Can accountable care organisations deliver a truly GP-led NHS?

Dr Martin Marshall says GPs should not reject out of hand the latest fad among policy wonks: accountable care organisations. Set up correctly, he argues, they might be able to deliver on promises of a GP-led health service.

Sometimes it makes a lot of sense for GPs to keep their heads down when ‘new’ ideas are trumpeted by government. It is good to remind ourselves of Rudolph Klein’s sage aphorism: ‘innovation is a function of amnesia’. Too often bright new ideas are a rehash of old initiatives that didn’t work in the past and won’t work any better just because they have been given a fancy new name.

So what about accountable care organisations (ACOs), the latest idea to emerge from the US which has caused a frenzy of excitement amongst policy wonks in NHS England? My advice is: lift your heads up and take a look. The name might change (the King's Fund has already coined a new term, ‘place-based care’) but I don’t think that the idea will go away.

What are ACOs? In the context of the NHS they are essentially a partnership between primary, acute, community, social care and third sector providers who have agreed to take responsibility for providing all care for a given population for a defined (and long) period of time. Most importantly, the partnership is held to account for achieving a set of pre-agreed quality outcomes within a given budget.

Focus on long-term outcomes

Think about it; the implications of this simple model may be significant. ACOs could herald the demise of the purchaser-provider split. They remove the need for frequent competitive tendering of contracts. They are likely to eliminate the micro-management of processes of care and allow professionals to focus on long-term outcomes (clinical, functional and experiential) and population health improvement.

They incentivise providers to preferentially allocate funding to the most cost-effective part of the system (general practice) and to focus on addressing the broader determinants of health. They encourage providers to disinvest in wasteful and ineffective interventions and will deter hospitals from empire building.

And all of this would happen because the deeply embedded sectoral barriers and dysfunctional incentives currently in place in the NHS are replaced by a shared set of values, a chance to build a stable set of relationships and a common set of objectives. The model isn’t rocket science but its implications are radical.

The building blocks for ACOs are being put in place right now across the country with the formation of a growing number of ambitious provider partnerships, some areas combining their health and social care budgets and others awarding long term, outcomes-oriented contracts for older people’s care. New legislation isn’t required to create ACOs, nor are distracting top-down structural reorganisations.

The biggest danger is that at a local level large acute trusts will seize on ACOs as a way of getting a bigger slice of the financial pie. Robust primary care partners are required to ensure that this doesn’t happen. Some people feel safer within their traditional boundaries, anxious about jumping into bed with new powerful partners. But ACOs provide a rare opportunity to realise the rhetoric of a general practice-led NHS, and to address some of the poor policy decisions of the past.

  • Dr Martin Marshall is a GP in Newham, East London and Professor of Healthcare Improvement at UCL

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