Intended for healthcare professionals

Feature Briefing

Moving to accountable care in the NHS

BMJ 2018; 360 doi: (Published 31 January 2018) Cite this as: BMJ 2018;360:k442
  1. Tom Moberly, UK editor
  1. The BMJ
  1. tmoberly{at}

What do we know about efforts to integrate health and social care in England, asks Tom Moberly

How will UK accountable care organisations differ from those in the US?

In the US, accountable care organisations (ACOs) were formed under Barack Obama’s health reforms by groups of healthcare providers coming together to serve a given population. These organisations are accountable, to patients and funders, for arranging care that meets set quality standards within a fixed budget. In the English NHS, the plan is that ACOs will evolve from sustainability and transformation partnerships (STPs).1 They will integrate funding for, and be responsible for delivery of, all health and social care within a defined area. The health think tank the King’s Fund points out that it is “the idea of holding providers to account for improving [the totality of] health and outcomes for defined populations” that is the aspect of accountable care being adopted from the US to the UK. “Elements such as who pays for the care or who delivers it are not being adopted,” it points out. “Put simply, accountable care is integrated care.”2

What legislation will establish and govern ACOs?

This has yet to be determined, though NHS England announced on 25 January that it will launch a public consultation on the prototype contract for ACOs. NHS England has said that ACOs will not be a new type of legal entity and will not affect the commissioning structure of the NHS. “The consultation will set out how the contract fits within the NHS as a whole; look at the ways existing statutory duties of NHS commissioners and providers would be performed under it (including how this would work with existing governance arrangements); and will set out how public accountability and patient choice would be preserved,” it says.

In late 2017, the government consulted on draft regulations to allow the piloting of a draft ACO contract. The government says that it intended to lay these regulations before parliament in February 2018 but that this might be delayed in light of a health select committee inquiry on, and two legal challenges to, the introduction of ACOs. The King’s Fund says that because the UK now has a minority government “legislation on the NHS is off the agenda for the time being.”

How ACOs will encourage collaboration without new legislation to change the commissioning structure of the NHS is unclear. “The vestiges of market based reforms remain, but they have taken a back seat as the need for NHS organisations to work together to make decisions on the use of resources has been given higher priority,” the King’s Fund says.

Will legislation prevent private companies from taking ACO contracts?

None is planned. Jeremy Hunt has pointed out that NHS commissioners are bound by regulations that prevent them from discriminating against private companies when awarding contracts. In a letter on 22 January 2018, he said that amending these regulations was outside the scope of the current proposals. But, he said, such an amendment “may be something a future parliament may wish to consider.”

The King’s Fund argues that, rather than opening up the NHS to increased privatisation and competition, accountable care is likely to have the opposite effect. “The main participants involved in developing accountable care are NHS organisations and partners in the public sector and they are making progress by collaborating, not competing,” it says. The King’s Fund says that there is no evidence that private providers are taking a bigger role in areas that are furthest ahead in developing accountable care.

Why could ACOs be successful when other reorganisations have failed?

Simon Stevens, NHS England’s chief executive, has argued that transforming STPs into ACOs will improve care by driving integration across health and social care providers. “We are now embarked on the biggest national move to integrating care of any major Western country,” he said in June 2017. Stevens believes that this improved integration will be achieved by dissolving the boundaries between commissioners and providers that have existed since an internal market was introduced into the NHS in 1990. “For patients, this means better joined up services in place of what has often been a fragmented system that passes people from pillar to post,” he argued.

NHS England has said that ACOs are just one part of larger work to integrate patient care across services. “ACOs are only one tool for integrating primary care, mental health, social care, and hospital services, and not the only or main way to integrate services,” it says. “Most areas are seeking to do so through voluntary, non-contractual partnerships where GPs, hospitals, commissioners, and local government collaborate to improve services for their population. NHS England will be announcing the next wave of these collaborative partnerships shortly.”

Does establishing ACOs mean the NHS’s internal market was a mistake?

Stevens said in June 2017 that he thought that patient care would improve if boundaries between commissioners and providers were dissolved. That’s not the same as saying that they never should have existed and that introducing the internal market in 1990 was a mistake. It is clear, nonetheless, that NHS England believes that, in 2018, dismantling the internal market will help to improve patient care, for which it says there is “widespread support.”


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