Intended for healthcare professionals


Can accountable care organisations really improve the English NHS? Lessons from the United States

BMJ 2018; 360 doi: (Published 02 March 2018) Cite this as: BMJ 2018;360:k921
  1. Hugh Alderwick, Harkness fellow1,
  2. Stephen M Shortell, professor of health policy and management2,
  3. Adam D M Briggs, Harkness fellow3,
  4. Elliott S Fisher, professor3
  1. 1Center for Health and Community, University of California, San Francisco, CA, USA
  2. 2School of Public Health, University of California, Berkeley, CA, USA
  3. 3Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
  1. Correspondence to: H Alderwick Hugh.Alderwick{at}

NHS policy makers should not copy US ACOs but they can learn from their experience, say Hugh Alderwick and colleagues

Everybody in the NHS policy world in England seems to be talking about accountable care organisations (ACOs)—a concept borrowed from the US. Some, including NHS England and the health secretary, see ACOs (and the related accountable care systems) as a route to better NHS care.123 Others view them with suspicion—for example, as a means to cutting services4 or a route to NHS privatisation.5 The Department of Health is proposing to amend the NHS standard contract to make it easier for ACOs to develop,6 with implications for general practitioners and others. But there is much confusion about what ACOs are and how they could affect NHS care.

Here we summarise evidence on ACOs in the US—including what they look like, their effect on the quality and cost of healthcare, and how they are redesigning care. Recognising major differences in context, we offer lessons from the US experience for NHS policy makers as they consider the future of similar ventures in England.78

What are ACOs in the US?

ACOs were established under the Affordable Care Act in 2010 as groups of healthcare providers held accountable for care quality and costs. Rather than being paid on a purely fee-for-service basis, ACOs receive a capitated budget from their payer—the government or a commercial insurer—to provide a range of services for a defined patient population and meet quality targets. Any financial savings are shared between the payer and the ACO. The idea is that providers within ACOs have greater incentives to collaborate to improve quality and reduce costs. There are now nearly 1000 ACOs in the US, serving over 32 million people.9 While ACOs are relatively new, they build on a long …

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