England General practitioner General Practitioners Committee

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Fully formed MCPs and PACS are examples of an ACO (accountable care organisation), where a single organisation is contracted to provide agreed services to a defined population.

The ACO may sub-contract some services, but they are ultimately responsible for the cost and quality of care for their population within an agreed budget. Existing providers, therefore, may be employed directly by the ACO, or may potentially be merged. Advanced ACOs would cover the majority of the health and care services, including public health.

In October 2015, the Government announced its intention to create a new 'voluntary' contract to be used by GPs and other providers in England, in order to provide 'at scale' general practice and integrated services as described above. The latest updated version of a draft MCP contract was published in August 2017, and has been adapted to be usable for all types of ACOs . The contract is aimed at providers who wish to provide integrated care 'at scale' over populations of at least 50,000 patients.

At the same time, NHS England also mandated health and care systems in England, divided into 44 areas, or footprints, to come together and develop an STP (sustainability and transformation plan). These are five year, umbrella plans, detailing how different providers in local areas will work in partnership to implement the five year forward view. NHS England expect that these STPs will evolve into ACS (accountable care systems).

ACS involve local NHS organisations, potentially in partnership with local authorities, working together as an integrated system. The ACS has collective responsibility for resources and population health in their area, rather than a single organisation holding the contract as in an ACO. In time, it is expected that some ACS may establish an ACO. In both ACS and ACOs the traditional division between commissioners and providers is blurring.


NHS England’s contractual frameworks outline 3 different paths for ACO development

  • Virtual

    Providers of services would enter into an 'alliance agreement' with the commissioning bodies, which would overlay (but not replace) regular commissioning processes, setting out an agreement to achieve greater integration of these services (e.g. shared managing of resources, governance arrangements, risk sharing agreements, operational delivery of services).

    The services themselves would remain governed by the regular commissioning procedures and contracts, and in this way, the virtual model is effectively an ACS rather than an ACO.

    NHS England have produced a template Alliance Agreement for use by commissioners but this could be adapted based on individual provider or population needs. The agreement is owned by the providers and commissioners within it.

    Diagrammatical representation of the virtual model:

    Salaried GPs diagram

  • Partially integrated

    This model would provide a single contract for everything included in care provision (primary, secondary, community, mental health, public health, social care and aspects of local authority care provision) apart from core general practice. This would form a 'whole population provider' which holds a single contract with the commissioner, and holds agreements with the GP practices in the area to form the overall ACO.

    The whole population provider could be a new organisation or an existing organisation which would take the lead role. It would be responsible for the provision of services but may not necessarily deliver all the services itself but could instead hold subcontracts with other providers.

    It could include primary care services that fall outside of core general practice (including QOF, DESs and local provision of primary care). Whilst GP practices may still hold their GMS/PMS contracts, any primary care services beyond that which fall under the scope of the ACO may either be delivered by the practice or join the 'whole population provider'.

    The whole population provider (i.e. the ACO contract holder) would be required to integrate the services they provide directly with the core primary medical services in that area and agree with the GP practices in the area how that will occur using an 'integration agreement'.

    Diagrammatical representation of the partially integrated model:

    Salaried GPs diagram

  • Fully integrated

    This will see all services procured in a single contract between the commissioners and a single legal entity. This organisation would be responsible for the provision and integration of all care services; it could deliver all services directly, or could sub-contract for services to be delivered by other providers.

    The overall contract would run for a limited period of 10-15 years, and include a break period every 2 years, to allow for evaluation of the development of the ACO and the services provided under the contract.

    Provision has been made within this model for GP practices to suspend their GMS/PMS/APMS contracts (for an agreed amount of time), which may later be reactivated. GPs can reactivate their G/PMS contracts at two year intervals or at the termination or expiry of the ACO contract.

    This is likely to affect salaried GPs, but there are limits as to what can be nationally guaranteed and a number of practicalities would need to be worked out locally. As a general rule, GPs reactivating their contracts would need to show that staff roles move back to the practice as a result of reactivation at which point staff could TUPE back.

    Diagrammatical representation of the fully integrated model:

    Salaried GPs diagram