Accountable Care Organisations

NHS reorganisation

The Next Step To Privatisation? They Aren’t Accountable, They Don’t Seem To Offer Better Care And They Are Not Really Organisations.

The biggest ever NHS tender for £6bn over 10 years was launched recently for a Local Care Organisation – a single provider for all “out of hospital” health and care services for 600,000 people in Manchester.
The contract will be let by a partnership between the council and a new single Clinical Commissioning Group.

This is the latest variant of an ACO – we shall be seeing more of them over the next few years.

What are Accountable Care Organisations?

An ACO is a group of providers contracted by a commissioner taking responsibility for providing all care for a given population for a defined time. Providers are held accountable for achieving agreed quality outcomes within a given budget. They often focus on high-cost patients such as the frail elderly.

Improved Care?

There is little data on this, apart from a passing mention of carrying out diabetic tests consistently. Despite the name, people don’t seem very interested in the quality of care.

Cost effective?

By contrast, the literature abounds with analysis of their cost effectiveness. And the evidence is mixed. The initial group of ACOs which seem to have started in 2010 have improved care at reduced costs – but that is probably because they were very expensive in the first place, so it was relatively easy for them to reduce costs.

Overall half of Accountable Care Organisations seem to have done well, half have not.


Well, they seem to be accountable to their commissioners – but I have seen no mention of ACOs being accountable to their users. That element seems absent from all analysis and description.

What is integrated care, after all?

There are many definitions – coordination between sectors such as social care and the NHS; coordination between parts of the NHS, like primary and secondary care; improved links within a discipline like mental and physical health; linked record systems. And often, its meaning elides into increased care in the community.

It seems intuitively correct that better care means coordinated care. But there are many claims for integration that are not borne out by evidence. In particular, that it saves money and improves outcomes. Sadly, most of the STP plans rely on this more or less evidence-free planning.

ACOs in England

Large tenders are unstable. Others have included the £800m UnitingCare Partnership project and the £1bn franchising of Hinchingbrooke Health Care Trust, both ending in high profile collapses. This LCO and other similar arrangements may go the same way.

One positive aspect of Accountable Care Organisations is that they eliminate Payment by Results which underpins the pseudo-market in the NHS, pitting one Trust against another and sidelining general practice. In ACOs savings can be recycled and success depends on collaboration between sectors.

ACOs (and STPs) are likely to make CCGs redundant, despite their legal status. More sidelining of general practice.

ACOs are a set-up for privatisation. Large groups are more appealing than lots of small organisations. Commissioners will have “a contract with a single organisation for the great majority of health and care services and for population health in the area.” Labour will insist that the ‘single organisation’ be part of the public sector. The Manchester LCO procurement notice has already attracted the interest of private firms.


Accountable Care Organisations are not accountable, they don’t seem to offer better care and they are not really organisations. Why should we import an untried and probably ineffective model? As pretty much everyone agrees, the government’s not-so-hidden agenda is the destruction of the NHS and its privatisation. ACOs are a step in that direction.

The SHA rejects the fragmentation and marketisation of the NHS, both the internal and external market. We want to see a coordinated Health and Care Service that offers localised care with national standards, spanning the NHS and social care.

Reorganisations rarely improve outcomes. Deckchairs and Titanic springs to mind. What is really needed is an end to austerity – but this government is clearly set against that. Only an adequate financial settlement can deliver the health and social care service that we all want to see.

Don’t be fooled by the rhetoric of Local or Accountable Care Organisations – in the current circumstance, with this government – they are dangerous.