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Long read

Accountable care explained


There is a more up-to-date version of this article

Since this piece was published NHS England has changed the name of accountable care systems to integrated care systems, which describes more accurately the work being done in the 10 areas of England operating in this way. We have published an updated long read: Integrated care systems explained.

What is accountable care?

The basic idea behind accountable care is that different organisations from the health and care system work together to improve the health of their local population by integrating services and tackling the causes of ill health.

It marks a shift away from policies that have encouraged competition towards an approach that relies on collaboration between the different organisations delivering care – such as hospitals, GPs, community services, mental health services and social care – and the organisations paying for it – including clinical commissioning groups (CCGs) and local authorities.

This represents a different way of working for the NHS – the emphasis is on places, populations and systems rather than organisations. If successful, accountable care will accelerate the implementation of new care models designed to integrate care and promote population health. It will also enable local leaders to take more control of funding and performance in their areas with much less involvement by national bodies and regulators.

Where does the term ‘accountable care’ come from?

The language of accountable care comes from the US, where accountable care organisations (ACOs) were set up under President Obama’s health reforms in an attempt to improve care and reduce growing costs.

In England, the term ‘accountable care’ has been adopted and adapted to describe the arrangements developing to support more collaborative working between organisations across the health and care system. These are variously described as accountable care systems (ACSs), accountable care partnerships (ACPs) and accountable care organisations (ACOs) (see below for definitions).

While the term accountable care is relatively new, the underlying concept is not. Accountable care is the latest attempt to make a reality of ambitions for health care organisations to work more closely together to improve care and maximise value from available resources. There is widespread agreement that changes to integrate care need to happen for health and care services to meet the needs of an ageing population.

Does accountable care mean we are moving to a US-style health system or that the NHS is being privatised?

No. The aspect of accountable care that has been adopted from the United States is the idea of holding providers to account for improving health and outcomes for defined populations. Elements such as who pays for the care or who delivers it are not being adopted. Like current NHS services, the English version of accountable care would be tax funded. Some areas developing accountable care might choose to buy in support and expertise from private companies, for example to introduce IT systems, but there is a long history of NHS organisations accessing this type of support. There is nothing to suggest that accountable care will lead to private providers playing a bigger role in delivering clinical services than they do now.

What does accountable care mean for commissioning?

One of the consequences of these developments is that the commissioner/provider split that has underpinned health policy since the early 1990s is unravelling. CCGs are working more closely with each other and with local authorities to develop joint or integrated commissioning, and with providers to plan care for their populations. Commissioning is likely to become more strategic, focusing on the planning and funding of new models of integrated care rather than being based on annual contracting rounds as it is currently. It is also likely to involve use of longer term, outcome-based contracts in place of the current system of Payment by Results, which was designed to support choice and competition.

Are ACPs, ACOs and ACSs the same thing?

The terms ACP, ACO and ACS are used interchangeably by some, but there are differences between them.

  • Accountable care partnerships (ACPs) are alliances of NHS providers that work together to deliver care by agreeing to collaborate rather than compete. These providers include hospitals, community services, mental health services and GPs. Social care and independent and third sector providers may also be involved.

  • Accountable care organisations (ACOs) are a more formal version of an ACP that may result when NHS providers agree to merge to create a single organisation or when commissioners use competitive procurement to invite bids from organisations capable of taking on a contract to deliver services to a defined population.

  • Accountable care systems (ACSs) have evolved from STPs and take the lead in planning and commissioning care for their populations and providing system leadership. They bring together NHS providers and commissioners and local authorities to work in partnership in improving health and care in their area. In many cases, several ACPs may sit within a larger ACS area.

How are accountable care systems developing in practice?

Since NHS England outlined ambitions for sustainability and transformation partnerships (STPs) to evolve into ACSs, 10 areas have been selected to lead their development. Two of these – Greater Manchester and Surrey Heartlands – are part of the government’s devolution programme.

All 10 areas have been working to put in place the structures that are needed for an accountable care system to work. For example, they are forming boards, appointing leaders to oversee the system, and making agreements to share money and responsibility for performance.

The most important test of the success of ACSs is whether they can improve health and care for local people. Areas developing ACSs are building on the work of the 50 vanguard sites across England that have been implementing new models of care to change how care is delivered, for example, by introducing multi-professional community teams to support older people. Early evidence suggests that this work is beginning to improve services and moderate demand for hospital care.

Does accountable care require a change in the law?

STPs and ACSs are a way of overcoming the complexities of the Health and Social Care Act 2012 and filling the vacuum in system leadership that it left. Areas developing accountable care systems are putting in place governance arrangements that enable them to make progress without changing the law. Experience shows that working around the legislation is not straightforward. At some point, changes will be needed to align the statutory framework with the direction of travel.