It appears NHS England have gone cold on Accountable Care Organisations with the publication of the latest guidance. But what might the new draft contract mean for general practice and what should interested GPs consider doing next? Ben Gowland works his way through the tangle of documents and suggests some of the answers.

NHS England have recently published an updated version of the MCP contract, now termed an Accountable Care Organisation or ACO contract. As ever with NHS England, there are an inordinate number of documents, all of which are inexplicably difficult to find on their website (here). I discussed the original publication of the draft MCP contract in detail previously, and would strongly recommend you take a look at this to understand the key components of the different versions of the model (the “virtual”, the “partially integrated” and the “fully integrated” MCP) and their implications for general practice. In this article I will focus on what is different or has changed in the new publication.

The most noticeable shift is the overall drop in enthusiasm the documents display for the new models. Where previously you had the sense that those producing the documents believed ACOs to represent the next step for the NHS that is now no longer the case. Instead, it has become clear that Accountable Care Systems (ACS’s) are the new black, and ACOs may instead be something of a distraction. Take this paragraph for example, ‘ACO procurements are lengthy and complex, and the development of ACOs relies on a strong underlying approach to care design, engagement and collaboration. For these reasons, most parts of the country are looking to become ACSs before they consider whether to introduce ACOs for some or all of their local population.’

An ACS, for those not familiar with the concept, ‘is an evolved version of an STP, potentially covering a sub–set of an STP’s geography, in which commissioners and providers, in partnership with Local Authorities, take explicit collective responsibility for resources and population health. In return, they will gain greater freedom and control over the operation of their local health system and how funding is deployed’. ACS’s can cover large areas relatively quickly, do not require contractual or legal changes, and represent the quickest route for the NHS out of the current purchaser provider split. ACOs must demonstrate ‘consistency with STP/ACS plans for the future’, and, just so that we are clear, ‘In most places, we expect that ACS development will precede the development of ACOs in order to lay the right foundations.’

The shift from “MCP” to “ACO” has come about whilst previously the draft contract applied only to MCPs, with a separate contract promised for the PACS models, now the contract ‘is usable for accountable care models generally, including MCP and PACS models’. A sceptic might think that given the shift of focus towards ACS’s, and the lack of traction generally for the PACS model, that centrally it was not deemed worth the effort to fulfil the initial promise of a separate PACS contract.

Nevertheless, there have been some interesting developments in the iteration from the original draft. There is confirmation that activity sub-contracted from the ACO to practices will be pensionable. The fully integrated model no longer relies on APMS directions, replaced by less prescriptive directions that offer more local freedom. GPs can sell their premises to the MCP, ‘where the MCP has the capital to buy the property and there is clear value for money’. GPs may be able to buy in as partners or owners of MCPs, but given the cost that is needed to cover (amongst other things) the downside risk of the contract I would suspect it will be beyond the reach of most individuals.

Much has been made in the GP press of the changes to GP practices’ “right to return” (from the fully integrated model back to the original GMS/PMS contract), whereby the patients will not necessarily follow the contract (you can have your contract back but not your list). What it actually says is, ‘If the GP reactivated in the first two years of the ACO Contract the default would be that patients previously on their registered list follow the GP to be re-registered with the practice. If they reactivate after these first two years the patients will remain with the MCP unless they request to follow the GP.’ In reality this means the practice has to decide whether or not it is going to stay or leave within the first two years.

Not all GP practices in the same area have to go down the same route, ‘It’s important that individual GPs have a choice and do not feel pushed into a particular contractual model because it is preferred by the majority. In many of the emerging MCP localities GPs are expressing interest in a range of contractual models in the same locality.’ I assume this is an attempt to move at the pace of the enthusiasts rather than be hampered by those resisting change, but I am not sure how well it will serve general practice going forward to end up in this type of mixed economy.

This version of the ‘GP participation in an MCP’ document is littered with examples and case studies of benefits existing areas have achieved or foresee. I suspect this is in an attempt to make what is essentially a very dry document into something more accessible to GPs. However, the lingering sense left by these is that the majority of the benefits highlighted can be delivered through practices working together, and so do not directly encourage GPs to take the radical step of joining an ACO. It would make sense if they were benefits that could only be achieved as part of an ACO, but by and large this is not the case.

At the same time there a strong reference in the documents to the emerging primary care home model, ‘All accountable models build on strong primary care foundations. In many Vanguards the model is based on local units of integrated primary care provision serving natural communities of 30–50,000 population.’ I think this is an important statement for GP practices trying to find a way through all of this. If ACO development is uncertain whilst Accountable Care Systems come to the fore, and the many of the purported benefits can be delivered by working with others, then developing a clear focus on a local population and building effective working relationships with the other local practices (in whatever form that might take) might be the most pragmatic step for practices to take right now.