The NHS world is changing. I wrote last week about the impact of commissioning on general practice, and this week I consider what the move towards accountable care organisations and systems means for GPs and practices.

What is accountable care? The Kings Fund has helpfully described it as comprising of three core elements,

“First, they involve a provider or, more usually, an alliance of providers that collaborate to meet the needs of a defined population. Second, these providers take responsibility for a budget allocated by a commissioner or alliance of commissioners to deliver a range of services to that population. And third, ACOs work under a contract that specifies the outcomes and other objectives they are required to achieve within the given budget, often extending over a number of years.”

Rune reading, particularly in the NHS, is a difficult game. But all the signs point to accountable care organisations and systems (often used interchangeably to describe very similar arrangements) as the direction of travel. STP plans, NHS leaders and politicians are all making noises to suggest it is exactly where we are heading, despite the reticence to create new legislation with the disaster of the last NHS legislation so fresh in people’s minds.

If accountable care is where we are going, what does it mean for general practice? To help answer that, there are three further questions for us to consider.

1. What role will general practice play in an accountable care system?

Here the options appear to be threefold. General practice could choose simply not to engage. Indeed, some of the early accountable care pilots report engaging GPs to be one of their key challenges. The problem here is some of the budget for general practice will transfer from local commissioners to the accountable care system. If this is dominated by the acute hospital and other large provider organisations there is an obvious risk some funding streams will dry up.

Conversely, for accountable care systems seeking to deliver outcome rather than activity goals within a fixed funding envelope, international examples such as the Canterbury Health Board in New Zealand have shown the rate of growth of hospital activity can be moderated by investing in services in the community. There is opportunity for general practice within accountable care systems, meaning active engagement could well benefit the profession as well as the local population.

General practice could choose to play the role of “strong voice around the table”. It could ensure it is involved in accountable care system decision making, and almost take on an LMC type role to ensure risk to practices is minimised and funding streams are maintained and, where possible, developed.

Or it could attempt to play a leading role. Accountable care systems are very much at the developmental stage. There is no fixed blueprint for how they will look or how they will operate. Active leadership now could drive the evolution of these systems to ensure they are built around core general practice and the delivery of joined up and effective prevention and out of hospital care.

2. What scale will the accountable care system operate at?

Equally, the answer to this question is not clear yet. On the one hand we have the devolution project in Manchester creating an accountable care system spanning the whole of Greater Manchester. On the other, the primary care home (PCH) initiative is promoting accountable care for populations of 30-50,000.

In most places, size has not been determined. It may be that “layers” emerge, with smaller local areas where they exist (maybe PCH size) feeding in to larger areas (maybe acute hospital catchment area size), in turn feeding into even larger areas (whole STP size, a la Manchester). What “feeding into” in this context means is anybody’s guess.

For general practice, the scale chosen is likely to be important. If an accountable care system operates at acute hospital catchment area size, general practice would need to be well led and organised to be able to match the voice of its acute counterpart. At STP level, how does it prevent its voice being drowned out by the multitude of other big voices around the table?

Even operating at a locality or neighbourhood level of 30-50,000, practices will need to find a way of working well together and creating a strong single voice. To influence the scale at which accountable care operates locally practices will need to be involved at an early stage of the discussions. Once final decisions are taken, they will be hard to undo.

3.How will general practice build the relationships it needs to participate in accountable care?

It is clear a system reliant on collaboration between providers is going to be a challenge for general practice which is currently organised into nearly 8,000 individual business units. Practices will first and foremost need to build relationships with each other. Some practices are merging themselves into a size that means they will individually be ready. Some are forming federations. For others the currently existing CCG localities may provide a platform practices can build on. Key here is if practices want accountable care systems to work for them, as opposed to simply becoming their new masters, the ability to work effectively together is undoubtedly task one.

Equally, GP groups (whether it be large practices, federations, or localities) have to find a way of working together. Ultimately there is going to be one GP voice in an accountable care system. For that voice to be effective it will need to be unified. The acute trust, for example, will have a single, clear voice. If general practice cannot create the same level of cohesion, its voice will be diluted, and influence correspondingly diminished.

Finally, GP groups will need to be able work collaboratively with other providers. The aim is not that these systems become the fora within which providers fight each other for their share of the fixed amount of funding available. Rather, it is for barriers between organisations to be removed and for more effective ways of delivering care to be developed for patients. This requires productive relationships based on trust. For general practice it will require strong local leadership that practices believe in and are prepared to back when decisions are made – there will not be the time or opportunity for every decision to go back to each practice for a vote.

The overriding message for general practice is accountable care is coming. As such, practices may want to consider how they want accountable care to work locally, to identify what role they want to play in both shaping and delivering this future, and to reflect on how ready they are for this new system which has significant implications for the future of general practice.