With the move to ACS and ACO models presenting challenges, Christian Dingwall and Jamie Foster explore eight steps to smooth the transition

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As the move from sustainability and transformation partnerships to accountable care systems and accountable care organisations picks up pace, infrastructure is developing to facilitate its delivery, including NHS England’s draft ACO contract and framework for technology and support services. 

But the move to ACS and ACO models from the present, where numerous sovereign organisations work together, remains complex and challenging. At Hempsons, we have sought to demonstrate the “art of the possible” with eight steps for STPs and their constituent organisations to consider when taking the first steps towards ACSs and ACOs:

Christian dingwall 3x2

Christian Dingwall

Jamie foster 3x2

Jamie Foster


Much is possible within the existing legislative framework with a phased implementation approach ensuring the “buy in” of key partners. “Quick wins” include setting up partnership boards and putting in place a memorandum of understanding or alliance contract.


It is common for there to be multiple proposed ACSs/ACOs per STP footprint and early clarity about the key partners in each is essential. Key issues include the commissioners’ role and the extent to which they transfer “tactical” commissioning responsibilities to provider organisations, as well as how primary care engages with the rest of the system.


For STPs or models set up through collaboration or partnership arrangements, the most substantial governance risks relate to the fact that these arrangements are not corporate bodies and have no decision making powers in themselves. So, partners need to think hard to ensure their decision making structures are clear, simple and effective.


In time, commissioners may award a single contract to an ACO but until then partners must operate through a network of contracting arrangements. The ACO contract may allow an ACO provider to support the discharge of certain clinical commissioning group duties, recognising that CCGs will retain responsibility for discharging their statutory functions.


The draft ACO contract and guidance envisages a new payment approach but this is likely to take time. Meanwhile, partners must consider building on existing payment regimes to support the development of their model, including through risk/reward share arrangements.

Organisational form 

Which organisational form best suits a particular accountable care model? There’s no “right answer”. Early discussions between partners about organisational form can help move the model forward. 

The preferred choice of an organisation will depend on factors including contracting, procurement law, tax and workforce implications as well as the ability to satisfy the requirements of the regulators’ Integrated Support and Assurance Process.


Partners must make sure key enablers are built into the model from an early stage including shared workforce, harnessing technology and innovation and shared estate.


Competition and procurement rules continue to apply to the NHS, even those designed for a less competitive and more collaborative NHS, and seem likely to do so for the foreseeable future. It is therefore vital to ensure compliance with these rules in developing the model.

Christian Dingwall and Jamie Foster are partners at Hempsons.