NHS England reveals first national contract for ACOs

NHS England has published the first version of its ”accountable care organisation contract”.

The documents say that establishing an ACO can be “lengthy and complex”, and suggest that most areas need to move to an “accountable care system” first.

Speaking about the need for an ACO contract, the documents say: “An [ACO] cannot simply be willed into being through a transactional contracting process… However, to be sustainable and fulfil their potential, all MCPs ultimately need to be commissioned rather than rely on a shared vision and goodwill.

“In this way money flows and contracts and organisational structures all actively help rather than hinder staff to do the right thing.”

NHS England had been developing what it called a “multispeciality community provider contract”, and published a draft of this in December. 

However, this has been superseded by the new ACO contract, for use by two of the new care models outlined in the Forward View: MCPs (the primary care led model), and primary and acute care systems (generally based around an acute trust).

The documents also suggest that some legal changes are still required before the most advanced version of the ACO contract can be used.

There are three versions of the contract depending on the extent of GP integration. These are known as virtually, partially and fully integrated.

Under the ”partially integrated” version, commissioners would procure a single contract for its population but GP services would not be included, and the ACO provider would need to sign an “integration agreement” with practices in the area.

For the ”fully integrated” version of the contract, GPs would become salaried employees and would be able to “suspend” their GMS or PMS contract. As a result their patient list would become part of the ACO/MCP, but the GPs could potentially return to their previous contract if the ACO failed.

However, NHS England notes in the contract documents that this option would require a change to current law, to temporarily remove the requirement on GPs to provide services to their registered patient list. The national commissioner has said it is currently working with the Department of Health on this amendment.

According to the document the DH has also drafted a new set of directions for APMS contracts, which will form a major part of ACO contracts. These are expected to be published later this year. The current APMS contract is “not fit for purpose” for the use as an ACO, the documents say.

In addition, the documents highlight a number of “limits” on the guarantees NHS England will be able to offer GPs who “suspend” their GMS or PMS contracts. 

GPs who choose to fully integrate with an ACO would have the option of ”reactivating” their GMS or PMS contract every two years. However, if this is done after the first two years, patients would remain with the ACO provider, unless they ask to be transferred back.

NHS England also says that it is hoping that Section 75a legislation, which allows clinical commissioning groups and councils to pool budgets, will be amended by 2018, because it currently limits which services could be included in an ACO contract.

The documents identify a number of “organisational forms” which could hold the ACO contract. These include:

• A GP owned organisation, which could take the form of a limited company by shares or limited liability partnership;
• Corporate joint venture in which GPs and another organisation come together to form a new legal entity;
• An existing NHS body, for example a foundation trust or NHS trust;
• A “host arrangement”, in which an organisation hosts the ACO contract but decisions are made through a “forum” of partners from other providers.