General practice is on a cliff edge - and ACOs could tip it over

The latest acronym to hit the NHS is ACO – Accountable Care Organisations. You would be forgiven for sighing with disbelief at yet another change to the way the NHS operates. It wasn’t enough for the Conservative led coalition to push through the single biggest reorganisation of the NHS with the Health and Social Care Act 2012 – a change so big you could ‘see it from space’ according to the then NHS chief executive David Nicholson.

ACOs are the latest reorganisation by NHS England which Simon Stevens expects to “deliver fast-track improvements, such as fewer emergency hospitalisations and better care in people’s homes”. On the face of it that sounds like a good plan but the potential seismic shift in how the NHS runs under an ACO is frightening.

ACOs will seek to bring together all organisations (providers and commissioners) offering health and social care under ‘one roof’ in a geographical area. Social care is now based on means testing so you have to pay if you have some savings. There is a risk health care will go down a similar route within an ACO. All those in an ACO will be jointly responsible for care – and crucially jointly responsible for the multi million pound deficits run up by hospital trusts due to government underfunding. GPs beware…. you could also be responsible for sorting out that deficit within the ACO.

Another concern is that an ACO will be very much driven by secondary care given the large budgets they have and offices full of lawyers, accountants and managers. General practice is already in such a bad place with wholly inadequate funding, inability to retain or recruit GPs and a workforce so ground down with work and stress they haven’t got the time to speak out or stand up to such proposals. LMCs have a vital role to play as the true advocate for GPs and they must be central to any discussions on reconfiguration of services.

ACOs have the potential to remove the list based general practice that has served our patients well since 1948 and consume all patients into the ACO with the role of the GP as yet being unclear. It may be that the GPs become salaried in their ‘ACO practice’ or salaried to the local hospital trust. It is hard to see the independent contractor model surviving such a shift in ethos of how the NHS is configured. Private companies and insurance firms will be watching this change with interest as they will see a big opportunity to profit by working with ACOs by taking on lucrative contracts or offering insurance products to patients in such a large health organisation. Government legislation will allow this to happen.

Practices who are very large or have strong voices may be able to ride this storm but the threats are clear. The NHS is in such a mess with massive underfunding, a demoralised profession and politicians with no interest in preserving what was once the jewel in the crown that was general practice.

There may be some hope heading our way though. The government have singularly failed to explain these changes or consult on them and this has angered many people. Health professionals including Professor Allyson Pollock and Dr Ben White (who has already taken Jeremy Hunt to court over the junior doctor dispute) have launched a crowdfunding appeal to take the government to the high court for a judicial review over the ACO changes. It might make the government think twice and I urge you to support them.

General practice is on a cliff edge. ACOs pose significant threats and it is vital we inform ourselves on these huge changes to the NHS and speak out about them before it is too late.

This article first appeared in


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