So, what’s so great about an ACO?

I had Jim Mackey in the back of the cab the other day…

Actually, this is true. I really did drive him between two meetings in the Midlands so he could make a ludicrously tight schedule. And no, I’m not a taxi driver in my spare time. The reason I mention this (outrageous name-dropping aside) is that it is clear to me that we are heading at speed towards an ACO (Accountable Care Organisation) environment and the senior bods at NHSE and NHSI are right behind this. Don’t fight it people, its coming.

The great thing about Jim (who I rank as the best leader I have met in the NHS) is that not only does he talk the talk but he walks the walk too. His former organisation (Northumbria) is well on its way to being an ACO with the right partners in the North East. ACOs aren’t fantasy.

What is so great about them then? Well, I think the answer is simple – whole population budgets (‘WPBs’). Given my background is different (Law and Investment Banking), my view is that allowing providers to sort out ‘the money’ themselves is the only way to sort the system. The madness of Lansley commissioning needs to be consigned to the dustbin of history and we need to make decisions based on clinical evidence backed by financial robustness.

NHS finances are unbelievably ‘Mickey Mouse’ in concept. The whole idea of a control total is mad and it takes away all incentives. A ‘system in financial balance’ is never going to be achieved while any vestige of current commissioning remains. It should simply be a money transfer mechanism, there to ensure that the right providers are incentivised (commissioned) to provide a service based on medical outcomes that meet national targets. Commissioning is not there to decide how this happens. Most GPs (I would say) have lost faith in CCGs anyway.

So give providers the money. Tell them what you want (as outcomes) and sign a contract with them. Then get lost until contract review comes up. A regulator will make sure that the provider is doing what it said it will. Just one regulator please. No need to have NHSEs, NHSIs, CQCs etc., etc. At this point I believe the following will happen:

  • Providers now don’t compete; they must co-operate (because real money is at stake).
  • Sensible decisions can be made about pathways, A&E admissions, hospital discharge, what an Urgent Care offer actually is, how we actually embed prevention as opposed to just talking about it.
  • Self-interest of the one becomes self-interest of the whole. If the person next to you is not doing their bit, then everyone else will want to know why. This kind of peer pressure will bring results, believe me.
  • Realistic decisions can be made about estates, procurement, the relationship with drug suppliers, contracts etc., etc. Once you know that we have £x to spend and if we spend too much we go bust, people behave a bit differently. GPs inherently get this.


I find that our various GP Federations and cohorts are coming ‘on-side’ with the realisation that the direction of travel is towards something different. Yes, there are still many that are too busy to think about it in detail, but almost without exception nationally they are prepared to delegate the responsibility to find out how this will work in practice.  The ‘few’ that are entrusted in exploring the way forward seem the naturally entrepreneurial and opinion-former types. What I find interesting is that they all say a very similar thing to me – ‘John, what is the engine of change? Because if there isn’t one, then I have heard it all before’. This skepticism is easy to understand. How many false dawns have there been? Universally they climb on board when you frame the engine as ‘control of the health budget’.

This is what GPs (as providers and NOT commissioners) want. A chance to have a say in how the money is really spent. Once the realisation dawns that there is a very real chance of this happening, GPs should actively seek a place at the table. They must have one, because even if a trust has the governance standards and financial clout to bid for an MCP contract, it cannot deliver it without GPs.

So, I believe we must move into this brave new world of trusting each other as providers. The good news is that it is not a pipe dream; go back far enough and you will see we had a perfectly serviceable provider model before. My dear Dad spoke regularly to GPs as a consultant and they knew they could always call him for an opinion. A&E admissions didn’t seem much of a problem back then.


John Tacchi hails from a medical family but had a career as a barrister and investment banker before a brush with cancer persuaded him to re-evaluate life priorities. A graduate of the NHS Executive Fast Track Programme, he began his career in the NHS as CEO of BIG Practice Ltd, a large 86 practice GP Provider company in Birmingham. Now in the acute sector, he continues to have a strong interest in the future of General Practice and is a firm believer that if the NHS is to be saved then the direction of travel must be towards Accountable Care Organisations.

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