The Darzi review brings community providers the policies they have long called for but the new austerity means they must prove their worth with cost-effective innovations

Providers of community health services have long demanded guidance, policy and direction. This has duly arrived with the Darzi review and the multiple publications under the banner of Transforming Community Services. As the clamour increases for guidance on the detail of organisational form for primary care trust provider arms, why are we asking for more direction?

One answer is that Transforming Community Services is looking for solutions to many, sometimes competing, issues that have never been tackled in the NHS. Ensuring community services are definable in terms of cost and activity while creating organisation structures that are affordable and reinforce quality provision is in itself a challenge.

Add in the context that commissioners need to drive for more contestability and plurality in the market and it is easy to understand why this seems all too complex and the call for more guidance rings out.

The Transforming Community Services framework is the last opportunity for PCT provider arms to get their house in order and prepare for the future. Irrespective of the decision on organisational form, PCT providers should work on becoming financially viable, well governed and legally constituted.

The ability to supply innovative, quality services at an affordable level and self certify that all of this is being provided safely should be the primary goal of a provider arm - the organisational form should reinforce this work, not drive it.

The complicating factor is how to establish community providers in the era of austerity we have now entered. Indeed can the health economy afford the set-up and revenue costs of community foundation trusts and social enterprises? I heard last week to my astonishment that community services could be 40 per cent more efficient - so could the future constrictions in the NHS budget be solved through cuts in revenue for these services alone? Only if we want a detrimental short term response to the economic downturn.

What we really need to do is commission and deliver health and social care services where they will produce the greatest benefit to the patient and be cost-effective to provide.

To realise the Darzi and framework vision, commissioners need to focus their market management strategies on more than the portfolio of services found in PCT provider arms. Services that should be open to competition from the market should include non-secure mental healthcare; all spend in primary care that does not come under the general medical or personal medical services contracts; and any healthcare delivered in acute hospitals that could be provided elsewhere. This would give strong commissioners every chance to shift services onto non-tariff arrangements closer to where patients live.

To ensure provider arms are ready to bridge the gap between primary care and the high cost reactive acute sector, basic deficiencies within provider arm operations need to be solved rapidly. A priority is to correct the inadequacies in the National IT programme solutions for community services that remain adaptations of practice/list based systems and, on the whole, are not fit for purpose. Following rapidly behind is the collaborative work providers and commissioners need to undertake to understand activity, pricing and quality outcomes.

Until both these elements are resolved no systematic analysis is possible to bust the growing perception - or myth - that community services are the fatted calf of the NHS, ready for trimming and exploitation. It is ironic that in acute service areas, where the NHS is rich in data and knowledge on effectiveness, true cost and pricing, there is less of a challenge to market dominance and cost-effectiveness.

Community providers must take some of the responsibilities to resolve this situation. Without willing, community based providers there will never be a realistic market for commissioners to shift services out of acute care and break some of the traditional service models.

The plea from PCT provider arms must be for time to mature during the coming 18 months to prove their worth and help find solutions to cost-effective, quality service provision that also tackles health inequalities. A community geriatrician recently told me how her joint work with a local GP in two care homes had saved the PCT the equivalent of her salary in a six month period, just through rationalising medication use and reducing supplements through improved nutrition.

These and other community based innovations will, I am sure, provide solutions to the provision of personalised care at affordable prices in the coming financially challenged years.