What NHS England isn’t telling you, and more indispensable insight. This week by HSJ primary and community correspondent Rebecca Thomas.

HSJ’s coverage of Lord Carter’s new report on unwarranted variation in community and mental health services provoked a strong reaction from readers.

It was not so much the actual report that captured attention, but the peer’s personal observation that combined acute and community trusts seemed more efficient than standalone community organisations.

They were, he told HSJ, generally better placed to manage discharge and flow.

Some readers objected to Lord Carter’s comments on the grounds his report doesn’t actually include any analysis comparing types of provider.

Despite this, it clearly favours organisational integration as a direction for community services.

One particularly loaded sentence says community trusts must “put institutional self-interest aside” and “respond flexibly” to opportunities created by primary care networks (for the uninitiated – these are emergent clusters of GP practices, generally around 30-70,000 population).

This may mean, the report says, that community health services are “increasingly” provided as part of extended primary care teams, or alternatively by “integrated primary, community and acute hospital provision, rather than by standalone community trusts”.

This has been a familiar strategic dilemma for some time – but that doesn’t mean the comments won’t raise hackles for many in the sector.

They might point out that “primary care networks” are, for the vast majority of England, more of a nice idea than a real provider structure; and that acute led providers are commonly mistrusted by staff in primary care.

The benefits of shunting community services into either have hardly been proven – so why pursue yet more restructure in a sector which has already endured plenty of reorganisation?

The report’s observations shouldn’t really come as a surprise given the direction endorsed by NHS England in recent years, backing primary care networks as extended community based providers, and acute trusts reaching outwards under the primary and acute care services (PACS) model.

The latest example of the latter may arrive in Plymouth, HSJ recently reported, where it appears that services provided by a social enterprise may move into the acute trust.

The recommendation that got left behind

In February I wrote about the community services forward view that was left behind. This week I want to draw your attention to the community services recommendation that was left behind.

A draft version of the Carter review which I have seen suggested there should be a national director of community services. Lord Carter has confirmed he dropped it after NHS England intervened.

One source said the intervention came from the organisation’s chief executive, Simon Stevens.

NHS England, NHS Improvement and Lord Carter’s reasoning for the omission was that having a national leader specifically for community services would put the sector in a “silo”, and be antithetical to service integration. It’s a debate not dissimilar to the discussion above about the rightful home for community services.

The argument which persuaded Lord Carter may be reasonable if there were not already director leads for mental health and primary care – whose presence is to a degree beginning to pay off.

The final Carter report highlights the “disparity” between national leadership for mental health and community services but falls short of highlighting the lack of a national figure for the latter.

Two recent HSJ stories perfectly illustrated the consequences of having no national champion fighting for community services. The first reveals two clinical commissioning groups’ plans to cut community services to improve their financial position (while protecting mental health and primary care spend).

The second story suggests social enterprise providers working for the NHS – which are predominantly in community services – may not get government funding for the Agenda for Change pay rise.

Whether community services’ future lies with integrated organisations or not, they need to be higher on the national agenda – and to get some financial protection. Both would be aided by the presence of a skilled and influential national lead.