Clinical leadership is changing in response to Lord Darzi's review of the NHS, but the changes have not been uniform across the health community.

For the last 60 years, consultants in secondary care have been paid for caring for patients. There has been little measure of activity, and the result is doctors in the UK have treated patients with consideration to evidence-based medicine rather than because they have some treatment that may or may not offer a benefit (unlike some of our European and American cousins). Clinical directors in secondary care have been charged with managing their colleagues but not the budget.

But the NHS is changing; consultants and nurses (specialist nurses in particular) are being asked to demonstrate their value to provider trusts by the income they bring into the trust. Failure to do so has resulted in the loss of specialist nursing posts.

Suddenly, the shift is to the business of financial balance. Clinical directors are now budget holders but not necessarily with the skills to manage service improvement, understand the complexities of capacity and demand, or recognise the importance of protected time for clinical teams to reflect on what they do and how they could improve the care they provide.

In primary care, the new bigger primary care trusts have established professional executive committees. Their size (outside London) can be a challenge - North Yorkshire PCT is bigger than Belgium! This has resulted in poorer clinical engagement with primary care health teams. Some PEC chairs remain uncertain of their role and have insufficient time to carry out their responsibilities.

Future challenges

What do High Quality Care for All and the 10 strategic health authority reports tell us the challenges for the future are? We know the vision is for care closer to home, where possible, that change should be clinically led and patient focused, that we need to consider how we can integrate health and social care.

This will require a new breed of clinical leader, one whose focus is on delivering the best care by working with partners to develop effective, efficient care pathways. Waits are not an issue any more - the focus is on quality and outcomes.

Where are these new leaders likely to come from? It is unlikely to be from secondary care initially.

However, in primary care we can see the young green shoots of practice-based commissioning at last becoming firmly established in many PCTs. Early work has delivered some significant shifts in clinical services aimed at supporting the 18-week target and improving quality for patients.

All SHAs will shortly be looking to develop clinical leaders for the future. They should look long and hard in primary care and mental health - there are some potentially very good leaders there, but they need nurturing, investment and support.