The joint Audit Commission and Healthcare Commission report on the progress of reform highlights issues such as commissioning not driving movement of care from hospitals, and wide variation in implementation of reform nationally.

Shortly we expect Lord Darzi's nationwide vision for the NHS for the next decade. We already know that any changes will be locally and clinically led. But by whom? Where is the leadership in primary care to deliver this work?

Compared with an acute hospital where clinical leaders such as medical and clinical directors are explicitly working to lead teams of senior doctors, primary care trusts struggle to find clinical leaders. Apart from the professional executive committee chair, many PCTs struggle to find primary care clinicians - in particular doctors - who will help them locally deliver the leadership required for services.

Primary care doctors are trusted by patients, know how well local health and social services work together (or not!) and are best placed to lead any movement of services from hospitals and the integration of health and social care.

Unless PCTs invest significantly in primary care clinical leadership now, significant progress with reform and Lord Darzi's vision will be slow.

Primary care clinicians - especially doctors - care about the NHS and must understand that they need to lead it locally with PCT support, to help with the development and delivery of a 21st century NHS to patients.

Dr David Levy, medical director, North Trent Cancer Network