Of all the unwelcome consequences of the NHS reforms, perhaps the most unexpected is HSJ’s revelation that the leadership of clinical commissioning will be overwhelmingly male.

Two thirds of NHS staff are female, but men have always tended to dominate. Last year’s HSJ100 list of the most influential people in health featured just 19 women. But given the HSJ100 deals with a strata where the glass ceiling might be thought to be thickest, the gender imbalance of the clinical commissioning groups’ leadership is startling. Just 15 per cent of CCG leads are women. In the North West it is just 7 per cent, in the West Midlands only 6.

Things were very different with primary care trusts. PCTs proved successful in giving leadership opportunities to women, some with a clinical background. Department of Health national managing director of commissioning Dame Barbara Hakin began her ascent as chief executive of Bradford South and West PCT. Half the PCT clusters are still led by women.

During the past decade, significant effort was put into improving the NHS’s record on equal opportunities. It had limited success, but there were important advances.

In this austere era, work on increasing equality is proving hard to justify. The price is a gender imbalance among NHS leaders – at national and local level – which is starting to resemble that of the last time the UK suffered such an economic downturn, the early 1980s.