NHS London has highlighted concerns over the implementation of Lord Darzi's proposals for healthcare, raising its rating of the risks of insufficient leadership from amber to red.

There are particular circumstances in London that may explain weak leadership of primary care trusts: they were not reconfigured and operate over comparatively small areas. Some suggest that NHS London itself should be offering PCTs more support to strengthen their leaders. There have also been repeated warnings that PCTs' limited salaries leave them struggling to compete to attract the best managers.

Of course this is not to say there are no talented people in primary care in London, or indeed that there might not be similar problems on the horizon elsewhere.

But either way, a failure to implement Lord Darzi's recommendations in the capital would have repercussions all over the country.

While the strategic health authority could not have known that the respected surgeon they had recruited to deliver a vision for London would subsequently be appointed health minister and tasked with drawing up proposals for the whole of the NHS, what happens next in the capital has become imbued with a far wider significance for NHS staff and politicians alike.

As we have seen with the Conservatives' stance on polyclinics this week, London is seen as the blueprint for Lord Darzi's national review - whether or not it proves to bear any resemblance to it.

A high-profile failure in London could shake confidence in the process as a whole, which would be bad news for all strategic health authorities, not to mention ministers.

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