The NHS Plan published in 2000 was an ambitious agenda committing sustained increases in funding alongside reforms which aimed to redesign services around the needs of the patient. For the first time it introduced the idea of earned autonomy.

Shifting the Balance of Power published less than two years later further acknowledged that the days of the man in Whitehall knowing best had passed. The Bevanite mantra of wanting to hear every bed-pan dropping was outdated ? but when did that happen anyway? Instead it outlined plans for primary care trusts, charged as the leading drivers of reform, to hold 75 per cent of the NHS budget by 2004. By 2008 PCTs would be expected to control an even larger share of the budget. They would have the freedom to commission secondary and other care, with decisions on providers increasingly informed by patient choice.

PCTs are crucial to the success of the reform agenda. Yet there is a view, shared earlier this year by the head of the No. 10 Delivery Unit Michael Barber, that many PCTs are at best struggling and at worst failing to fulfil their potential. The task of managing huge NHS budgets and commissioning specialised services are enormously challenging. How well these challenges are met has serious implications for the provision of NHS services as whole, but in particular for national priorities such as cancer.

The warning outlined in the leaked note from the Delivery Unit focussed on the shortages of commissioners in the new PCTs. In addition, many PCTs don't employ people with the required expertise or specific responsibility for commissioning of cancer services and treatments. This, compounded by a preoccupation with organisational development and the fact that PCTs are relatively young organisations, has shown that many trusts are unequal to the task of planning how best to spend funds designated for cancer services ? a view apparently shared by the Cancer Tsar Mike Richards in a recent interview in the Health Service Journal.

What's more, the results of an exceptional tracking exercise into funding for cancer services carried out earlier this year showed clear geographical variations in the funding of cancer services ? a situation that many clinicians say has worsened since PCTs have begun to take control of local health funds. The data, published in May, revealed that in the first year of the cancer plan some cancer networks had received less than 60 per cent of the funding they were supposed to from PCTs.

The registered number of patients covered by PCTs ranges from 57,000 residents to 334,000. These huge variations in populations are also causing variations in the standard of care and treatment of people affected by cancer. Some PCTs are simply too small to commission cancer services, whereas others are merging and collaborating to create what the King's Fund describes as "critical managerial mass" and therefore improving progress in some areas.

Technology and service guidance from the National Institute for Clinical Excellence across the board should demand a significant proportion of the funding allocated to the newly developing PCTs. Yet recent data published by CancerBACUP and Roche showed dramatic evidence of continuing postcode prescribing in relation to the breast cancer treatment Herceptin. According to the data, only 14 per cent of women living in the Midlands have access to Herceptin compared to 61 per cent of women living in the South West. The data was for Herceptin, but the results are believed to hold true for other NICE-approved treatments.

Anecdotal evidence suggests that the lottery in care is continuing in many cancer treatments, because some PCTs are unwilling to release funding for newly appraised drugs. The desire to balance the books takes precedence. In addition, a recent report by breast cancer charities showed that many PCTs are unclear who is responsible for implementing NICE guidance and that monitoring systems, where they exist, vary enormously. There is also anecdotal evidence of conservative prescribing. But given the lack of any formal data collection or monitoring, the true answer is ? nobody knows.

Devolving power to the frontline is intended to improve local services and increase patient choice, yet there is a real danger that when it comes to specialised services, variation in the standard of local services will widen, making real patient choice impossible.

At the very least, the government needs to be vigilant about not just setting national standards, but also making sure they are audited and enforced and that regular data is published so that healthcare professionals and patients alike know what is happening locally. The new CHAI could fulfil this function. Only then will real patient choice start to become a reality.

If standards are to be set and met with regard to national health priorities like cancer, PCTs are going to need help. There are many possible solutions. Ringfencing for cancer budgets would ensure money for innovation. Devolving cancer spending to cancer networks would be popular and work well. Consortia of PCTs attached to geographical network areas would deliver the necessary critical managerial mass. What's vital is that informed debate takes place to discuss how best to go forward and that it is pragmatic and outcome focused rather than ideological.

The government must bear in mind, though, that the public already knows what it wants. A recent MORI poll commissioned by CancerBACUP showed that most people ? 92 per cent ? want to cancer spending to be decided nationally, not locally, and that 58 per cent want to see a national budget for cancer.