Dr Bobbie Jacobson should take off her public health hat and try to be more objective when commenting on the role of trust medical directors.

She is right in suggesting that 'much greater benefits to health can be achieved by targeting efforts at the whole population', but this ignores the fact that the most disadvantaged members of society are not currently reached by health improvement campaigns. So, the need is not for most healthcare practitioners to 'focus their efforts on the populations at highest risk of disease', but for all of us to ensure the efforts to target the whole population do indeed reach it.

In this, it is difficult to see how medical directors of acute hospital trusts can do more than be aware of the larger picture. I agree that we should be so aware, but it is public health doctors' role to be active.

I would agree that a tighter strategic rein needs to be kept on all elements of the clinical governance cycle. Perhaps Dr Jacobson is also right that 'primary care trusts will be in a unique position', and it is perhaps they who should act as a bridge between the acute sector and the imperatives of the public health approach to prevention and health improvement. I do not decry the need for acute sector medical directors to understand public health issues.

But to imply that only public health doctors are capable of understanding this is old-style silo thinking.

Dr K Judkins Senior consultant anaesthetist Pinderfields Burn Centre Wakefield