The Abrams report1 offers updated (but interim) guidance, given the “urgent need to clarify the public health function” in the light of the reforms of the NHS that have occurred since the Acheson report.2 It actually says little about the public health function and misses an ideal opportunity to further the cause of public health. It shows uncertainty about clinical advisory mechanisms, continues the tradition of professional territorialism, and reverses the current, welcome move towards a service focused on primary care. It also fails to address the tension between independent objectivity and managerial pragmatism, and it does not consider the best way of deploying public health specialists across the purchaser-provider split.

The NHS Management Executive has issued advice for purchasers requiring them to have a close involvement with general practitioners, constant dialogue with providers, shared medical advisory mechanisms, and access to clinical advice.3 The Abrams report suggests that it is the director of public health, as “the focus for a comprehensive public health strategy,” who should fulfil such responsibilities. The effectiveness of such strategies, however, depends on an appropriate clinical contribution, and the report's proposals risk restricting purchasers in their choice of professional advice.

A survey of purchasing plans in London shows that most planned changes concern efficiency, with some affecting accessibility but …