Yes, we admit it, GP risk management thresholds are variable ('Risky business', page 28, 31 May), but no more than those of hospital doctors, nurses, therapists and care managers.

The proposed academic theory, designed to create downward pressure on referral activity, seems to miss some fundamental points that need action now by primary care trusts.

1. Referral to hospital is just one of the maladaptive processes which GPs have subconsciously developed as a response to increasing service pressure with no increase in resources.

The primary care system is highly accessible and, unlike hospital, does not have waiting lists to shield it from public demand. GPs need more support to manage the pressure, and a greater variety of referral pathways.

Guaranteed 48-hour access will logically increase referrals.

2. GPs who appear to be low referrers should be causing concern, not being portrayed as figures of excellence. What is happening to their seriously ill patients? Do they turn up at A&E with advanced disease? Solid evidence is required.

3. PCTs have yet to define what the inequalities agenda means to them. If we are to start to really address the inverse care law we need to deliberately increase referral rates in deprived areas or reduce them in affluent areas. Is this happening anywhere?

So yes, GP risk management thresholds are variable, but let's be more creative, use the modernisation agenda and concentrate on some of the real issues mentioned above.

Dr Peter Fink Hon Secretary Manchester LMC Co-Director Manchester, Salford and Trafford HAZ