Just as the UK receives the dubious benefits of Professor Alain Enthoven's latest thinking that it should follow the US down the pathway of market development to create competition at consumer level (news focus, page 10, 2 December), I observed on a recent visit to a number of health maintenance organisations in the US that many are failing, and even the largest and best managed companies are staring bankruptcy in the face.

Many of the policy makers and thinkers in the US who supported the formation of HMOs, with physicians managing the risks, are now changing their minds as the basic flaws of the concept become apparent.

Size does not protect HMOs.

Directives, strict referral guidelines and controls on treatment eligibility merely enrage consumers.

The risks involved in setting up primary care trusts in the UK are simply too great. Transferring financial risk just lets the government off the hook and shifts blame to the managers and clinicians at primary care level.

Graham Curtis Jenkins Counselling in Primary Care Trust