Is this what the NHS has come to?

THE Archbishop of York put his finger on it.

"This is not a factory where goods are produced," he said on a visit to York Hospital. "And it's not a retail shop where money is made."

The point he was making was that the NHS should be, above all, about caring for people. It shouldn't be about targets, or cutting corners to save money.

Try telling that to York pensioner Rita Bennett.

As we reported yesterday, the 62-year-old has been housebound and living in constant pain for almost two years because of crippling osteoarthritis.

Originally, an NHS consultant told her he could not operate because she weighed 18 stones. Since then, Rita has lost weight but claims she is still waiting for a proper assessment.

She had a pain-relieving injection in her spine on the NHS, and has had acupuncture.

But now she has been told she faces another four month wait for physiotherapy.

So desperate is she that she is now planning to use her £3,000 savings money set aside to fund a shortfall in her mortgage to pay for private treatment.

Rita has become the face of all that is wrong with the health service as it struggles to cope with mounting debt.

North Yorkshire's four primary care trusts, which effectively commission health care, are in debt to the tune of £51million. The Selby and York Primary Care Trust alone needs to cut its spending by nearly £23million over the next year in order to balance its books.

In order to do so, it has proposed a raft of measures to cut back on the number of patients being referred for hospital treatment.

The measures include: l Plans to limit the availability of sterilisation a vasectomy for a man where there is not a clinical need l An increased level of pain and discomfort for osteoarthritis sufferers needing hip and knee replacements before they should be seen in hospital, measured using the controversial New Zealand scale l A threshold for cataract operations.

Primary Care Trust bosses insist that the measures are being put into place to ensure patients are not referred for unnecessary operations, and that the health service gets the best value for its money.

But the proposals have already led to York GPs warning about a "third world" service.

So what is the reality?

The new measures to cut back on referrals are being driven by the primary care trust, not by GPs or hospital bosses.

There are two areas that are causing the latter particular concern: the so-called New Zealand "pain scale", used when deciding whether patients should be referred for hip or knee replacements; and a new system for screening and sometimes blocking GP referrals more generally.

So what do these mean for patient care?

The New Zealand Scale The New Zealand Scale measures patients against a set of "priority criteria" for major surgery for hips and knees.

Divided into sections including "pain" and "functional activity", the scale gives a set of scores which measure how much a person's life is affected by their condition.

Pain levels can range from "mild" to "severe". Patients are also judged on how far they can walk and other limitations in their life, for example putting on shoes or managing stairs.

Under new rules, only patients who score 70 out of 100 on the scale should be referred to hospital for treatment.

Dr David Geddes, medical director of the Selby and York Primary Care Trust, insists that patients who do not score 70 on the scale will, where appropriate, be referred for intermediate-level medical care.

This, he says, could involve a home assessment of their needs and a range of options including acupuncture, physiotherapy and occupational therapy.

The point is, he insists, that patients can very well be treated appropriately in a range of ways that fall short of a knee or hip replacement, and that the primary care trust has a duty to use its money carefully. "We recognise that there is a cohort of patients who actually we can manage with more conservative measures," he says.

Other GPs, however, see the scale as unreasonable. Patients have to score 70 on the New Zealand scale to qualify for hospital treatment, says Dr David Hartley, chairman of the York Group of GPs and a doctor at the Jorvik Medical Practice. "And I have found it impossible to get anybody to that level. That includes people waking in the night with pain, people who have trouble getting themselves dressed, people who are regularly taking painkillers. I have not been able to get them to that level (70) on the scale."

Referring patients for intermediate care such as physiotherapy or occupational therapy often isn't the answer, he says, because often they have "been through this route already".

The reality, Dr Hartley says, is that the scale is part of a system designed to save money by blocking or delaying patients' access to treatment. And it is patients that are suffering.

Screening of GP referrals Under a new system introduced last year the Referral and Clinical Assessment System, or RACAS for short all patients in the York and Selby area referred to hospital for orthopaedic treatment now have their referrals assessed by the primary care trust.

That essentially means their GP's decision to refer them is vetted' by a panel.

There are a number of reasons for this, Dr Geddes says. In the past, the primary care trust, which pays for such referrals, only knew what GPs were doing when it picked up the bill.

The new system means it is now able to get good quality information about exactly what patients are being referred for.

That means it is able to monitor what GPs are doing, identify areas where they are perhaps referring unnecessarily, and look at possible alternatives to hospital treatment.

The system of screening GP referrals is now being extended to include gynaecology referrals and referrals related to skin conditions. In future, those being referred to hospital for ear, nose and throat surgery may also be included.

Dr Geddes says part of the aim of the new system is to ensure that those who get surgery are those who really need it. "Surgical procedures have to be focussed on those most at need," he says. But he concedes that the financial problems faced by the primary care trust have "brought into focus" the need to get value for money. "We want to provide a service that is responsive to people's needs, clinically effective and within the resources available to us," he says.

Many GPs, however, see the new system simply as a way of blocking patients' access to hospital treatment and also as undermining family doctors themselves.

Dr David Fair, a GP with the Jorvik Medical Practice, says the screening system is another barrier to treatment that is inevitably going to cause more delays for patients waiting for operations. "How can it do anything but cause more delays?" he says.

Dr John Iredale, chairman of the York and Selby GPs' committee, says he has already had patients who he had referred to hospital blocked by the primary care trust.

One woman in particular needed surgery on painful swelling on her wrist: a condition the primary care trust does not consider serious.

In the particular case of his patient, he decided she did need surgery but his referral was rejected.

"It is not clear what we do now," he says. "Do we wait for the patient to come back?"

There is no doubt that the new system is an attempt to reduce the number of patients being referred for treatment, Dr Iredale says, on the assumption that GPs were referring patients when it was not necessary.

But that is simply not the case, he insists. "This is reducing the quality of service that patients should expect, and it is driven by cost."

Jim Easton, chief executive of York Hospital, says he has no objection to the new system in principle.

"But patients must not be delayed (in getting treatment) and it must be clinicians making the decisions rather than (administrators)," he says.

He understands the worry that the new measures will act as barriers to hospital treatment, he says. "We (the hospital) are asking the same questions as patients," he says. "The key is that we should not do anything that is detrimental to patients."