What has happened in this case?

Martin Bircher, an orthopaedic surgeon at St George's Hospital, London has spoken out after he was told to stop carrying out his specialist work repairing smashed pelvises, often the result of car accidents.

Because of the highly specialised nature of his work, Mr Bircher takes patients from around the country.

But hospital managers told him last month that he had to stop taking patients from outside the immediate area for two months.

Instead, the priority had to be given to local patients, and routine work.

But Mr Bircher has warned some people could be left permanently disabled because of the hospital's action.

What will this mean for patients who need this specialist surgery?

As there are no more than a dozen surgeons expert in pelvic reconstruction in the country, patients are likely to be operated on by someone who has not specialised in that area.

Mr Bircher said he has already heard of operations on patients at local district hospitals which had had "disastrous outcomes".

A Royal College of Surgeons (RCS) report into the care of patients with complex pelvic injuries recommends a specialist unit should be involved within 24 hours of a patient being admitted.

Mr High Phillips, consultant orthopaedic surgeon at the Norfolk and Norwich NHS Trust, and author of the RCS report, told BBC News Online: "Martin Bircher is one of the small number of highly trained and experienced orthopaedic surgeons that deal with very severe injuries."

He said he was not surprised at the situation Mr Bircher was in: "The pressure on the chief executive from his political masters will be very great."

"The issue isn't just confined to pelvic fractures, it's also seen in other types of severe medicine."

Why has the hospital done this?

The explanation the trust gave in a letter to Mr Bircher was that the patient's own primary care trust was often unwilling to foot the bill for the specialist hospital treatment.

It also told him it was "no longer acceptable" for operations on local patients to be cancelled while urgent pelvic operations on people from outside the area were carried out.

Are there external pressures on hospitals?

Yes. The government has set waiting list targets, and all hospitals are under pressure to meet them.

But many doctors are concerned that such pressure skews care so that while those waiting for routine, simpler, operations may be seen more quickly, others needing more complex surgery may have to wait longer - or miss out completely.

Dr Peter Hawker, chairman of the British Medical Association's consultants' committee, said the St George's case was an example of the "perverse pressures" the NHS was under.

He added: "Of course we want patients needing routine surgery to be treated promptly, but this must not be at the expense of life saving surgery for patients with complex injuries.

"If the concept of the NHS is to have any practical meaning, then surgeons with highly specialist skills must be able to offer their expertise outside the narrow catchment area of their own hospital.

"Arguments about how this specialist care is funded can wait, the patient cannot".

Why has the government set these targets?

When Labour was elected in 1997, one of its key pledges was to cut the number of patients waiting for treatment by 100,000.

It achieved this in May 2000, and has since turned its attention to cutting waiting times.

Initiatives including boosting the capacity of the NHS with many more doctors and nurses and building new hospitals, as well as sending some patients abroad and use spare capacity in the UK's private sector have been introduced.

There are also schemes aimed at encouraging doctors to treat more patients as out-patients.

But reports by NHS watchdog the Audit Commission have suggested even more patients could receive treatment if people who did not really need to be in hospital were not admitted, and more operations could be carried out if the service was better organised.

The government has set a target of a maximum 12-month wait for NHS operations by the end of 2003 and to just six months by 2005.

It failed to meet a target of maximum 15 month waits at the end of March this year because of the poor performance of one hospital meant the NHS failed to meet that target.

Is there any evidence pressure to meet waiting list targets affects hospitals' clinical priority?

Last year, a National Audit Office report found 10 trusts had manipulated figures in a bid to meet hospital targets, affecting over 600 patients.

Some hospitals had failed to add patients to waiting lists, others were deleted and in some cases medical records were adjusted to suggest patients had been treated on time.

Dr Evan Harris MP, Liberal Democrat health spokesman, said setting maximum waiting times would inevitably distort clinical priorities.

He added: "There is no doubt that patients' lives are being lost because hospitals are being forced to treat targets instead of being allowed to care for patients."

Dr Liam Fox MP, Shadow Health Secretary, added: "It is absolutely disgusting that people with serious conditions are being forced to wait for operations, whilst minor conditions are dealt with in an attempt to meet government targets."