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Surgeons say patients in some parts of England have spent months waiting in pain because of delayed operations or new restrictions on who qualifies for treatment.

In several areas routine surgery was put on hold for months, while in many others new thresholds for hip and knee replacements have been introduced.

The moves are part of the NHS drive to find £20bn efficiency savings by 2015.

The government said performance should be measured by outcomes not numbers.

Surgeons have described the delays faced by patients as "devastating and cruel". Peter Kay, the president of the British Orthopaedic Association (BOA), says they've become increasingly frustrated that hip and knee replacements are being targeted as a way of finding savings.

"We've started to get reports over the last nine months that access to these services are being restricted.

"GPs were told not so send as many patients to hospital, maybe to delay referrals until the end of the financial year while perhaps introducing thresholds for surgery."

He says that simply delaying surgery by one means or another does not improve the outcome for patients as their condition can deteriorate.

"The double jeopardy is that patients wait longer in pain, and when they have the operation, the result might not have been as good as it otherwise would have been had they had it early. "

Limits and delays

The ����ý asked orthopaedic surgeons through the BOA if they had seen delays to these operations as a result of measures introduced during the last financial year.

Overall, 692 surgeons in England sent the ����ý information about the policy on hip and knee replacement of their local Primary Care Trust (PCT).

Between them they covered the majority of PCTs in England. In some areas no restrictions were being imposed, but in others the specialists reported delays or new thresholds for surgery.

106 surgeons told the ����ý routine operations had been put on hold in their area. Others described new limits on when patients qualify for hip or knee replacements.

152 specialists said patients now have to be more disabled or in greater pain, and 118 told us hip and knee surgery had been regarded as a procedure of low priority.

The data reveals a picture of overlapping restrictions, with some surgeons reporting more than one new policy had been introduced in the same area.

Routine surgery put on hold

A number of PCTs have been explicit about their decisions to put all routine operations on hold for several months up to April to help balance their budgets by the end of the financial year. They include Warrington, Sheffield, Eastern and Coastal Kent, Bury and Warwickshire.

Alex Waring, a patient in Warwickshire, was told he was being referred for an urgent knee replacement in August of last year. Now he looks at that letter with bewilderment as more than seven months later he is still waiting for surgery.

Mr Waring has already had one successful knee replacement and says he is in daily pain waiting for this second operation.

"It's excruciating sometimes to put it mildly. And it affects you at the times when you're not expecting it. I get off my mobile scooter and nearly fall over because my knee is gone, the pain, you've to sit there until the pain just goes away."

Invisible waiting

Putting routine operations on hold means that GPs simply stop referring their patients for surgery. So although a patient might be waiting longer, this isn't recorded in the official waiting statistics.

Another way of adding invisible waiting time into the system is to implement stricter new criteria which have the effect of delaying the point when a patient can be referred for treatment. An investigation by the ����ý also found evidence in many PCT board papers of new thresholds being added for hip and knee replacements.

They include introducing scoring systems for patients for pain or disability, or not allowing some obese patients to be referred for surgery until they have been on a weight loss programme.

Professor John Appleby, chief economist at the Kings Fund, says it is a mystery why these operations are being targeted for savings. "I find it difficult to understand. Hip operations are quite expensive, but patients get a lot of benefit for that money. This is actually very good value for money indeed."

These delays and restrictions are a response to the financial challenge facing the NHS in England. The scale of it was set out under the last Labour government, but the decisions on how to find those savings are being made now.

The coalition government has stopped performance managing the 18 week waiting time, although it remains a legal right under the NHS constitution.

A Department of Health spokesman said: "When clinicians and patients are making decisions about joint replacement surgery, it is right that other procedures - which could provide better outcomes for patients and provide better value for taxpayers - are also considered.

"Our modernisation plans for greater patient choice will drive improvements in quality and waiting times as we focus on the entire patient pathway, not just a narrow part of it, so that people live longer healthier lives."