As his referrals are rejected, Jobbing Doctor comes to realise the grim reality of what GP commissioning has in store.
Over the last few days I have had two referrals rejected as not fundable in the current climate.
In a list of procedures that need to be done, both will have significant psychological benefits for my patients. But they can't have it, and that is that. I will have to tell them that a decision has been made on my behalf as to what is best for my patients. At the moment I can play the 'good guy'. In two years time it will be in my name.
It is getting worse elsewhere, as colleagues are being told not to refer this month because the money has run out. This delay will result in some catastrophe at some point. It is inevitable, as GPs change their roles from advocates to rationers.
If it were that everything was being scaled back, but I know some sacred cows are being allowed to continue: the most sacred of these is the various Government-sponsored initiatives that their advisers told them were good for the NHS: you know the list - NHS Direct, NHS Choices, PFI, Darzi centres, walk-in clinics, ISTCs, a panoply of profligacy to try and buy votes.
There seems to be little will to put some of these schemes to the sword. For us, in the provinces (as the Metropolitan elite likes to consider us), there is the additional annoyance that many of the plans and schemes are developed on the basis that they might work in London, and therefore politicians without patience have decided to implement without review or reflection.
They have also been ineptly negotiated with the private sector, so if the managers want to end the contract, it can only be done at ruinous cost. That is one of the legacies that the GP consortia face.
So what is to be done? I cannot play the good guy and the bad guy all at once. Although, in times gone past, when patients' wants were subordinate to patients' needs, we were able to do this. However, the new relationship has been adjusted in such a way that all the decisions like this are being seen to be local.
I know how problems can affect people, as I hear their stories every day. Minor operations like varicose vein surgery will have to wait till there are major problems, and then deferred surgery will be more complex, less successful and more expensive. A cut in time saves nine. But not in Lansley's NHS.
GPs are being offered responsibility, without power. Accountability without effect on policy. This, to me, seems to be the most lethal of poisoned chalices.
On a larger political level there is significant risk. If the Secretary of State is proved right, and there will really be a liberation of the service, then Cassandras like me will have been proved wrong. If the opponents of the change are right, then Lansley's career will be over, as will the Liberal Democrat fellow travellers, and we all will be losers.
Why are the Government pushing forward with such a dangerous strategy? Why are they risking fragmenting the NHS, causing hospitals to become destabilised or closed down, and demonising GPs for it? Why are they risking all this on a policy that is getting more and more opponents by the day? Why do they not listen to the ordinary doctors, rather choosing to smooch with the few who agree with them?
This is a Conservative administration. The NHS is a socialist construct. There is an idealistic chasm here.
The other reason they are pursuing it is more obvious.
Pure and simple.
The Jobbing Doctor is a general practitioner in a deprived urban area of England.Click here for more from Jobbing Doctor Jobbing doctor