WHEN 'choice' has been the buzz-word on the lips of politicians who talked about the NHS while seeking votes in the recent election, is it not ironic a large proportion of orthopaedic patients in Herefordshire are now denied the right of choosing to be seen and treated at their local district general hospital?

Patient choice, it would seem, is less important than government targets now the election is over.

Important though the issue of orthopaedic referrals is in its own right, it has much greater significance as yet another symptom of the difficulties facing the County Hospital and of the hospital's future viability (or non-viability) as a reasonably comprehensive DGH.

Hospitals with relatively small catchment populations and which are themselves, therefore, relatively small, like the County Hospital, cannot achieve the financial economies of scale which are feasible in larger communities.

In recent years these financial limitations have been compounded by other issues which cause particular difficulties for smaller departments, especially the implications of the European Working Time Directive and the increasing requirements for greater specialisation.

As the regional adviser to the Royal College of Physicians in the late 1990s, I saw first-hand the difficulties caused by the restrictions in service forced on the two smallest DGHs in the West Midlands Region at that time, first at Rugby and then at Kidderminster.

It was clearly only a matter of time before slightly larger hospitals such as Hereford would also be affected.

The restricted services provided at Rugby and Kidderminster have undoubtedly caused both inconvenience and hardship but the difficulties of travel from these areas, to hospitals in Coventry and in Worcester respectively, pale into insignificance in comparison with the difficulties presented by a restricted service to the much larger populations in the more geographically remote areas of Herefordshire and mid-Wales.

The County Hospital is not, of course, the only smaller DGH struggling to provide a service in a geographically remote area.

Similar hospitals in Wales and Scotland have benefited from the historically higher levels of NHS funding in those countries, but in England the hospitals in places such as Penzance, Barnstaple, Whitehaven and Scarborough face many of the same problems which affect us.

Hereford has two additional problems. We were the first such hospital to have a new building funded by the Private Finance Initiative (PFI) and, although some politicians and managers may still wish to pretend otherwise, there is no doubt PFI hospitals are more expensive than traditionally funded ones. That is why we could not afford to have sufficient beds in the new hospital.

During the planning stage the consultant staff repeatedly advised the hospital would not be big enough, but we were told we did not know what we were talking about - and I have no doubt there will be some NHS managers proposing a similar response to this letter!

The second of Hereford's additional problems has been caused by the decision of Herefordshire District Health Authority and subsequently Herefordshire Primary Care Trust (PCT) to spend, over many years, a greater than the national average proportion of income on services in Primary and Community Care; and therefore, inevitably, a lower than the national average proportion on specialist services in the DGH.

It has, of course, been national policy to increase resources in Primary and Community Care and some of these services are, inevitably, more costly to provide in rural areas like Herefordshire. However, the balance of funding in Herefordshire has been, as is now becoming all too evident, to the severe detriment of the DGH.

It may (and probably will) be argued that, as a former hospital consultant, I am biased in favour of spending on the DGH. However, now restrictions are being placed on such a fundamental DGH service as orthopaedics, there can be no doubt whatsoever the viability of the County Hospital as a proper DGH is under threat.

If this threat is to be lifted there must be an immediate commitment by the PCT to significant investment in services at the County Hospital.

Recruitment of trained staff is a national problem in the NHS so it should be no surprise there are particular difficulties in attracting consultant cardiologists, radiologists and other staff, both medical and non-medical, to Hereford when any prospective candidates can see the hospital is under-sized, its services are under-funded and under-resourced, and its future as a proper DGH therefore uncertain.

Experience elsewhere must make it doubtful whether the people of Herefordshire have the political clout to save the County Hospital from further cuts in service.

Some things however are certain.

Although it may be inconvenient, local people can, if it is really necessary, go elsewhere for their hip and knee replacements; but remember, the surgeons who do these operations are the same ones who will operate if you fall and break your leg or if your limbs are mangled in a road accident.

If much of the non-emergency work goes out of the county there will no longer be sufficient surgeons left to provide a rota for 24 hour emergency cover.

Remember too that every £ the PCT spends on providing services and operations in Worcester or in other hospitals is £1 less to help sustain the County Hospital. Remember also that once a service is lost it is very difficult to get it re-established.

Having worked in Herefordshire for 25 years I know local people do want a choice in the provision of hospital care and that, without any shadow of a doubt, the first choice of the great majority would be for a good quality service at the County Hospital, in as many specialties as possible and certainly in all the major specialties.

If this is indeed what is wanted then people must take action now. They must not only lobby both NHS managers and politicians but they must also prevent NHS money leaving the county by insisting on their right to choose their local DGH whenever possible.

Clearly there will be some in severe pain who will need their operations to be done as soon as possible, wherever they can be provided. But there will be others for whom, for example, a seven month wait for an appointment in Hereford is preferable to a five month wait for an appointment elsewhere. If so, insist on a referral to Hereford and, if the referral is returned to your GP, complain to the PCT and also ask your GP to keep a record of the referral so a true and meaningful local waiting list can be constructed. This is important because the disgraceful practice of returning referrals serves a double purpose. It not only allows local NHS managers to appear to be meeting waiting list targets and thereby keep their noses clean, but it also allows the greater NHS mandarins and government ministers to claim, because targets have been met, there cannot be any un-met need and therefore there's no requirement for additional investment in Hereford. Clever, isn't it?

Henry Connor, (retired consultant physician)

Vineyard Road, Hereford.