NHS bosses have come under fire over plans to ration surgery and treatments for patients - in a move that goes against official guidance.
The Royal College of Surgeons (RCS) has accused six Birmingham region Clinical Commission Groups (CCGs) of taking its guidance out of context or misusing it in an attempt to slash services to patients.
In some cases, the CCGs have said their plans are supported by clinical evidence when in fact they contravene guidance on the issue.
The RCS said the move could prevent patients receiving necessary treatment.
Between them, the CCGs are responsible for the planning and commissioning of health care services for more than two million patients.
Under the plans, cataract surgery, hip and knee replacements, tonsil and cyst removal would be severely restricted, as would grommets for children and varicose vein removal.
Groin hernia repairs would be severely restricted, while treatment for chronic back pain, specific back pain and non-specific back pain (where it is unclear what is causing the pain) would also be restricted.
Cosmetic surgery, including breast reductions and removal of non-cancerous moles, would also be mostly stopped, as would circumcision.
Despite the National Institute for Health and Care Excellence (Nice) saying hysterectomy is an option for heavy periods, this would only be paid for by the CCGs if other treatment and approaches had failed.
Under the CCGs' plans, only patients that meet a strict criteria will be allowed any of the 45 procedures listed, with GPs having to apply for specific funding for those with "exceptional clinical need".
In a leaflet for patients, the CCGs insist the move is not about saving money but in a policy document for GPs, they say: "CCGs have limited budgets; these are used to commission healthcare that meets the reasonable requirements of its patients, subject to the CCG staying within the budget it has been allocated."
The 86-page document - called the Policy For Procedures Of Lower Clinical Value - covers patients seen by doctors across Birmingham.
The RCS said the document makes "extensive reference to clinical guidance published by the RCS and surgical specialty associations (SSAs) but either ignores or cites it out of context.
"Some policies are presented as if they are supported by clinically-evidenced guidance but in fact contravene this guidance."
Paul O'Flynn, the RCS's lead for commissioning, said in the letter to the heads of the CCGs: "The RCS believes patients' access to treatment must be based on clinical assessment and evidence-based practice.
"We strongly urge you to reconsider your position. The RCS has produced clear guidance, accredited by Nice, and this should be fully taken into account in CCGs' commissioning policies. In this case, our guidance has been misrepresented and incorrectly referenced in many places."
The RCS said it objected to plans to only fund surgery for irreducible or partly reducible inguinal hernias, or those that cause pain that limits daily activity, or are strangulated or obstructed - which goes against current RCS guidance.
It said the policy to document five or more episodes of glue ear in a child before being referred for grommets was "not evidenced" in RCS, SSAs or Nice guidance.
The RCS also objected to a policy of referring patients to hip and knee surgery only if their BMI is below 35 and the plan to only remove adenoids if undertaken at the same time as grommets or tonsillectomy.
It said the policy of only surgically treating more advanced cases of varicose veins was also not based on evidence.
"Varicose veins that are not treated at an earlier stage are likely to deteriorate and require later surgery," it said.
It also accused the CCGs of "misrepresentation of RCS guidance on back pain treatment".
The letter has been sent to the heads of NHS Birmingham Cross City CCG, NHS Birmingham South Central CCG, NHS Sandwell and West Birmingham CCG, NHS Solihull CCG, NHS Walsall CCG and NHS Wolverhampton CCG.
Other areas of healthcare are also being rationed by CCGs.
In November, it emerged that Mid Essex CCG planned to axe GP physiotherapy services, hearing aids and vasectomies - instead telling patients to go private.
It wants to stop prescriptions for gluten-free foods, axe hearing aids for people with mild hearing loss and stop female sterilisation.
It said patients could go private instead or buy items on the "high street", whilst women wanting sterilisation should opt for other "low risk" forms of contraception.
The CCG is among those that no longer offers IVF, alongside NHS North East Essex, and South Norfolk CCGs.
Bedfordshire CCG also plans to stop funding IVF.