As NHS cuts bite, we will soon see the next eruption of popular anger

Andrew Lansley's disruptive reorganisation will see waiting lists go up and treatments withdrawn. The blue touchpaper is lit

Rioting by a few, peaceful protest by many, an attack on the heir to the throne and the throwing of bricks at Treasury windows, all this makes eye-popping TV news footage. But plenty more issues over the next year have the same potential to light the blue touchpaper of public opinion, without necessarily spilling on to the streets.

Political volcanologists watching for eruptions should be turning their seismographs on the NHS. In his early days, David Cameron saw that the NHS could do the most damage to Conservatives: he neutralised fears of Tory plans to dismantle it by pledging himself pink in the face to protect it. He even used his sick son's NHS treatment as proof of his sincerity. The NHS would get a "real increase" every year, with none of the plague of disruptions visited on it by previous governments. The sacred text of the coalition agreement promised: "We will stop the top-down reorganisations of the NHS that have got in the way of patient care." But now each pledge is broken. John Healey, shadow health secretary, emerging as a soberly effective and emphatic critic, this week exposed how new inflation figures show the NHS will suffer a real cut, alongside its most radically disruptive reorganisation.

Listen to the warning rumblings. This week, at the thinktank the King's Fund, there was a stunned silence followed by a great ripple of approval as a key NHS executive burst out in frustration that the service was heading for "a bloody awful train crash". The chief executive of Ealing primary care trust, now taking over several neighbouring PCTs, spoke with passionate authority of how all his time is taken up with reorganisation, "completely clearing out my team and making a whole series of new appointments ? I am not spending a moment thinking about patient care or money".

Many primary care trusts have heavy debts they are expected to pay off fast, before handing over to GPs to commission all NHS services. No one thinks it possible. PCTs are sending out letters ordering GPs not to refer patients for anything but urgent surgery. In public they talk of stopping cosmetic procedures and treatments for tattoo removal ? or, as Zoe Williams reported this week, stopping IVF, causing immense suffering. However, the cancellations go much further ? Surrey, Warwickshire, Lancashire and almost every other PCT is delaying surgery for hips, knees and even cataracts, sometimes until the new financial year.

By banning GPs from referring, they avoid falling foul of Labour's NHS rule requiring treatment within 18 weeks of GP referral. Other delaying wheezes include refusing to treat smokers until they take a course on giving up (Surrey, �35m overspent) or fat patients until they lower their body mass index (Portsmouth City). Some stay within 18 weeks by delaying all surgery until 16 weeks ? though that catches up with itself.

What happens when PCTs save money? They pass their debts on to hospitals, which suddenly find their surgeons have fewer patients to treat and less money coming in. The only effective cost-saving is through strategic planning ? to rationalise services into specialist hospitals, as with the life-saving stroke treatment re-organisations. But the government is scrapping strategic health authorities, believing a perfect market will rationalise itself. That requires a lot of hospitals to go bust ? politically impossible since Cameron joined pre-election hospital protests pledging no closures.

Alarm is widespread, but usually off the record. The Ealing PCT manager was only echoing the sentiments of the head of the NHS, Sir David Nicholson, who told the health select committee that the PCTs being abolished were in "meltdown" as the best managers fled: only "Stalinist" controls could now keep a grip on NHS finances he warned. The former Tory health secretary, Stephen Dorrell, head of the committee, gave a taster of what his report next week may say, warning the same meeting that no health service had ever achieved what is now being squeezed from the NHS, a 4% annual saving for four years.

Waiting lists are where the NHS bursts out under pressure. Professor John Appleby of the King's Fund is monitoring them, not trusting the government to keep the figures. Whitehall departments may stop collecting central data: in the guise of localism, ministers say it's up to local citizens to hold services to account, with no need for centralised figures or odious comparisons.

This week health secretary Andrew Lansley ignored every red light to launch 52 pathfinder GP consortia, commissioning services for a quarter of the population. He claims they will "put patients at the heart of everything the NHS does". That sounds cosy, as if your local GP will commission for you; but most consortia will be larger and more remote from patients than the PCTs they replace. One pathfinder is Great West Commissioning in West London, where GPs have contracted United Health to run its referrals.

Only a quarter of GPs in surveys express enthusiasm. Dr Clare Gerada, head of the Royal College of GPs, has been fiercely critical, warning that, if GPs are responsible for rationing, they will lose people's trust. Patients will eye their doctor's BMW in the drive and ask if that's why they aren't getting a treatment they need.

The government has put GPs in command: they may be saints as individuals but, collectively, they have held governments to ransom ever since 1948. They rarely do anything new without extra pay: look how they bamboozled John Reid and Alan Milburn into a huge rise. Their tough four-year freeze ends conveniently just as the new system goes live in April 2013. Already fuming at suggestions of a pension cut and retirement at 65, expect them to force a goodly screw, pushing the �3bn cost of Lansley's plan higher. The chair of the Association of Independent Medical Accountants warns that GPs' pension protests will "make the student demos look tame". Hyperbole, no doubt.

But look at this cocktail of trouble brewing ? an organisational upheaval, significant numbers of GPs opposed, and an unprecedented real cut in cash when the NHS needs 3% to stand still. Now watch the fast-rising surgical waiting lists. Every local and national paper will fill up with NHS anecdotes of woe by next year. Labour all but abolished waiting lists for the first time, but waiting used to top the poll of public discontent year after year. As with the tuition fees fiasco, this reorganisation at a time of the harshest funding was an ideological choice. The NHS will provide another crisis of the government's own making.

Polly Toynbee

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