Outpatient clinics are out-of-date and much of their function could occur in primary care, says the NHS Confederation. But will not some clinics always be needed? Mark Gould examines the arguments

What would you do if your hospital outpatient department was blown up in a freak accident? do not rebuild it, says a new report, which suggests many of the 43 million outpatient attendances a year are a waste of time for staff and patients.

The report's author, Nigel Edwards, policy director of the NHS Confederation, says outpatient sessions are an embarrassing legacy of the 'British obsession with queuing' rather than proven best practice.

Their continued existence also stems in part from the British malaise of accepting second-best.

Work by the National Patient Access Team shows that about 12 per cent of patients do not attend outpatient clinics and many are dissatisfied with the experience when they do attend.

Consultations are often too short, with doctors spending only half their time seeing patients.

The rest 'seems to be consumed by having to deal with the consequences of the chaotic organisation of the clinic'. And NPAT says up to 50 per cent of the process steps involve a 'hand-off ' leading to 'error, duplication or delay'.

Frighteningly, it finds 'there is little relationship between the urgency of the referral and the speed with which patients are seen'.

Nigel Edwards argues that the system has such inherent flaws that throwing all the money in chancellor Gordon Brown's Treasury war chest at it would only magnify the problems.

And it appears that the continued sub-specialisation of medicine is encouraging the proliferation of a huge number of consultant-to-consultant referrals within hospitals.

'If staff only spend half the time seeing patients then increasing capacity will not solve matters and will not deliver the NHS plan, ' the report says. Rather Mr Edwards calls for doctors, nurses and managers across the NHS to think imaginatively about the best settings to deliver care.

'I am not proposing that the Department of Health take up these proposals and say 'do it like this'. It would be better if the DoH decided to let go a bit rather than direct people. '

That could well happen. Mr Edwards' report, Modernising Outpatients, carries a ministerial endorsement from health secretary Alan Milburn.

Yet flying in the face of political rhetoric from all sides about wasteful NHS bureaucracy, Mr Edwards says the end of outpatients would require more managers, including more clinicians doing their own management work in different surroundings.

'Good outpatient managers are a relatively new breed - what happened when I first worked in hospital was you had an outpatient sister who was not employed for her managerial acumen.

'I can't put a figure on the numbers of managers needed, but it may well be they need to be clinicians or people already working at primary care trust level. '

Referring to the chaos of conventional outpatient clinics, Mr Edwards says it is vital that more clinicians are 'thinking managerially' and says 'but by being better organisers they will get better outcomes, too'.

He wants the money and staff invested in traditional outpatient settings to move into primary care, employing more nurse specialists in sigmoidoscopy and endoscopy; into pharmacy services for anticoagulation, diabetes and other chronic conditions, and into using e-mail and telemedicine to communicate.

However new services are configured, they should follow patient flow rather than be stuck to the old inefficient function of an outpatient clinic.

Managers say they are already breaking out of the old waitingroom mindset. Helen Tees, a group clinical practice manager at University Hospital Birmingham trust, who has been involved in outpatient services as a nurse and a manager since 1974, says the traditional outpatient episode is already changing in a way the confederation would approve of.

'There is a willingness to change from everyone involved, I think.

And that has come at a time when the technology allows us to change as well. We have one-stop and fasttrack services for breast cancer and we are developing a fast-track colorectal screening service. '

But she agrees with the Hospital Consultants and Specialists Association, which stresses that there will always be a need for some outpatient clinics.

'We are already taking services to patients where it is appropriate, but where you need the big diagnostic things like barium enemas or CT scans you will still need patients to come to hospital. That is not to say that with telemedicine and e-mails that a follow-up outpatient appointment might not need to happen. '

And a service development manager, who asked not to be named, at University College Hospitals trust in central London agrees that change is all about providing care and services in the most appropriate environment.

'Patients from specialisms who are traditionally referred to secondary care, like non-acute dermatology, benefit from being seen in primary care. '

To do this the trust has been talking to GPs and community trusts to develop suitable referral protocols. They are also setting up a system where GPs can arrange direct booking for outpatient clinics that do require a secondary-care setting.

'Those patients not seen in secondary care need careful support and management in primary care.

We are also reviewing the role and purpose of follow-up appointments. '

And he agrees that GP specialists, nurse consultants and nursing and therapy staff working in new collaborations with hospital colleagues are key to the success of managing patients in primary care rather than secondary care.

'All these changes need to happen in context of a shift in resources to support the process. The skill will be to strike a balance of resources during this transition. '