The NHS Confederation is pushing for a radical restructuring of the way health services are delivered in a move that would see an 'end to outpatients'.

In a report, endorsed by health secretary Alan Milburn, the confederation claims that the current model of outpatient services is outdated and 'destined to fail'.

It cites findings from the National Patient Access Team which suggest that between 30-70 per cent of the work carried out in outpatients 'does not add value' for the patient.

It adds that services have been built on 'the British tradition of queuing' and that 'simply investing in more capacity will not deliver the type of improvements sought by the NHS plan'.

The confederation recommends a model which would blur the boundaries between primary and secondary care with welldefined care pathways and specialists in primary care as well as in hospitals.

By promoting the concept of specialist GPs, nurses and therapists and shared training the confederation believes that 'in some cases the idea of a referral can be dispensed with altogether'.

Such a major shift would also mean a transfer of staff and resources from traditional outpatient services into primary care, with sessions currently based in hospitals relocated into 'primary care networks'.

Mr Milburn - who incorporated a number of confederation policy ideas into the NHS plan - welcomed the report, saying: 'The NHS plan is all about doing things differently, with the patient at the centre. This report highlights how that can be done for the 12.1 million people who visit outpatients each year.

'The NHS must continually ask itself whether it can do things better. This is a demonstration that it can.' Mr Milburn was this week set to visit an orthopaedic unit at North Cheshire trust, where consultants have been training GP 'orthopaedic fellows' to ensure more appropriate referrals and a better service for patients.

Consultant in orthopaedic surgery Harry Casserly said: 'We have a lot of people waiting to see consultants in outpatients. If we could get people seen more appropriately in primary care we could not get rid of outpatients, but streamline it.'

The new system means patients have investigations done in primary care before seeing a consultant. More follow-up work is also carried out by the GPs.

Barbara Hakim, chief executive of Bradford South and West primary care trust, said several GPs have now trained alongside Bradford Hospital trust consultants in specialties such as ENT, dermatology and rheumatology, forming joint teams ofGPs and consultants.

'Patients can be referred to the whole team, and GPs deal with some of those cases themselves.'

She added: 'In some specialties There is almost no primarysecondary care divide. GPs can register a patient directly on to a consultant's inpatient list.'

But Hospital Consultants' and Specialists'Association past president Winston Peters said the idea of ending outpatients altogether 'sounds barmy'.

'Outpatient appointments should be about diagnosis and treatment planning and getting investigations underway.

I do not think you can do that outside the orbit of the person doing the treatment. It could be dangerous in terms of treatment planning.

'I do not see a way out of an outpatient clinic.'