Primary care must take the strain in a modern health service

Few images mock the notion of a modern, patient-friendly NHS more than the sight of people waiting hours on end in an outpatient department. Yet 43 million such waits take place every year, in scenes evocative of the 1940s and deeply symbolic of the British attachment to queuing. The trouble is that, in this age of instant gratification, the British - like everyone else - are much less enthusiastic about queuing than they used to be, even in the NHS. And they are voting with their feet: 12 per cent of outpatients now fail to turn up to appointments.

Ironically, for many it will not matter. The National Patient Access Team has calculated that between 30 and 70 per cent of outpatient work is of no value to the patient, with consultations too short and half the doctor's time absorbed by other concerns. In these modernising times, such facts alone would normally signal an area ripe for radical reorganisation - if they didn't sound its death knell altogether.

But there is more: outpatient clinic organisation is chaotic and typified by error, duplication and delay, with the urgency of a referral bearing little relation to the speed with which the patient is seen. In a service where modish terms like 'one-stop' and 'fast-track' have a special cachet, the outpatient department remains stuck in a bygone era.

Some lateral thinking is needed, as the NHS Confederation points out in its report on modernising outpatient services: not simply lots more money, but imaginative ways of exploiting the opportunities offered by new technology and - above all - changes to traditional attitudes and working practices.

As with so much else, parts of the NHS are already showing the way. And as with so much else, many of the solutions lie in primary care though GPs may groan at another addition to their burdens. It is unlikely that outpatients will disappear completely, but a huge swathe of the work carried out in these departments could and ought to be done in primary care. Indeed, if it is not, no amount of modernisation elsewhere may be sufficient to maintain the NHS's popularity with the public.