A million fewer patients could be seen by hospital specialists under new government plans and instead will be cared for nearer their homes.

The move is designed to save unnecessary appointments by ensuring GPs deal with more patients themselves rather than make referrals.

However, the plans will spark fears that signs of illness could be missed if patients are not seen by a specialist.

Hospital consultants could also be forced out of wards to visit those who still qualify for outpatient appointments at clinics or surgeries rather than making patients travel to them.

The proposals, to be unveiled on Tuesday, have already provoked controversy. Department of Health sources admitted that it had still to agree terms with doctors to travel to patients, adding: 'The big obstacle is the consultants, who would rather sit in a district general hospital and have people come to them.'

Political infighting is also likely to be triggered by plans to invite private companies to provide GP services in areas lacking family doctors - particularly since the Prime Minister's former health adviser, Simon Stevens, is likely to benefit. He now runs the European division of a private healthcare giant which has just won the contract to provide GPs in a trial scheme in Derbyshire.

A white paper to be published this week by Patricia Hewitt, the Health Secretary, will, however, argue for a rethink of where and how patients are treated. It will say better monitoring of the chronically ill can stop people needing to go to hospital.

'Germany has no outpatient appointments carried out in hospital,' said a DoH source. 'There is a big issue about it being inconvenient and expensive [to travel for outpatient appointments] and people being forced to wait hours for the convenience of surgeons.'

Five million outpatients needing appointments in gynaecology, urology, ear nose and throat, trauma and orthopaedics and dermatology would in future be seen in the community by a travelling consultant.

But there would also be up to a million fewer outpatient appointments. Patients would be treated instead by their GP, senior nurse or other expert such as a physiotherapist.