King Edward VIII Hospital, Durban, is the major tertiary medical care centre for blacks in Natal and KwaZulu. Annually, there are approximately 35,000 patients who attend the Paediatric Outpatient Department for the first time. A representative sample of 280 of these records was reviewed to determine the proportion of patients who: (i) had been referred from other levels of the health service; and (ii) could have been treated in a primary care facility. A large proportion (78.5%; 95% confidence interval (CI) 73.6-83.4%) were unreferred. In addition, 42.2% (CI 36.4-48.0%) could have been medically managed in a primary care facility. More unreferred compared with referred patients could have been managed in a primary care facility (48.6% v. 18.6%; P less than 0.001). The findings suggest that an improved primary health care service in Natal and KwaZulu would reduce the number of inappropriate paediatric outpatient visits.