Appointments in general practice: supporting information

This is an experimental statistics publication.

Experimental statistics are series of statistics that are in the testing phase and not yet fully developed for several reasons such as:

• poor coverage
• poor data quality
• data undergoing evaluation

This publication is classified as experimental statistics due to variations in practice coverage. Early releases only included data from participating practices using EMIS and TPP GP systems with later releases including data from practices using Microtest, Informatica and Vision. Variations in the quality of data contained within a number of fields also contributes to the publication being classed as experimental statistics.

Users should be aware of the status and constraints of this data. The limitations of each measure are explained in the data quality section below.

NHS Digital regularly ask for feedback from users of its publications, which are experimental statistics, to help further development.

Provide feedback.

NHS Digital publishes this information to support winter preparedness and provide information about scheduled activity within primary care. The aim is to inform users, who range from a healthcare professional to an inquiring citizen, about appointments within primary care. NHS Digital produce this information monthly, containing information about the most recent month and the previous 18 months (where available).The aim of the publication is to inform users about activity and usage of GP appointments historically and how primary care is impacted by seasonal pressures, such as winter.

The publication initially included data from participating practices using EMIS and TPP GP systems. Microtest data was first included in the April 2019 release, with data from November 2018; Vision data was first included in the June 2019 release, with data from January 2018; Informatica data was first added in the June 2020 release with data from December 2018. Data from both these GP systems will continue to be included in subsequent releases.

This information does not give a complete view of GP activity so should not be used to infer a view of workload. The publication covers scheduled and planned activity recorded on the GP appointment system only, rather than the totality of interactions or activity/workload. It does not reflect all work happening within a primary care setting or assess the complexity of activity. No patient identifiable information has been collected or is included in this release.

Details of which GP activities are included, partially included or not included in the publication.

Included

• scheduled surgery appointments
• scheduled telephone consultations

The following activities are partially included, if they are in the GP system as individual appointments and booked to a patient:

• telephone triage
• online consultations
• home visits
• immunisations
• extended access appointments

Appointments outside of core hours with a valid status, Attended, Did not attend (DNA) or Unknown will also be included. See Data quality for more details.

Not included

The following activities are not included:

• administration
• supervision
• consultation activity NOT booked via appointment systems
• training
• meetings
• paperwork
• contacting specialists
• teaching
• prescriptions: reviewing
• prescriptions: actions and results
• running the business
• dealing with complaints
• complying with regulation
• processing laboratory tests
• cancelled appointments that were not rebooked

The following information is presented at Clinical Commissioning Group (CCG) level to track activity levels for appointments that have already happened, as recorded in participating EMIS, TPP, Vision, Informatica and Microtest practices in England:

• activity levels for appointments that have already taken place
• number of appointments by the date the appointment was scheduled to happen
• number of appointments marked as 'DNA' (did not attend)
• the health care professional type of the person seeing the patient
• the mode of the appointments (face to face, over the phone etc)
• the time elapsed from when the appointment was booked until when it was scheduled to happen

Appointments with patients are one part of the workload of a GP, which will typically also include many other tasks such as paperwork, meetings and liaising with other health care professionals. Not all GP activity, consultations or encounters are presented in this publication as only appointment slots captured in the practice system are collected.

The number of appointments required can vary based on the needs of patients driven by a number of uncaptured factors. For example the age distribution in an area or the prevalence of long-term illnesses.

This information does not give a complete view of GP activity so should not be used to infer a view of workload.

No information on the demand (the volume of people attempting to book appointments) is presented in this release.

No information is included on capacity (the proportion of available appointments that are used) of appointments in general practice.

This publication does not include any information on appointments marked as ‘available’. These may include:

• unused patient facing appointments
• untimed appointments
• administrative tasks
• training
• breaks
• appointments which were cancelled by patients at short notice and not rebooked to another patient
• any appointment or activity not recorded in the practice appointment system

The outbreak of Coronavirus (COVID-19) has led to unprecedented changes in the business processes within General Practices and subsequently the GP appointments data within this publication. The variation in approach to appointment management between practices is likely to be greater than usual during the Coronavirus outbreak and as a result data quality will be impacted. These changes in clinical practice and use of GP appointment recording systems impact upon on what can be inferred from this data and as such they should continue to be considered as experimental statistics (see the ‘Experimental Statistics’ tab for further information).

The total number of planned and scheduled appointments recorded in GP practice systems has declined during the Coronavirus outbreak. It is important to note that this decline does not necessarily imply that GPs are having fewer interactions with patients. Practices are likely to be operating very differently in response to the pandemic and consequently may be recording encounters and interactions in different ways.  One such change could be an increase in the use of list appointments, in which several patients are contacted but only one notional appointment slot appears in the collected data. With the change in guidance for social distancing, and under revised NHS England operating guidance, much of the contact between General Practice and patients has moved to telephone or video service. Partial or total ‘triage’ systems have taken over from routine appointment booking, to reduce risks for patients and service staff. These innovations do not have universal recording or reporting standards in place yet – so much of this capacity, flexibility and consultation activity is not reflected in the GP appointment statistics collected and published.

With the onset of the Coronavirus emergency, General Practice across England has undergone a rapid change of behaviour in scheduling and delivering both urgent and routine planned care, to protect patients and the NHS. This has led to a dramatic increase in telephone and video contacts including same day clinical triage interactions to assess and prioritise patient need, and a decrease in the number of traditional face-to-face scheduled appointments reported.

The experimental GP appointment data statistics reflect ONLY planned and scheduled encounters, and new standards and data collection methods are not yet available to reflect this emergency response in care delivery. As a result, the ongoing appointment data and management information published should be interpreted with caution, particularly in comparison to data collected before February 2020.

NHS Digital is working with the GP profession and NHS England to develop appropriate standards that will reflect the changes and status increasingly accurately, without additional burden to general practice. This will help practices, networks and service commissioners understand patterns of activity and capacity covering the full range of patient interactions in a digitally enabled service. Future updated reports will better inform planners, administrators and patients, and take account of new ways of working that are likely to be incorporated into routine General Practice after the emergency period

Not all practices in England are included in this release (see Data Quality: Practice Coverage) meaning the total number of appointments is not known. An estimate of the total number of appointments in England has been provided. The estimate is calculated by taking the number of registered patients from missing practices and doing a simple calculation based on the number of appointments per registered patient from the practices included in the data collection.

An example of this calculation for November 2019 is shown below:

This estimate does not include all GP activity or provide information about demand or capacity of appointments in general practice.

In each monthly release of this publication, the data is presented in two formats, the Summary document, which contains an 18 month timeseries with daily and regional counts for the most recent month, and zip files. The contents of the zip files are outlined here to provide support for their use.

Daily counts, at CCG level:

The csv files include data for each calendar month during the 18 month reporting period. The data is aggregated to daily counts, including breakdowns for Appointment Status, Healthcare Professional, Mode of Appointment and Time between Booking and Appointment. The data is aggregated to CCG level, with NHS Geographies included. There is also a coverage file included, providing the number of practice or patients included in the publication and the total number for the CCG for each month in the reporting period. These files can be used to look at appointments across all regions for a particular day, week or month. For example, you can look at the daily count of telephone appointments with an appointment status of Attended by NHS commissioning region.

Regional counts, at CCG level:

The csv files include data for each Regional Local Office for the 18 month reporting period. The data is aggregated to monthly counts, including breakdowns for Appointment Status, Healthcare Professional, Mode of Appointment and Time between Booking and Appointment. The data is aggregated to CCG level, with NHS Geographies up to regional local office included. These files can be used to look at appointments data for a particular region during the full reporting period. For example, you can look at the monthly timeseries count of face-to-face appointments by CCG for a chosen STP.

Fields included

CCG_CODE
CCG_ONS_CODE
STP_CODE
REGIONAL_LOCAL_OFFICE_ONS_CODE
Appointment_Date/Appointment_Month¹
APPT_STATUS
HCP_TYPE
APPT_MODE
TIME_BETWEEN_BOOK_AND_APPT
COUNT_OF_APPOINTMENTS

¹ _{Daily csv files contain Appointment_Date. Regional csv files contain Appointment_Month.}

Data is collected from GP systems which are designed to be flexible and for practices to use in everyday work and not for the purpose of data analysis. There are no national standards for data entry about activity and there is widespread variation in approach to appointment management between practices. This means that there are variations in data quality between practices.

The main known data quality issues are recorded below.

Information is included from participating EMIS, TPP, Vision and Microtest practices. Coverage information is included in Table 1 of the Appointments in General Practice Summary tables.

Practices with the following criteria have been excluded from the publication:

• inactive and closed practices
• practices with an appointment rate of less than 1 appointment per registered patient per year

CCGs with the following criteria have been excluded from the publication:

• CCGs with 1 included practice
• CCGs with 0 included practices

Prior to the July 2019 release, practices with less than 1,000 registered patients were also excluded from the publication. 

The data collected from GP systems includes appointments recorded at any time of day, including core and non-core hours. There has been no restriction or cleaning of the data based on the time an appointment occurred therefore appointments with a valid status (Attended, DNA or Unknown) outside of core hours will be included.

Extended access appointments are funded directly by CCGs and occur outside of opening hours of 8am to 6.30pm, Monday to Friday and any time on Saturday or Sunday. Practices are required by CCGs to provide extended access to general practice for their whole population. These appointments are often managed outside of the core practice system and may not always be collected with this data.

Therefore, not all extended access information is included in this release. However, appointments outside of core hours provided outside of the extended access scheme, for example by a locally agreed Direct Enhanced Service (DES), will be included.

Some appointments are included in the GP system serve as lists of activities that need to happen at any point in the day. Practices generally use these so that they appear at the top of the calendar for clinician’s attention. These are often used as reminders or daily task lists and often do not have a specific start or end time or appear to start very early in the morning (6am or before). The majority of these appointments do not have an Attended, DNA or Unknown status so are excluded from this release. These appointments may include for some practices

• telephone triage lists
• home visit lists

This may cause counts for these patient interaction types to appear lower in this data release than in practice.

Available appointments

Available appointments are collected but not included in this publication due to data quality issues.

As all information in GP appointment systems are collected, this includes any time reserved for breaks, training, admin etc. It is not currently possible to distinguish this time from potentially patient facing slots that go unused. This means any data on available appointments is misleading and will not be used at this time.

Example GP calendar

In the below, all 'Available' status appointments are removed from the publication. This is a mix of admin time, breaks and unused patient facing slots.

This is an illustrative example intended to highlight types of appointments that are or are not included in the results. Some healthcare professionals will see more patients than indicated here.

The appointment status shows whether the appointment is available, booked, attended, cancelled or the patient did not attend. This status changes over time, for example when a patient makes a booking, the appointment status changes from ‘Available’ to ‘Booked’. This release reports the final status of each appointment. 

In most cases, at the time of the appointment a ‘Booked’ status will be changed to either ‘Attended’ or ‘DNA’. In some cases (3-6% of monthly appointments), the final status of an appointment remains as ‘Booked’. It is not known from the data whether these appointments were actually attended or not. For this reason, these appointments are reported as 'Unknown' status.

Due to an issue with the data collection, DNA appointments were not captured correctly after June 2018 and are under reported until and including November 2018 for all practices using the TPP SystmOne system.

Healthcare professional type (HCP Type) was incorrectly extracted for some practices from October 2017 onwards. This has led to potential incorrect reporting of some HCP Types, including nurses. The only HCP type currently collected with high enough consistency for publication is GP. Therefore, all other HCP types are reported as 'Other Practice Staff' throughout this release.

Blank or missing HCP types are due to the use of generic lists for GPs (for example visits and prescription requests) or staff not set up correctly on the system (for example medical students and team leaders).

Where HCP Type is included it has been grouped in the following way.

The occupations grouped as HCP type 'GP' are:

• GP registrar
• Locum GP
• Principal GP

The occupations grouped as HCP type 'Other Practice Staff' are:

• Acupuncturist
• Chiropodist
• Community Psychiatric Nurse
• Counsellor
• Dispenser
• District Nurse
• Health Visitor
• Interpreter/Link Worker
• Osteopath
• Other Practice Staff
• Physiotherapist
• Practice Nurse

If HCP type is recorded as NULL / Missing Data it will be classified as Unknown.

It is possible that a small proportion of GP appointments are classified within Other Practice Staff due to incorrect mappings with data suppliers, for example Trainee GP or GP Partner.

The mode of the appointment shows the setting of the consultation. For example, face-to-face, telephone or home visit. This is set locally by the practices so may not represent the actual care setting of the appointment. For example, some video conference appointments may be logged by the practice as face-to-face.

Most face-to-face time is booked as individual appointment time, typically with one patient attending each time slot. By contrast, many telephone triage and home visits appear as one long blocked period of time which are not booked to individual patients.

Some home visits and telephone triage sessions are booked in to early morning sessions (6am to 6.20am) for each GP as untimed appointments but the consultations happen in the afternoon. They are booked in to early morning sessions so that they appear on the top of the appointment book screen for each GP. At some practices, home visits are logged at reception and not in the practice system.

Unless home visits and telephone triage are logged as individual appointments and booked to a patient they will not appear in this publication.

Appointments marked as online, video or video conference are shown as 'Online / Video'. This may or may not include a video element. Non-video based online consultations such as live chat or Voice over Internet Protocol (VoIP) and video-based appointments are all included in this category.

Practices using the Vision GP system are unable to supply appointment mode data. Consequently the proportion of appointments with an 'Unknown' appointment mode is higher in releases from July 2019 onwards when Vision practices were included in the publication.

Time elapsed from when the booking was made to when the appointment happened is presented in this release. There are several factors that drive this variable, including:

• appointment availability at the practice
• patient availability
• urgency of the appointment
• GP advice
• regular/repeat appointments that may be booked in advance

Several publications have been produced previously analysing primary care appointment activity and trends. This resource compares methods in analysis of the QResearch database in 2008 with the methods for this publication.