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 classed as experimental statistics due to variations in the quality of data contained within a number of fields.

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 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 activity and usage of general practice (GP) appointments within primary care. NHS Digital produce this information monthly, containing information about the previous 30 months (where available).

The publication initially included data from participating practices using EMIS and TPP GP systems. Cegedim 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. Microtest data was first included in the April 2019 release, with data from November 2018; and has since ceased providing data as of February 2021. Babylon (GP at Hand) data was first added in the March 2022 release with data from January 2021.

Data is collected from GP systems, which are designed for practices to use in everyday work and not for the purpose of data analysis. There is widespread variation in approach to appointment management as practices manage their appointment books in the way they best feel allows them to manage the health and care of their patients and not for the purpose of data analysis. This means that there are variations in data quality between practices.

This publication 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
• enhanced 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 Sub Integrated Care Board (ICB) location level to track activity levels for appointments that have already happened, as recorded in participating EMIS, TPP, Cegedim, Informatica, Microtest (to February 2021) and Babylon (GP at Hand) 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
• the recorded duration of attended appointments
• the recorded national category, service setting and context type of the appointment

From November 2022 the information below is also presented at practice level:

• activity levels for appointments that have already taken place
• the time elapsed from when the appointment was booked until when it was scheduled to happen
• the health care professional type of the person seeing the patient
• the mode of the appointment
• the recorded national category of the appointment

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

Variations in working methods and recording between practices must be considered alongside the data quality issues below when interpreting practice level data.

The system supplier the practice uses to manage their appointment book impacts on the data included in this collection. Currently data is received from EMIS, TPP, Informatica, Cegedim and Babylon (GP at Hand). Practices using other system suppliers will not have their data included in this publication. Practices using a combination of suppliers to manage their appointment book may also have only partial data included.

Other factors that should be considered include:

• The demographics of the patients registered at the practice. For example, practices are likely to have differing age profiles of patients which in turn will impact on the demand and nature of appointments required.
• The level of deprivation in the local area served by the practice and the impact of this on the prevalence of long term illnesses.
• The number of care homes the practice offers services to.
• The use of list and untimed appointments. These appointments are included in the GP system and serve as lists of activities that need to happen at any point in the day and often include telephone triage lists and home visits. These may appear in the appointment book as one appointment whereas other practices may record these as individual appointments throughout the day.

General practice activity provided via PCNs on behalf of practices is not yet collected and therefore these appointments will not be included in this data. Similarly, enhanced access activity may also not be included unless it is recorded directly in a practices’ main appointments system.

The outbreak of Coronavirus (COVID-19) led to unprecedented changes in the business processes within general practices and subsequently the appointments data within this publication. The variation in approach to appointment management between practices is likely to have been greater than usual during the pandemic and as a result there is an impact on data quality.  

The total number of planned and scheduled appointments recorded in GP practice systems declined during the Coronavirus outbreak. Guidance around social distancing and revised NHS England operating guidance resulted in much of the contact between general practice and patients changing to telephone or video services to reduce risks to patients and staff. These innovations did not have universal recording or reporting standards in place so much of this capacity, flexibility and consultation activity is not reflected in the GP appointment statistics collected and published during this time.

COVID-19 vaccination data is recorded through other systems. The GP appointments data collection contains only a proportion of this data, and thus we cannot use this data to give a clear picture of COVID-19 vaccination activity. In this publication, we have removed any data received from the GP System suppliers that related to COVID-19 vaccination activity and have added data taken from the National Immunisation Management System (NIMS) vaccination dataset on all COVID-19 vaccination activity carried out by PCN or GP Practices to gain a clearer picture of activity in General Practice. More information about the NIMS vaccination dataset can be found here.

Please note that this publication is not considered an official data source for COVID-19 vaccinations and has only been provided for context and to provide additional information. The official source of vaccination data can be found here.

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 a 30 month timeseries with daily and regional counts for the most recent month, and zipped CSV files. The contents of the zip files are outlined here to provide support for their use. Metadata for each of the CSV files can be found here.

Daily counts at sub ICB location level:

The csv files include data for each calendar month during the 30 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 date. The data is aggregated to sub ICB location level, with NHS geographies included.

There is also a coverage file included, providing the number of practices or patients included in the publication and the total number for the sub ICB location 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 sub ICB location level:

The csv files include data for each ICB for the 30 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 date. The data is aggregated to sub ICB location level, with NHS geographies up to NHS commissioning region included. These files can be used to look at appointments data for a particular geography during the full reporting period. For example, you can look at the monthly timeseries count of face-to-face appointments by sub ICB location for a chosen ICB.

COVID vaccination appointments (NIMS):

The csv file includes COVID-19 vaccination activity carried out by PCNs or practices from the NIMS vaccination dataset for each calendar month during the 30 month reporting period. The data includes a national, regional, ICB and sub ICB location breakdown of vaccine appointment counts, including ONS codes. This file can be used to look at COVID-19 vaccine appointments data for a particular region during the full reporting period. For example, you can look at the monthly timeseries count of vaccine appointments by sub ICB location for a chosen ICB.

National categorisation, SDS role groups and actual duration CSVs: 

Additional CSVs were added from March 2022 for each of the following measures: national categories, SDS role and actual duration. The data includes a national, regional, ICB and sub ICB location breakdown of appointment counts, including ONS codes.

National overview CSV:

A national overview CSV file is available from September 2022. This contains counts of appointments broken down by month, status, HCP type, mode, service setting, context type and national category at national level. This allows combinations of measures to be applied that aren’t available in other files. For example it is possible to identify the number of appointments with a HCP type of GP for a specific national category.

In each monthly release of this publication from November 2022, practice level data is provided separately to the main publication in two formats: the summary document, which contains data for the most recent month, and zip files which contain csv files of data for the most recent three months.

Each csv file contains practice level breakdowns of appointments by HCP type, national category, mode and the time between booking and appointment date. This allows combinations of measures to be applied that are not available in the summary document. For example, a count of telephone appointments with a GP for a specific national category.

Metadata for the CSV file can be found here.

Babylon (GP at Hand) is a digital first NHS GP practice which offers appointments with GPs and other health care professionals primarily by video call or telephone. Face to face appointments are also offered when necessary at a number of practices within London and one in Birmingham. Due to this, data received from Babylon (GP at Hand) differs compared to other suppliers, specifically when looking at appointment mode as a greater proportion of appointments are recorded as being via telephone or video.

All appointment activity undertaken by Babylon (GP at Hand) is recorded under two practices: E85124 GP At Hand located in NHS North West London sub ICB location (W2U32) and Y06487 Babylon GP at Hand Birmingham which is also mapped to the same sub ICB location. The impact of this on the total number of appointments for this sub ICB location is minor.

Data in the appointments in general practice collection is known to contain a number of data quality issues. This is due to variation in working methods and recording between different practices. Practices manage their appointment books in the way they best feel allows them to manage the health and care of their patients and not for the purpose of data analysis and there is a widespread variation in approach to appointment management between practices.

The main known data quality issues are recorded below.

Information is included from participating EMIS, TPP, Cegedim, Microtest (to February 2021) and Babylon (GP at Hand) 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

Up to November 2022 sub ICB locations with the one or zero included practices were excluded from the publication.

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.

Enhanced access appointments are funded directly by sub ICB locations 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 sub ICB locations 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. 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.

General practice activity delivered by PCNs on behalf of practices is not yet collected so is not included in this publication. NHS Digital is currently working with PCNs to establish how this data can feed into the collection.

Some appointments 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 between June and November 2018 and are under reported 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.

For information on how this differs from SDS Role Group go to the SDS role group section.

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 into early morning sessions (6am to 6.20am) for each GP as untimed appointments but the consultations happen in the afternoon. They are booked into 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.

GP system suppliers have different mechanisms that allow practices to select the mode of an appointment. NHS Digital then map these to four different mode types to ensure consistency between suppliers for publication.

EMIS

Within EMIS systems, the appointment mode is one of four fixed values which are then mapped for publication purposes as outlined below:

Data quality issues may arise from some practices recording all or the majority of their appointments as ‘appointment’ rather than ‘telephone’, ‘visit’ etc.

TPP

There are three methods within TPP SystmOne to assign a mode to an appointment.

1. Default slot types – there are two default slot types: telephone and video. These are mapped to ‘telephone’ and ‘video/online’ respectively within the publication.
2. User created slot types – these can be assigned a long list of non-exclusive flags, some of which correspond to a mode, e.g. ‘Telephone Review’, ‘Home Visit’, ‘Online’. When a flag that corresponds to a mode is assigned to a slot type, that attribute is used to define the appointment mode. A priority order exists if more than one flag is assigned.
3. Face to face appointments - appointments that are not Default Slot Types (Telephone and Video) and where no flag that corresponds to a mode is selected for a user created slot type then the assumption is that the appointment is ‘face to face’.

This method again introduces data quality issues due to system and user behaviour when setting up appointments.

Babylon (GP at Hand)

Babylon allow mode to be recorded against one of three values which are mapped to the publication as below:

Cegedim and Informatica

Cegedim and Informatica systems are unable to record the appointment mode in a way that enables it to be mapped to the four modes presented in the publication. As such appointments for practices using these system suppliers are recorded as having an unknown mode.

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

Data is taken from the National Immunisation Management Service (NIMS) vaccination dataset. NIMS is the System of Record for the NHS COVID-19 vaccination programme in England.

For the Appointments in General Practice publication NHS Digital include only covid-19 vaccination activity carried out by a PCN or GP Practice. Practice PCN’s have been identified as those with a site code identifying them as a branch surgery. Data can be added to the NIMS system at anytime, therefore the cut off for data included in this publication is the same date as the GP Appointments data is received from the system suppliers. This means that historic figures may change with each release.

The methodology for identifying valid covid vaccinations is reviewed each time a new booster dose is introduced and we work with colleagues at NHS England to align methodologies. This means NIMS figures are subject to revision and can change between publications.

Actual duration data was first included in the April 2022 release with data from December 2021.

Actual duration is the length in minutes of the consultation that took place and is included for appointments with an attended status only.

This field is recorded differently depending on the practice’s system supplier. For example, EMIS record the actual duration as the time between the patient being called into their appointment and the time the clinician records that the consultation is complete. TPP can record the start time as either when the consultation is started, when a clinician calls for a patient or when the appointment status is changed to ‘in progress’. The end time is recorded as when the appointment is marked as finished with the actual duration being the difference between these two times. This leads to variations in data quality that NHS Digital are continuing to work with system suppliers to address.

For practices using the EMIS system it is not possible to record the actual duration of appointments with the appointment mode ‘Online / Video’, or ‘Home Visit’. For practices using the Babylon (GP at Hand) system it is not possible to record the actual duration of appointments with the appointment mode ‘Face to Face’. These appointments will therefore be counted within the ‘Unknown / Data Quality Issue’ category within this publication.

Any appointments with a null duration or a duration of less than 1 minute or greater than 60 minutes have been grouped into an ‘Unknown / Data Quality Issue’ category within this publication.

National Category data was first included in the April 2022 release with data from August 2021.

National Categories

In August 2020, NHS England and NHS Improvement and the British Medical Association published “More accurate general practice appointment data – guidance”, which established consistent principles for recording of patient-facing appointments in general practice. As a result of this NHS England and NHS Improvement, in partnership with NHS Digital, has introduced this new set of GP appointment categories to better capture general practice workload and demand. This is achieved by practices assigning a predefined category to the various appointment types within their appointment books.

More information on the ‘Standardised GP Appointment Categories’ and the ‘More accurate general practice appointment data guidance’ can be found below:

https://www.england.nhs.uk/publication/gpad-appointment-categorisation-guidance-2021-22/

https://www.england.nhs.uk/gp/gpad/more-accurate-general-practice-appointment-data/

National category data was first included in the March 2022 release with data from August 2021. The data is received from practices using the EMIS, TPP (System One) and Informatica GP systems. National category data for Cegedim (formerly Vision) is included in the September 2022 release with data from August 2022.  Babylon (GP at Hand) are not currently enabled to record national categories or supply these to NHS Digital. 

The data for national categories is presented in three parts:

• Service Setting
• Context Type
• National Category

The service setting describes the provision of care in which the appointment was delivered. There are four service settings. Where category data is not received then an appointment is assigned to an ‘Unmapped’ setting.

The national categories are subdivided into three ‘context types’. The context describes whether an appointment is an encounter relating to direct patient care, or an activity undertaken as part of patient care where the patient is not involved. Where category data is not received then an appointment is assigned to an ‘unmapped’ context type.

Appointment types that have been mapped, but not to a Care Related Encounter are assigned to the ‘Inconsistent Mapping’ context type with further analysis planned to establish whether new categories in future releases are needed, or additional assistance and guidance is required for mapping.

*As of the December 2022 publication, 'Care Related Encounter but does not fit into any other category' is included in the 'Care Related Encounter' context type. Prior to this the count of appointments under this category were assigned to Inconsistent Mapping. 

SDS role data was first included in the April 2022 release with data from December 2021.

The Spine Directory Service (SDS) provides details of organisations, people and systems registered across local and national NHS systems. Healthcare professionals are equipped with a Smart Card, onto which they register any relevant Role Based Access Controls (RBAC) enabling access to required application functions. The RBAC directory contains a list of SDS Role ID’s, SDS Role descriptions and healthcare professional groups. A healthcare professional may have multiple SDS Role ID’s on their Smart Card depending on the roles they perform. When creating an appointment on the GP system the appropriate SDS Role ID is used dependant on the nature of the appointment. NHS Digital collect the SDS Role ID, which is then used to identify the type of healthcare professional intended to deliver an appointment.

The data is received from practices using the EMIS and TPP (Systm One) GP systems. SDS Role data for Cegedim (formerly Vision) is included in the September 2022 release with data from August 2022. Informatica and Babylon (GP at Hand) do not currently supply SDS Role ID data. 

The ‘Appointments in General Practice’ publication already provides data split by Healthcare Professional (HCP). These are grouped as ‘GP’, ‘other practice staff’ or ‘unknown’. The SDS Role is a more granular view of the roles within the ‘other practice staff’ group allowing a more defined view of healthcare professional activity in practices. For publication these are aligned into five SDS role groups. 

It is important to note that HCP Type and SDS Role are recorded differently on GP systems, therefore the count of appointments with a GP in SDS role groupings will differ from the count in the GP HCP group.  HCP Type is taken from the GP system, whilst the SDS role grouping is taken from individual user Smart Cards. Users can have multiple roles on a smart card.

Both HCP Type and SDS role are currently presented for comparison purposes but moving forward the intention is to only publish SDS Role Groups and will remove HCP Type.

A table showing how each role is mapped can be found here.

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.