First reported 26 Feb 2016•Latest report 18 Dec 2025
Definition
What this concern includes
Includes deficiencies in the GP consultation system or its dedicated controls that materially limit timely, sufficiently thorough or effective assessment and communication, including appointment capacity or duration and consultation arrangements that impede understanding of deterioration.
Not included
Excludes generic workforce, administrative or communication failures not specifically tied to the safety of GP consultation provision.
Excludes failures in hospital, ambulance, prescribing, discharge, or other care pathways unless the assertion specifically concerns GP consultation provision.
Excludes isolated documentation, follow-up, referral, or clinical-management failures that do not make GP consultation provision itself unsafe.
Reports
17
Distinct published reports
Individual concerns
19
A report can raise multiple concerns
Date range
2016–2025
First to latest report issue date
Stated actions
27
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care7
NHS England5
NHS Greater Manchester Integrated Care Board5
NHS Birmingham and Solihull Integrated Care Board2
Ashfield Surgery1
Beech Cliffe Grange1
Beech Cliffe Limited1
Black Country Family Practice1
Egton Medical Information Systems Limited1
Family of Richard Parkes1
Greater Manchester Health and Social Care Partnership1
Midlands Partnership University NHS Foundation Trust1
Nottinghamshire Healthcare NHS Foundation Trust1
Partnering Health Limited1
Queen Mary University of London1
Integrated care board7
Ministerial department7
Executive non-departmental public body5
Healthcare site4
NHS trust2
Private limited company2
Health-system partnership1
Independent healthcare provider1
Residential care home1
University1
Type not available1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Hampshire, Portsmouth Southampton
Concerns raised1
Blocking of direct booking with a patient's own GP for face-to-face assessment
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Insufficient GP appointment time for holistic review of patients with chronic disease
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
General practices are responsible for operating arrangements, including individual appointment duration and addressing patients’ physical and mental health needs.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Appointment time constraints mean clinicians often rely on patients and families to disclose mental health problems rather than proactively identifying them.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Lack of guidance for using telephone appointments instead of face-to-face appointments in general practice
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Produce and distribute a briefing for Greater Manchester GPs on appointment-mode appropriateness, contextual mental-health risk, family involvement, confidentiality, and Zero Suicide Alliance guidance.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 18 June 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Telephone and online consultations remain appropriate for many patients, depending on their clinical circumstances; face-to-face appointments are not universally required.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to ask all appropriate questions during the 6-8 week GP check
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottinghamshire
Concerns raised1
Lack of robust GP clinical assessments for prisoners
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to provide face-to-face GP assessment when deterioration may be present
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Review systems for recording and prioritising consultation and home-visit requests.
Stated by North Trafford Group PracticeStated completedThe respondent said that this action was complete when they made their response on 29 April 2022.
Action
Remind reception staff to record every home-visit request in the clinical system for clinician assessment.
Stated by North Trafford Group PracticeStated completedThe respondent said that this action was complete when they made their response on 29 April 2022.
Action
Reinforce home-visit request recording requirements through reception staff orientation and training.
Stated by North Trafford Group PracticeStated plannedThe respondent said that this action was planned when they made their response on 29 April 2022.
Action
Progress the Greater Manchester access action plan to increase general-practice capacity and appointments, expand face-to-face GP access, reduce avoidable demand, and improve healthcare inequalities.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2022.
Action
Review the balance between remote and face-to-face consultations across Greater Manchester general practices.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing digital systems provide clinician-triaged access to telephone, video, face-to-face consultations or home visits, with alternatives for patients unable to use them.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
CQC and NHS England will make required improvements across practices that do not meet patients’ reasonable needs.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to provide physical examination during telephone GP consultations where clinically needed
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure of GP consultation arrangements to support effective communication about deteriorating health
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Review patient experience feedback monthly to identify poor primary-care experiences and access inequalities.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 August 2021.
Action
Discuss negative patient feedback with relevant practices to support learning and improvement.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 August 2021.
Action
Introduce six-monthly patient surveys at individual practices from October 2021 to assess primary-care access and delivery.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 August 2021.
Action
Conduct an individual practice clinician survey in October 2021 to assess primary-care delivery during the pandemic.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 August 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
National general practice guidance required remote triage and face-to-face appointments where clinically appropriate, addressing concerns about remote-only care.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The CCG cannot determine how GP consultations are undertaken because it lacks legal powers and is not party to the nationally negotiated contract.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
Existing guidance, procedures and resources are considered sufficient to support safe remote general practice consultations alongside face-to-face appointments.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to provide physical examination during GP consultations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Produce and iteratively update standard operating procedures for safe remote triage and selection of consultation methods in general practice.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 August 2021.
Action
Develop and maintain joint NHS England–RCGP guidance and learning resources on choosing remote or face-to-face consultations, patient safety and shared decision-making.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 August 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing remote-triage procedures and consultation guidance address patient safety and require face-to-face review where clinically appropriate.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing guidance, procedures, training and safety resources are considered sufficient to support safe remote general practice consultations.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised1
Failure of the EMIS consultation-list mitigation to reliably ensure practitioner logout and re-login
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Update the induction pack with EMIS appointment-screen guidance and disseminate it to new staff, nursing staff, locums and relevant Primary Care Networks.
Stated by Ashfield SurgeryStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
Action
Use manual log-off and log-on refreshing as a workaround to identify newly added appointments and prevent missed appointments.
Stated by Ashfield SurgeryStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
Action
Update and disseminate appointment-refresh self-help guidance through the customer portal and EMIS Web information feed.
Stated by EMIS GroupStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
Action
Issue Safety Advisory Notice SAN 2021-005 to GP Practices and Clinical Services about the appointment-refresh risk and required actions.
Stated by EMIS GroupStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
Action
Develop an automated appointment-book refresh solution for current-day appointments and inactive user sessions.
Stated by EMIS GroupStated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021.
Action
Roll out the completed appointment-refresh functionality to all users through controlled implementation and effectiveness and performance checks.
Stated by EMIS GroupStated plannedThe respondent said that this action was planned when they made their response on 8 March 2021.
Action
Issue a Safety Advisory Notice to GP practices and clinical services setting out required actions and further information.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
Action
Send all GP practices information about appointment-refresh risks, resolution steps and IT support contacts.
Stated by NHS Birmingham and Solihull Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Manual Appointment Refresh is currently sufficient; users do not need to log out and back into EMIS while automatic refresh is developed.
Stated by EMIS GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes deficiencies in the GP consultation system or its dedicated controls that materially limit timely, sufficiently thorough or effective assessment and communication, including appointment capacity or duration and consultation arrangements that impede understanding of deterioration.
