Disease registers by local health board, cluster and GP practice

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Next update expected:July 2026

Updates

4th December 2025
Dataset first published.

Main information

Designation
Official statistics
Data provider
Digital Health and Care Wales (DHCW)
Data source
Audit+
Time period covered
September 2020 to April 2025

Overview

Summary of dataset and variables

This StatsWales cube provides data on the number of patients on disease registers, the overall number of patients registered at GP practices and disease prevalence rates, using disease register data. These are lists of patients registered with GP practices who have been diagnosed with certain medical conditions.

Data collection or calculation

The information presented here is provided to the Welsh Government by Digital Health and Care Wales.

Prior to 30 September 2022, GP practices were required to maintain disease registers as part of the Quality Assurance and Improvement Framework (QAIF). Since 1 October 2023 maintenance of the same disease registers has been a core contractual requirement for GP practices. This change is administrative only and should not impact on data quality.

The data presented refers to a single point in time. Due to changes in QAIF over time, the reference dates are not exactly the same in each year. Data for 2020, 2021 and 2022 relate to 30 September; data for 2023 relates to 1 October; and all data from 2024 onwards relates to 1 April.

Data for 2023 onwards has been extracted using the Audit + system, which uses information directly from GP systems. Prior to this, disease register data was provided as part of a QAIF tool as it was a requirement that all practices provided disease register data through this tool, while practices were not required to use Audit +. Since disease register data became a core contractual requirement rather than a QAIF requirement, data has been extracted using Audit +.

Data for patients with any chronic condition and patients with any mental health condition is available from 1 April 2025 onwards.

A patient is counted as having one or more chronic conditions if they are recorded with one or more of the following conditions:

  • Epilepsy
  • Chronic Kidney Disease
  • Chronic Obstructive Pulmonary Disease
  • Coronary Heart Disease
  • Stroke and Transient Ischaemic Attack
  • Peripheral Arterial Disease
  • Diabetes Mellitus (including diabetes type 1, diabetes type 2 for patients aged 17 and over and remaining diabetes for patients aged 17 and over)

A patient is counted as having one or more mental health conditions if they are recorded with one or more of the conditions listed below. Note this differs from the 'mental health' disease register as it includes minor mental health conditions such as depression.

  • Dementia
  • Mental health (this refers to the mental health disease register and covers serious conditions only such as schizophrenia)
  • Depression
  • Low mood (where a patient has a record of low mood and an active repeat prescription for an anti-depressant)
  • Anxiety disorder (including panic disorders)

Prevalence rates are defined as patients on a certain disease register, as a percentage of all patients registered at a GP practice:

Number of patients on disease register / Number of patients registered at a GP practice * 100

For the following five age specific disease registers, the denominator shown above counts registered patients of the specified age using the age group data for 2023 onwards, with some estimation. Prior to this, the denominator from the QAIF extracts (which did not include age group data) was adjusted by estimating the number of patients registered at a GP practice for the relevant age (rather than the whole population), using the mid-year population estimates.

  • Diabetes mellitus (aged 17+)
  • Epilepsy (aged 18+)
  • Osteoporosis (aged 50+)
  • Rheumatoid Arthritis (aged 16+)
  • Obesity (aged 16+)
Statistical quality

The chronic condition and mental health data was extracted on 1 October 2025 by DHCW but is reported as of 1 April 2025 to align with the individual disease register data. Practices that closed between 2 April and 1 October 2025 (W97063 and W93643) are excluded. Also, although the 'Torfaen North' and 'Torfaen South' clusters merged as 'Torfaen' on 1 October 2025, the pre-merger cluster boundaries are reflected in the data.

Coverage information

2020: There was 100% coverage of GP practices in the QAIF data for 2019-20; data was based on all 399 active practices as at 30 September 2020. However, the Audit+ data was sourced from 395 out of 397 active practices as at 14 December, as two practices which provided QAIF disease register data were unable to provide Audit+ data.

2021: The QAIF data was based on 391 out of 392 active practices as at 30 September 2021. Data was not available for W97036. The Audit+ data was based on 390 practices out of 392 active practices as of October 2021.

2022: There was 100% coverage of GP practices in the QAIF data for 2021-22; data was based on all 386 active practices as at 30 September 2022. The Audit+ data is also based on all 386 practices.

2023: In 2023, all bar one practice (W97048) submitted data.

2024: In 2024, all practices submitted data.

2025: In 2025, all practices submitted data.

Rounding applied

Prevalence rates are rounded to 1 decimal place.

Related reports

Published by

Organisation
Welsh Government
Contact email
stats.healthinfo@gov.wales