This study examines the relationship between (i) measures of how appointment systems work; (ii) patients' views of the arrangements for seeing their general practitioner; and (iii) practice self-referral rates to accident and emergency departments (A&E). Nineteen general practices and one district general hospital A&E department in West Lothian, Scotland formed the setting for a prospective study employing analyses of computerized hospital records, of patients surveys, and of data collected by practices during an 8-week study period in 1993. Principal outcome measures were: (i) measures of appointment system operation corrected for practice list size [number of unbooked ('available') appointments, appointment provision, proportion of patients seen as 'extras']; (ii) patient views on practice appointment systems (reported dissatisfaction with arrangements for being seen, proportion of patients reporting they normally wait in excess of 15 minutes when attending to be seen, the perceived availability of a doctor to deal with (a) urgent and (b) non urgent problems); (iii) practice self-referral rates to local A&E department. Practices varied widely in their rate of provision of appointments, in the proportion of appointments which were unbooked at the start of the working day and in the proportion of patients identified as 'extras' by reception staff. These measures of appointment system operation correlated with patient dissatisfaction with the arrangements of seeing a doctor in their practice and with the perceived availability of a doctor to deal with non urgent problems. The measures did not, however, correlate with A&E self-referral rates after they had been corrected for distance between practice and hospital, or with the perceived availability of a doctor to deal with urgent problems.(ABSTRACT TRUNCATED AT 250 WORDS)