A new framework developed by researchers at the Nuffield Department of Primary Care Health Sciences sheds light on how general practices across the UK have adapted to delivering remote and digital care in the years following the COVID-19 pandemic.
Published in the NIHR’s Health and Social Care Delivery Research journal, the latest findings from the Remote by Default 2 (RBD2) study are based on a detailed investigation into 12 general practices in England, Scotland and Wales. Between 2021 and 2023, the research team used ethnographic observation, interviews and workshops to understand how practices responded to the rapid shift to remote care – and what happened afterwards.
The new framework, or typology of digital maturity in general practice, was a key output of the study and identified five distinct ways practices are approaching remote and digital services. It offers practical insights into the different forms of support practices may need and challenges the assumption that more digitalisation always leads to better care.
From crisis to routine
During the early phases of the COVID-19 pandemic, infection control measures meant patients could no longer walk into their local surgery to book or attend appointments. Instead, all requests had to come via phone, website or app, with most consultations delivered remotely by telephone, video or text message.
This change was one of the fastest and most significant shifts in the history of the NHS. Though initially considered temporary, many practices continue to use remote and digital systems well beyond the emergency phase.
By the end of 2023, all 12 practices in the study had settled into some form of hybrid model – combining remote and in-person care. But the form this hybrid care took varied greatly depending on each practice’s size, resources, patient population and values.
Some, especially larger, well-resourced practices, embraced digital innovation as a strategic priority. Others chose to scale back digital services in response to concerns about patient access, staff well-being or service quality. A small number returned to a more traditional model of care with selective use of technology.
To give examples, one practice that the researchers spoke to during the study was a small Welsh practice that returned to mostly face-to-face care when able to do so, saying this better suited their local community which included elderly and digitally excluded patients.
At the other end of the spectrum, a large city practice that the researchers worked with had a younger, more affluent patient population and so offered the majority of its services remotely and even helped other practices trial new digital tools.
The new typology
This diversity led the research team to develop the digital maturity typology to describe how practices are using digital tools and to guide policy and commissioning decisions.
The typology identifies five broad approaches:
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Digital trailblazers – actively lead digital innovation and support others to do the same.
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Digitally strategic – use digital tools in a planned way that aligns with practice values and patient needs.
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Digitally reactive – adopt digital solutions in response to pressure or policy, often without a clear strategy.
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Digitally hesitant – cautious or slow to adopt digital tools, often due to limited resources or past negative experiences.
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Strategically traditional – choose to prioritise in-person care, especially to meet the needs of digitally excluded patients.
This framework challenges the idea that practices not embracing digital care are ‘lagging behind’. Instead, it shows that scaling back or adapting technology can be a deliberate and appropriate choice.
Digital tools: benefits, challenges and trade-offs
The researchers identified a number of reasons that practices were actively choosing to return to in-person care or were cautious to adopt digital tools. They found that while some digital tools improved efficiency or convenience for certain patients, others created extra work or failed to deliver the expected benefits. For example, video consultations were trialled widely but often abandoned in favour of simpler telephone calls. Some online consultation systems increased administrative workload and made it harder for staff to prioritise urgent cases.
Addressing inequality
One of the clearest themes was the risk of digital exclusion. Patients with limited access to devices, poor internet connectivity or low confidence in using digital tools often struggled to navigate new systems. Practices serving more deprived communities were especially concerned that remote-first services could widening existing health inequalities.
In response, some practices introduced workarounds – such as allowing patients to fill in paper forms or having staff complete digital forms on their behalf. Others reduced their reliance on digital systems altogether.
Staff under pressure
The study also explored how staff adapted to these changes towards digital. Many reported increased stress, new pressures and higher workloads. Where teams had strong relationships and supportive leadership, they were more likely to find ways to embed and adapt digital systems. Where staff turnover was high or team cohesion was weak, digital systems could exacerbate problems.
A call for tailored support
The researchers concluded that there is no ‘one size fits all’ approach to digital care in general practice. While remote and digital care can bring real benefits, it must be implemented in ways that reflect the populations, resources and priorities of individual practices and their patients.
The digital maturity typology provides a practical tool for commissioners and policy makers to better understanding what kind of supporting different practices need. For example:
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Practices with strong infrastructure and digital leadership may be well-placed to pilot new technologies and share learning locally.
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Smaller practices in more deprived areas may prioritise in-person care to ensure no patients are excluded.
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Some practices may need targeted support to move from reactive use of digital tools to a more strategic and sustainable model.
The study’s lead author, Professor Trish Greenhalgh, Professor of Primary Care Health Sciences at NDPCHS, said:
'Our research shows that general practices across the UK are working hard to strike the right balance between digital innovation and accessible, high-quality care. Some have chosen to lead with technology; others have deliberately scaled back to protect equity and continuity for the particular communities they serve. There is no one-size-fits-all model – and policy support must reflect that.'
The authors call for policymakers, commissioners, professional bodies and health system leaders to provide more tailored, flexible support that recognises variation in practices’ digital maturity and patient needs, rather than enforcing blanket policies or targets. They also emphasise the need to invest in staff training, protect staff wellbeing and give practices time and space to reflect on what is and isn’t working. With these measures practices will be better prepared and enabled to adapt to ongoing change while maintaining high-quality, equitable care for all patients.