Introduction

Rationale

In this synoptic paper, we address how remote and digital services in UK general practice have changed since 2021. We define remote services as those in which the patient and clinician (or support staff member) are physically distant from one another, and digital services as those in which the encounter is digitally mediated in some way. An encounter at the reception desk in which the receptionist asks the patient a set of questions to populate an online consultation request form on their behalf is digital but not remote. A telephone encounter is remote but not necessarily digital, though modern telephony systems often include a digital component (e.g. asking the patient to select from a list of options by pressing a number). Many encounters in contemporary general practice are both remote and digitally mediated.

The early COVID-19 pandemic was a period of ‘opportunity, disruption and exposure’ for digital innovation in health care.1,2 UK general practice shifted at pace and scale from an almost exclusively in-person service to ‘total triage’ (in which patients seeking an appointment had to enter data on an online platform or provide such information by telephone before receiving a call-back from a clinician)3 and remote consultations (mostly by telephone, some video and e-consultations).2,4–6 These radical changes were cautiously welcomed as contributing to the long-overdue modernisation of healthcare services.1,2,7,8

From mid-2020, incentivised by an explicit policy push,9 many general practices attempted to routinise remote and digital services, and some (though not all) patients and staff learnt to communicate remotely and navigate the new systems.4,10–12 Benefits included greater convenience for some patients.12,13 but anticipated gains in efficiency were not clearly demonstrated – confirming earlier findings from before the pandemic.14,15 Other potential downsides included inequities of patient access10,16–20 and greater complexity of work practices (including inefficient double-handling).21 Concerns were also raised about overprescribing,22–24 overinvestigation,22 compromises to preventive medicine25 and long-term condition monitoring,26 reduced continuity of care27,28 and concerns about clinical risks.29 As noted below, we later showed that safety incidents linked to remote and digital services were extremely rare.30 Largely in response to patient complaints and negative press articles,31,32 policy shifted in the direction of a ‘face-to-face by default’ service.33

The policy goal of retaining and extending remote and digital services was thus tempered by legitimate concerns from clinicians, patients and the public about quality, safety and equity of care. The context of these changes is also noteworthy. The period 2020–3 came at the end of a long period of austerity in UK public services34,35 and was notable for rising professional concern about the poor state of material and technical infrastructure;2,36–38 a ‘slow crisis’ of recruitment, retention and skill mix in the healthcare workforce, particularly in primary care;36,39–45 and rising consultation rates (which reflected an ageing population, more – and more complex – illness, and rising patient expectations).45–47 Various policy incentives had been introduced in England to expand and extend new clinical and clinically related roles (e.g. extended roles for physician associates, pharmacists and paramedics).39,48,49

Objectives

In September 2021, we commenced data collection for a longitudinal (mostly qualitative) study, Remote by Default 2 (RBD2). This study built on our earlier mixed-methods study of the clinical and operational challenges associated with the rapid shift to remote and digital options during the early COVID-19 pandemic (RBD1).6,37,50–54 The focus of RBD2 was on exploring whether and how remote and digital services were being routinised and sustained in a sample of general practices. Our four original research questions for RBD2 were:

1. How can we make remote and digital care better and safer (including designing for digital inclusivity)?
2. How can we balance remote and digital options with traditional in-person care for those who need it?
3. How can we optimise workload and meet the training and well-being needs of general practice staff?
4. What are the infrastructural challenges of remote and digital services and how might they be overcome?

These questions were modified as the study unfolded. The final research questions and sub-questions are summarised in Table 1.

The study protocol95 and baseline findings11 for RBD2 have been published, along with a separate protocol for the care navigation work96 and various thematic papers described in detail below. In this synoptic paper, we outline the RBD2 study methods, summarise publications and describe our work on dissemination and impact.

Methods

RBD2 was a multisite, 28-month ethnographic case study of 12 UK general practices across England, Scotland, and Wales, with additional data from workshops, stakeholder interviews and documents. The data sources, along with their contribution to the study and caveats, are summarised in Appendix 1, Table 2. Data collection ran from September 2021 to December 2023. A social care extension to the original RBD2 study addressed care navigation by patients with particular needs and vulnerabilities (e.g. refugees, complex needs, elderly); data collection for that study ran from September 2022 to May 2023. Three linked PhDs and some smaller (e.g. student-led) projects drew on the RBD2 data set and examined related themes.

Our external advisory group had a lay chair and representation from academia, industry, policy (including national policy leads from England and Scotland), lay people and people with lived experience. All research participants gave written or verbal informed consent in accordance with our ethics protocol; low-literacy individuals were supplied with easy-read versions of information sheets and consent forms, and materials were translated as needed. Details of patient and public involvement (PPI) are given in the separate section below.

Practices were purposively sampled to achieve maximum variety in practice size (from 2300 to 31,000 patients), geographical locality (8 from England, 2 from Wales and 2 from Scotland), socioeconomic deprivation (explained in Equality, diversity and inclusion) and digital maturity. This sampling reflected established best practice for case study sampling – in other words, it was not intended to achieve statistical representation in any parameter but to achieve, overall, as wide a range in key axes of variation as possible. For example, having identified a large, digitally advanced practice situated in an urban centre with relatively low socioeconomic deprivation but high ethnic diversity, we then looked for practices to balance these characteristics, such as small practices, rural practices, less digitally mature practices and those serving more deprived populations.

At the outset, we classified digital maturity on a pragmatic five-point scale,95 seeking variety but oversampling from less digitally mature practices. Practices were invited to self-classify on this scale, and their assessment generally aligned with researchers’ assessments (in two cases, we assessed a practice’s digital maturity as one point higher than they ranked themselves). Our original scale, which was modified in the light of our findings, comprised: traditional (few digital services: three practices); traditional with lone innovator (few digital services but one keen staff member attempting to introduce more: two practices); digitally curious (experimenting with remote and digital technologies and reacting to prevailing trends in these, but without a clear strategy: four practices); digitally strategic (introducing and evaluating a wide range of remote and digital services as part of a wider practice strategy: two practices); and system-oriented (providing state-of-the-art digital services and supporting other practices: one practice).

Practice characteristics are described in detail in previous papers11,95 and summarised in Appendix 1, Table 3. We supplemented our original planned sample of 11 practices95 with an additional practice recruited soon after our protocol paper was submitted, mainly to avoid research fatigue as several PhD students had joined the team.

To collect data on these practices, we used an adapted researcher-in-residence model,101 in which one member of the research team built a relationship with practice staff, made repeated ethnographic visits, conducted semistructured interviews (in-person or remotely) with staff (n = 124 across the 12 practices) and patients (n = 31 across all practices), and collected basic descriptive statistics such as demographics of patient population, consultation numbers and waiting times. We identified 209 online patient reviews of their experiences in the 8 practices from England (comparable data were not available from Scotland or Wales). The study protocol included codesign work with patients and staff in 3 of the 12 practices in an effort to develop more patient-centred pathways for digital access.

The selection of which staff to interview and shadow at each practice was made largely on pragmatic grounds (who was keen, who was available), but also guided by the principle of surfacing and exploring all aspects of the patient-facing work of each practice. In practice, many of our in-depth interviews were with a named contact at the practice [general practitioner (GP) or practice manager], who linked us with other staff, from whom we identified other interviewees by snowballing. Ethnographic observation captured whoever was working in the setting at the time; details of how we ensured that no staff member of patient was involved in the ethnography against their will are given in the protocol95 and baseline findings11 papers.

Data on each practice were synthesised iteratively to build an ongoing picture of how the introduction of remote and digital services was evolving. After the data collection period ended, we fed back a summary narrative to each practice and amended it in response to feedback.

In addition to our longitudinal case studies of practices, we drew on additional data sources (see Appendix 1, Table 2). We interviewed 39 stakeholders for wider context, comprising senior policy-makers and representatives from industry and advocacy groups. These ‘elite’ stakeholder interviews also served to make contact with people in strategic positions who would help disseminate findings from the study. We also held four online multisector workshops with clinical, policy, industry and lay stakeholders (including staff and patients from participating practices but also extending beyond this sampling frame). The workshops addressed key cross-cutting themes: access and triage (April 2022, n = 48), quality and safety (September 2022, n = 35), workforce and training (January 2023, n = 63), and technologies and infrastructure (April 2023, n = 38). Each workshop generated a large amount of rich data including video archives of plenaries and breakout group discussions and led to follow-on work with practices and national policy-makers on the priority topic.

To pursue priority themes identified in the ethnography, stakeholder interviews and workshops, we collected various supplementary data sets. To further pursue an early theme around the challenges of training and supervising early-career GPs in a predominantly remote environment, we conducted additional interviews with 10 GP trainers and 10 trainees (shown in Appendix 1, Table 2 as supplementary data set 1). To further pursue the theme of patient safety (having identified no actual or near-miss safety incidents in our 12 participating practices), we sought access to national-level sources of anonymised safety incidents and obtained a total of 95 such incidents from training materials, complaints and closed indemnity claims in England and Wales (supplementary data set 2). To further pursue the theme of equity, we linked with an online network of GPs in Deep End practices (i.e. those with the highest levels of socioeconomic deprivation), visited some of their practices (where we observed front-desk activity and sat in on consultations), and interviewed GPs and patients (supplementary data set 3). Using separate funding from the National Institute for Health and Care Research (NIHR) School of Primary Care Research (SPCR), we appointed a PhD student (a multilingual researcher) to study elderly first-generation immigrants who lived in a deprived setting, spoke limited English and had various difficulties engaging with digital services (supplementary data set 4). Finally, attached medical students analysed press coverage of remote and digital services (supplementary data set 5).

In addition, we are currently conducting an SPCR-funded ethnographic study focused on decision-making about mode of consultation (ModCons) involving three of the 12 RBD2 practices; this will be reported separately.

Data from the RBD2 study – ethnographic field notes, interviews, extracts from documents and our own interim summaries of practices’ efforts at digitalisation – were uploaded to NVivo (QSR International, Warrington, UK) along with the supplementary data sets. The research team met regularly (approximately weekly) to discuss new findings and also our emerging picture of the whole. We used Braun and Clarke’s thematic analysis102 to gain familiarity with the study’s very large data set and identify priority cross-cutting topic areas which we then examined in detail by forming a focused working group for each: access (especially equity of access for particular need groups), quality (including safety, continuity and long-term condition monitoring), workforce and training, and technologies and infrastructure.

Theoretical analysis: case studies and thematic substudies

We used case study methodology to produce longitudinal case narratives of how remote and digital services unfolded on a practice by practice basis.103,104 Taking each of our 12 participating practices in turn, and beginning with a detailed familiarisation document,11 we considered how and why the provision of remote and digital care evolved from mid-2021 (approximately 15 months after the introduction of remote by default care as an emergency pandemic response3) to end 2023, using theories of organisational innovation and change.

We also undertook various thematic substudies. The different theoretical approaches for these substudies, along with the research questions which guided them, are summarised in Table 1. An additional small student project addressed press coverage of safety issues in 2021–2.105

Overview of key findings

Safety

As reported in Payne et al.,30 we combined a ‘Safety I’ analysis (exploring causes of real safety incidents retrospectively) with ‘Safety II’ analysis in the RBD2 practices (seeking individual, organisational and system-level explanations for how safety and near-miss incidents were avoided most of the time). The Safety I study (of safety incidents that were collected nationally, not from our 12 participating practices) showed that many of the following features were present in such incidents: patient allocated to a modality or digital pathway that was inappropriate to their needs, poor rapport building, gathering insufficient information, clinical assessment that was too superficial or had key gaps, and failure to take sufficient account of social circumstances. As a result, some diagnoses were overlooked or delayed and others were flawed. In some cases, the severity or urgency of the problem was underestimated; referral and treatment were misdirected or delayed; and safety netting and follow-up were inadequate. Patients with certain conditions seemed particularly vulnerable to safety incidents. These included complex pre-existing morbidity, chest or abdominal emergencies, ill-defined or generalised symptoms, safeguarding challenges, previous treatment that was ineffective, or communication difficulties (see our original publication for a more extensive list30). The study design did not allow us to fully capture whether safety issues were missed (e.g. failing to detect safeguarding concerns in a telephone consultation). The Safety II analysis showed that our 12 particpating general practices faced severe resource constraints, understaffing and high demand and that triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions. We concluded that while safety incidents are extremely rare in remote general practice, deaths and serious harms have resulted and the lack of resilience in the system is a major concern. We offered suggestions for patient, staff and system-level mitigations.

Equity

The RBD2 study revealed various inequities of access linked to well-established markers of disadvantage, especially poverty, low health or digital literacy, extremes of age, multimorbidity, poor housing (and especially homelessness), and conditions affecting cognition or communication. Individuals who had multiple markers of disadvantage were sometimes at very high risk of digital exclusion. In some cases, such individuals were unable to use (or engage with) any form of remote or digital health care. In others, they were able to use some low-tech options (e.g. a telephone call with a human) but not websites, apps or digital telephony systems (which required them to follow algorithmic ‘if you wish X, do Y’ instructions).

Digital inequity should be considered in relation to wider social inequities. Disadvantage is pervasive and exerts its effects through multiple mechanisms; simple unidimensional ‘fixes’ are unlikely to overcome these. Our papers on inequity were underpinned by various social science theories, which we explain briefly here before outlining the main findings of each paper.

As reported in Dakin et al.,63 we combined Dixon-Woods et al.’s theory of candidacy (in particular, concepts of self-assessment, help-seeking, adjudication and negotiation)62 with sociotechnical and technology structuration theories (in particular, concepts of user configuration, articulation, distanciation, disembedding, and recursivity) to produce and apply a novel theory of digital candidacy. To access contemporary health care, patients must find and navigate a complex sociotechnical network of human and digital actors linked in multimodal pathways. Synchronous, in-person conversations between humans have largely been replaced by asynchronous, digitally mediated interactions and triage decisions. Social structures are embodied by human actors and also (in different ways) by technological actors; they affect how people and technologies behave in different situations. Human and technological actors (in different ways) embody social structures which affect how they ‘act’ in social situations. Built into technologies are assumptions (often flawed) about what users want and need, and about their capabilities and rights. Various kinds of disadvantage influenced patients’ ability to (1) identify whether and how badly they were sick; (2) advocate for themselves; (3) overcome the limitations of technologies; and (4) navigate the various stages in the access pathway. Some were highly skilled at these tasks while others (typically those with multiple markers of disadvantage) struggled. We documented the prevailing expectation that patients must create and populate a ‘digital facsimile’ (by which we mean a detailed, accurate and persuasive version of themselves on their electronic record). Staff make their triage decision (and also many clinical decisions) on the basis of this digital facsimile. Not everyone is able to create an adequate digital facsimile. One that lacks sufficient detail, has gaps or mistakes, or is unpersuasive may lead the patient being deprioritised or allocated inappropriately. If staff are aware of these patients, they may use ‘tinkering’ to produce an appropriate, personalised access package, but it is not possible for staff always to identify and fully mitigate these cases. How people and technologies act, and the decisions they make, when someone tries to access care can have a profound influence on that person’s candidacy both in the immediate (current) situation and, over time (recursively), influence future attempts. We concluded that services need to be (co-)designed with attention to the exclusionary tendencies of digital technologies and technology-supported processes and pathways.

As reported by Rybczynska-Bunt et al.,66 we studied how different kinds of structural and personal disadvantage (e.g. severe economic hardship, homelessness, unemployment or job precarity, adverse past experiences, drug/alcohol use) combine and reinforce one another. We used Margaret Archer’s concept of ‘reflexivity’, meaning creative self-mastery that enables individuals to evaluate their social situation and act purposively within it. In short, people with complex health and social needs may be less able to reflect on their predicament and act to address it. Reflexivity is imperative in complex and changing social situations. We drew in particular on data from more disadvantaged settings in our data set. We supplemented this with in-depth clinical cases from additional ‘Deep End’ practices serving highly deprived populations (supplementary data set 3 – see Appendix 1, Table 2). We used a technique of ‘composite case studies’, crafting fictional stories by combining and fictionalising themes from multiple real patient participants, to illustrate different aspects of disadvantage. We showed how various axes of disadvantage intersect – for example, how current structural conditions (e.g. poverty, poor housing) combine with adverse past experiences and also with patients’ capacity to reflect on their predicament, advocate for themselves and act strategically. Sometimes, practice support staff manged to compensate when a patient showed fractured reflexivity, but their ability to do this was limited by their own awareness and the availability of staff. This paper concluded that remote and digital health care will continue to disadvantage people with complex needs in multiple ways unless a more systematic safety net can be introduced and resourced.

As reported by Husain et al.,71 we used the technique of developing fictional ‘personas’ to help practices consider the needs of patients with multiple intersection axes of disadvantage (especially poverty, advanced age and race). Drawing on supplementary data set 4 (participants recruited from a telehealth project in a deprived setting), we found that digital services created significant challenges for older patients with limited economic, social and linguistic resources and low digital, health, or system literacy. We produced four contrasting personas which captured the variety and complexity of how dimensions of disadvantage intersected and influenced identity and actions. The personas illustrate important themes including experience of racism and discrimination, disorientation, discontinuity, limited presence, weak relationships, loss of agency and mistrust of services and providers. Further publications from this sub-study are in preparation.

Continuity

As reported by Ladds et al.,72,73 we addressed continuity (a long-established and fiercely defended value in primary care) in the digital age. Traditional continuity, based on a one-to-one doctor–patient relationship, has declined in recent years. Our data showed that contemporary general practice is organisationally and technically complex, with multiple staff roles and technologies supporting patient access (e.g. electronic and telephone triage) and clinical encounters (e.g. telephone, video and electronic consultations); hence a re-evaluation of continuity’s relational, organisational, sociotechnical and professional characteristics was needed. Continuity was almost universally valued by both staff and patients but was differently defined across practices. It was invariably situated (i.e. strongly influenced by local practicalities and constraints) and effortful (i.e. it happened only insofar as people put in work to make it happen). Continuity had a number of key influences: the geographical locality and particular organisation setting; the nature of the technical infrastructure within the practice and more widely; and staff and patients’ personal values and preferred ways of working. Achieving continuity in digitalised settings often required staff to make small, ongoing adaptations (what is known in the sociology of technology as ‘articulation’ or ‘tinkering’). Through remote and digital modalities, continuity could be extended across space and time, thereby achieving (to some extent at least) continuity of the digital record and a shared understanding among the multidisciplinary team of a patient and their illness episode. For the most vulnerable patients, achieving continuity was sometimes labour-intensive and needed bespoke, individualised adaptations. Extending Haggerty et al.’s earlier work,74 we proposed a novel four-part ontology: first, continuity of the therapeutic relationship (which drew on psychodynamic and narrative theories); second, continuity of the illness episode (which drew chiefly on biomedical theories); third, continuity of distributed work (which drew on sociotechnical theories); and finally, continuity of the practice’s commitment to a community (which drew on theories of political economy and the ethics of care). This ontology allowed us to examine both successes (where continuity was achieved) and failures (where continuity was breached and care was fragmentated) from a theoretical perspective.

Other aspects of quality

As reported in Payne et al.77 and using generic59 and general practice-specific72,73,76 quality frameworks to analyse our data, we found that practices’ efforts to deliver on the different domains of quality occurred in a highly challenging context. Faced with the cumulative impacts of financial austerity, loss of resilience, increasingly complex patterns of illness and need, a diverse and fragmented workforce, material and digital infrastructure that was sometimes unfit for purpose, and distanciated (physically distant and asynchronous) ways of working, practices found that providing the human elements of traditional general practice (e.g. continuity of the therapeutic relationship, compassion, support) was difficult and sometimes impossible. Triage systems designed to increase efficiency had sometimes introduced new forms of inefficiency and compromised other quality domains including accessibility, patient-centredness and equity. Long-term condition monitoring and management varied in quality; while there were some convenience gains, there was also some evidence of quality compromises in some practices (e.g. they at times relied on remote, asynchronous data entry by patients and fragmented care by underqualified staff). Measures to mitigate digital exclusion (e.g. digital navigators) were evident in many practices but did not compensate for extremes of structural disadvantage. Many staff were stressed and demoralised. We concluded that some of the changes which characterise contemporary hybrid general practice (digitalisation, distanciation, role differentiation, protocolisation) have had the unintended effect of dehumanising, compromising and fragmenting care. We raised concerns about risks to patients and the traditional core values of general practice.

Training

As reported in Greenhalgh et al.,82 we found much remote and digital care is fragmented and requires input from multiple team members in a co-ordinated way; knowing what others can do (and are doing) is key. Learning to provide remote services occurred in the context of high workload, understaffing and complex workflows. Low confidence and perceived unmet training needs were common. People’s training priorities depended on their role. Novice clinicians prioritised basic technological skills and triage principles, ethics (e.g. privacy, consent), and communication and clinical skills. Established clinicians’ training priorities include advanced communication skills (e.g. maintaining rapport and attentiveness), working within the limits of technologies, making complex judgements, co-ordinating multi-professional care in a distributed environment, and training others. Much existing training was didactic and technology-focused (typically delivered by an online self-study module). While basic knowledge was often gained using such methods, the ability and confidence to make complex judgements needed experience, informal discussions and on-the-job methods such as shadowing. Staff valued whole-team training, but this was rarely available. Based on these findings, we offered an outline set of competencies for both clinicians and non-clinicians (reproduced in Appendix 1, Table 4). We concluded that the knowledge needed to deliver high-quality remote encounters to diverse patient groups is complex, collective and organisationally embedded, and that greater recognition was needed of the vital role of non-didactic training, for example joint clinical sessions, case-based discussions and in-person, whole-team, on-the-job training needs to be recognised.

Workforce

As reported in Dakin et al.,63 this substudy of staff experiences showed that most staff in participating practices perceived benefits from technology-supported tasks and processes, including convenience, efficiency, and more comprehensive patient care and that when remote ways of working aligned with the staff member’s personhood and values, fulfilment could result. However, many clinical and administrative staff experienced job dissatisfaction, worsened well-being and a sense of misalignment with professional identity and values. Drawing on work by Gill,85 we proposed this as a form of workplace suffering. Sometimes, staff experienced both benefits and drawbacks of remote and digital working simultaneously. This study also showed how the new routines and working styles associated with digitalisation, and the suffering ensuing from them, could cause relational strain among general practice teams. This, in turn, had downstream implications for team cohesiveness and practices’ ability to effectively co-ordinate and integrate their inter-related tasks and navigate ongoing challenges. We concluded that digitalisation in general practice generates new forms of workplace stress and may adversely affect team relationships. We proposed relational support interventions to reduce the impacts of technostress.

Technologies and infrastructure

Further publications on technologies and infrastructure are in preparation. In sum, we found that the policy focus tended to emphasise technological novelty and procurement of innovative products; less emphasis was placed on the human and organisational aspects of this adoption and assimilation process. A vast and confusing range of technologies (with varying functionality) was available, and more were in development. Procurement was often driven by standard protocols and occurred at locality or higher level, limiting practices’ ability to customise their purchases. Some practices were much better than others at identifying which technologies were available, negotiating which were purchased, successfully introducing these to their own practices, and improving their set-up in an ongoing way. In general, the infrastructure for digital general practice was weak and patchwork, with variable quality broadband and various legacy systems limiting the system’s overall capacity.

Variation in practice experiences and outcomes

As reported in Greenhalgh et al.,58 remote and digital services unfolded very differently across our 12 practices from mid-2021 to end 2023. Their hybrid (mixed digital and traditional) solutions ranged from a near-total return to in-person services (with very selective use of digital tools) to a single, digital-by-default access route, extensive use of digital processes and pathways, and more than half of all consultations delivered remotely. Practices’ efforts to find the appropriate balance between these extremes were shaped and constrained by numerous factors, including:

• policy drivers in a challenging context, including system complexity, austerity, rising clinical complexity, limitations in material and technical infrastructure and difficulties in staff recruitment, retention and skill mix
• organisational antecedents such as practice size, available resources, absorptive capacity (i.e. the practice’s existing technological set-up, in-practice capability and know-how, and extent of external horizon-scanning), historical path dependencies, leadership and practice relations
• organisational readiness for remote and digital modalities, which was strongly influenced by tension for change, practice values and population demographics
• technologies’ material properties and functionality, including fitness for purpose, usability, configurability, interoperability
• the work of embedding and sustaining technologies, including the ongoing, labour-intensive process of adapting and refining tasks, processes and team interactions, assessing the impact of these changes and adjusting the technological set-up as needed, and selectively abandoning technologies that prove unfit for purpose
• staff factors (e.g. confidence, risk aversion); interpersonal influence (e.g. via champions and ‘super-users’); and team relations (interpersonal trust, psychological safety); and
• patient factors (especially demographics, disease patterns and the needs and capabilities of vulnerable groups).

When technologies fitted poorly with tasks and routines, when staff were reluctant or when the work of embedding was inadequate or unsuccessful, inefficiencies in work processes and ‘technostress’ among staff resulted. In such situations, the patient experience was sometimes unsatisfactory and at times potentially unsafe.

We concluded that while there is wide variation in digital maturity among UK general practice, low use of remote and digital technologies and processes may be warranted. It may, for example, reflect local strategic choices, especially in relation to equity and patient preference. But low use may also indicate a reactive rather than strategic approach to digital innovation, leadership challenges, low absorptive capacity, deficiencies in resources and limited awareness of technological solutions. We offered an updated typology of digital maturity in general practice with suggestions for tailored support. This new typology, along with suggestions for supporting each type, is summarised in Appendix 1, Table 3. Our new digital maturity scale divides practices into five broad categories: digital trailblazer, digitally strategic, digitally reactive, digitally hesitant and strategically traditional.