CRediT contribution statement
Trisha Greenhalgh (https://orcid.org/0000-0003-2369-8088): Conceptualisation, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Supervision, Writing – original draft, Writing – reviewing and editing.
Anica Alvarez Nishio (https://orcid.org/0000-0001-9841-5682): Writing – reviewing and editing.
Aileen Clarke (https://orcid.org/0000-0001-8299-3146): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Richard Byng (https://orcid.org/0000-0001-7411-9467): Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Supervision, Writing – reviewing and editing.
Francesca Dakin (https://orcid.org/0000-0002-4105-4617): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Stuart Faulkner (https://orcid.org/0000-0002-6345-5323): Project administration, Writing – reviewing and editing.
Isabel Hanson (https://orcid.org/0009-0006-8356-2907): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Nina Hemmings (https://orcid.org/0009-0002-1911-3630): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Gemma Hughes (https://orcid.org/0000-0003-2930-1125): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Laiba Husain (https://orcid.org/0000-0001-9889-0889): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Asli Kalin (https://orcid.org/0000-0002-4338-3561): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Emma Ladds (https://orcid.org/0000-0001-9864-7408): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Ellen MacIver (https://orcid.org/0000-0003-2483-9858): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Lucy Moore (https://orcid.org/0000-0001-5089-993X): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Sarah O’Rourke (https://orcid.org/0000-0002-7272-0141): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Rebecca Payne (https://orcid.org/0000-0002-8954-7584): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Tabitha Pring (https://orcid.org/0000-0003-4572-3918): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Rebecca Rosen (https://orcid.org/0000-0001-6580-8324): Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Supervision, Writing – reviewing and editing.
Sarah Rybczynska-Bunt (https://orcid.org/0000-0002-4284-1081): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Sara E Shaw (https://orcid.org/0000-0002-7014-4793): Conceptualisation, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Supervision, Writing – reviewing and editing.
Nadia Swann (https://orcid.org/0009-0008-0471-6360): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Sietse Wieringa (https://orcid.org/0000-0002-7758-8493): Data curation, Formal analysis, Investigation, Writing – reviewing and editing.
Joseph Wherton (https://orcid.org/0000-0001-7701-4783): Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – reviewing and editing.
Patient data statement
No direct patient data are reported in this paper.
Data-sharing statement
Raw data from this qualitative study are not publicly available because of participant and practice confidentiality agreements. However, bona fide researchers with appropriate ethics approvals may apply to the lead author to discuss sharing of selected extracts.
Ethics statement
Full details of ethics and governance are given in the protocol95 and baseline findings11 papers. Briefly, the study was sponsored by the University of Oxford and had approval from East Midlands—Leicester South NHS Research Ethics Committee and UK Health Research Authority (September 2021, 21/EM/0170) and subsequent amendments.
Information governance statement
This study followed standard university guidelines on ‘Privacy by Design’. The project, methods data collection and storage strategy were reviewed by the Information Governance team (https://compliance.web.ox.ac.uk/individual-rights). The members of our research team analysed the data and have written some papers and reports, including a summary written for the general public (i.e. a lay summary). Our findings will continue to be published and available through journal publications. Participants will not be identified from any report or publication placed in the public domain. We may use de-identified quotes from interviews, observations or our notes in a conference presentation or teaching session. We will keep identifiable information about you including names, home address and telephone number – for 12 months after the study has finished. All interview recordings will be destroyed at the end of the study.
Research documents with personal information, such as consent forms, and copies of the interview text will be held securely at the University of Oxford for 15 years after the end of the study.
The University of Oxford is committed to handling all personal information in line with the UK Data Protection Act (2018) and the General Data Protection Regulation (EU GDPR) 2016/679.
Under the Data Protection legislation, University of Oxford is the Data Controller, and you can find out more about how we handle personal data, including how to exercise your individual rights and the contact details for our Data Protection Officer here: www.ox.ac.uk/privacy-policy.
Disclosure of interests
Full disclosure of interests: Completed ICMJE forms for all authors, including all related interests, are available in the toolkit on the NIHR Journals Library report publication page at https://doi.org/10.3310/QQTT4411.
Primary conflicts of interest: Trisha Greenhalgh is a member of Independent SAGE. Anica Alvarez Nishio is a lay Vice Chair of NICE Quality Standards Committee. She received consulting fees from the University of Oxford from 2023 and the University of Kent from 2024, and honoraria for lectures from the University of Kent (2019–25) and University of Liverpool from 2022 to 2025. She has received travel reimbursement from the Veterans Advice and Pensions Committee at the Ministry of Defence (2020–5). She sat on Thames Valley Policing Data Ethics Panel (2020–5). She was Vice Chair of NICE Quality and Safety Advisory Committee (2020–5), sat on NIHR Programme Grants for Applied Research panel (2019–25), and was President of Yale Club of London (2024–5). Richard Byng is a member of the Health Technology Assessment Prioritization Committee A (2022–5). Nina Hemmings is a Trustee at HSR UK. Rebecca Payne has received funding from NHS 111 Wales and an Honorarium from Management in Practice for a lecture; she is Chair of the NICE Quality Standards Committee (2022–5) and was a member of a technology appraisal panel (2021–4). She was previously a national professional adviser to the Care Quality Commission (2017–22). Sara E Shaw has received consultancy income from Ipsos Mori UK and honoraria from CRUK. She holds research grants from NIHR School for Primary Care Research (FR4 Project 594), NIHR Programme Grant for Applied Research RP-PG-0218-20001 and linked NIHR Programme Development Grant NIHR207604. NIHR Public Health Research Programme NIHR169828, and UKRI Medical Research Council/ESRC. Trisha Greenhalgh, Sara E Shaw and Richard Byng have received NIHR funding for previous research. Sietse Wieringa is on the advisory committee of UpToDate and on the Dutch Royal College of GPs Council. All other authors declare no conflicts of interest.
Department of Health and Social Care disclaimer
This publication presents independent research commissioned by the National Institute for Health and Care Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, MRC, NIHR Coordinating Centre, the Health and Social Care Delivery Research programme or the Department of Health and Social Care.
This synopsis was published based on current knowledge at the time and date of publication. NIHR is committed to being inclusive and will continually monitor best practice and guidance in relation to terminology and language to ensure that we remain relevant to our stakeholders.
Publications
Academic publications – empirical research
Greenhalgh T, Shaw SE, Alvarez Nishio A, Byng R, Clarke A, Dakin F, et al. Remote care in UK general practice: baseline data on 11 case studies. NIHR Open Res 2022;2:47.
Greenhalgh T, Clarke A, Byng R, Dakin F, Faulkner S, Hemmings N, et al. After the disruptive innovation: How remote and digital services were embedded, blended and abandoned in UK general practice – longitudinal study [published online ahead of print June 11 2025]. Health Soc Care Deliv Res 2025. https://doi.org/10.3310/KRWS4334
Hughes G, Rybczynska-Bunt S, Shasha’h S, Greene S, Shaw S, Greenhalgh T, et al. Protocol: how can people with social care needs be supported through processes of digital care navigation to access remote primary care? A multi-site case study in UK general practice of remote care as the ‘new normal’. NIHR Open Res. 2023;3:17.
Ladds E, Greenhalgh T. Modernising continuity: a new conceptual framework. Br J Gen Pract 2023;73:246–8.
Ladds E, Greenhalgh T, Byng R, Rybczynska-Bunt S, Kalin A, Shaw S. A contemporary ontology of continuity in general practice: capturing its multiple essences in a digital age. Soc Sci Med 2023 (1982);332:116112.
Payne R, Clarke A, Swann A, van Dael J, Brenman N, Rosen R, et al. Patient safety in remote primary care encounters: multi-method qualitative study combining Safety I and Safety II analysis. BMJ Qual Saf 2023;33:573–86. https://doi.org/10.1136/bmjqs-2023-016674.
Dakin FH, Rybczynska-Bunt S, Rosen R, Clarke A, Greenhalgh T. Access and triage in contemporary general practice: a novel theory of digital candidacy. Soc Sci Med 2024;349:116885.
Greenhalgh T, Payne R, Hemmings N, Leach H, Hanson I, Khan A, et al. Training needs for staff providing remote services in general practice: a mixed-methods study. Br J Gen Pract 2024;74:e17–26.
Husain L, Finlay T, Husain A, Wherton J, Hughes G, Greenhalgh T. Developing user personas to capture intersecting dimensions of disadvantage in marginalised older patients: a qualitative study. Br J Gen Pract 2024;74:e250–7.
Paparini S, Spitters S, Swinglehurst D, Brenman N, Wherton J, Gill M, et al. 45 How digital innovation in primary care disrupts the clinical consultation. BMJ Open 2024;14. https://doi.org/10.1136/bmjopen-2024-UCL-QHRN2024.45
Payne R, Dakin F, MacIver E, Swann N, Pring T, Clarke A. Challenges to quality in contemporary, hybrid general practice: a multi-site longitudinal case study. Br J Gen Pract 2024:75:e1–11. https://doi.org/10.3399/BJGP.2024.0184.
Rybczynska-Bunt S, Byng R, Spitters S, Shaw SE, Jameson B, Greenhalgh T. The reflexive imperative in the digital age: using Archer’s ‘fractured reflexivity’ to theorise widening inequities in UK general practice. Sociol Health Illn 2024;46:1772–91.
Song K, Hey M, Payne RE. Media depictions of primary care tele-consultation safety: analysis of UK newspapers. Br J Gen Pract 2024;74:e695–701.
Dakin F, Hemmings N, Kalin A, Moore L, Ladds E, Payne R, et al. Technostress, techno-suffering, and relational strain: a multi-method qualitative study of how remote and digital work affects staff in UK general practice. Br J Gen Pract 2025;75:e211–21. https://doi.org/10.3399/BJGP.2024.0322
Husain L, Greenhalgh T. Examining intersectionality and barriers to the uptake of video consultations among older adults from disadvantaged backgrounds with limited English proficiency: qualitative narrative interview study. J Med Internet Res 2025;27:e65690.
Academic publications – literature reviews, editorials and commentaries
Alami H, Lehoux P, Shaw SE, Papoutsi C, Rybczynska-Bunt S, Fortin JP. Virtual care and the inverse care law: implications for policy, practice, research, public and patients. Int J Environ Res Public Health 2022;19:10591.
Husain L, Greenhalgh T, Hughes G, Finlay T, Wherton J. Desperately seeking intersectionality in digital health disparity research: narrative review to inform a richer theorization of multiple disadvantage. J Med Internet Res 2022;24:e42358. https://doi.org/10.2196/42358
Alami H, Lehoux P, Miller FA, Shaw SE, Fortin JP. An urgent call for the environmental sustainability of health systems: a ‘sextuple aim’ to care for patients, costs, providers, population equity and the planet. Int J Health Plann Manage 2023;38:289–95.
Alami H, Shaw SE, Fortin JP, Savoldelli M, Fleet R, Têtu B. The ‘wrong pocket’ problem as a barrier to the integration of telehealth in health organisations and systems. Digit Health 2023;9:20552076231169835.
Dakin F, Rai T, Paparini S, Greenhalgh T. Supporting your support staff during crises: recommendations for practice leaders to develop a relational workplace. BMJ Lead 2023;7:1–7. https://doi.org/10.1136/leader-2023-000780
Pickard Strange M, Booth A, Akiki M, Wieringa S, Shaw SE. The role of virtual consulting in developing environmentally sustainable health care: systematic literature review. J Med Internet Res 2023;25:e44823.
Alami H, Lehoux P, Shaw SE, Niang M, Malas K, Fortin JP. To what extent can digital health technologies comply with the principles of responsible innovation? Practice- and policy-oriented research insights regarding an organisational and systemic issue. Int J Health Policy Manag 2024;13:8061. https://doi.org/10.34172/ijhpm.8061
Bak Kirk U, Payne R, Tweedie JA, Huibers L. ‘A tool for every job’: use of video in urgent primary care. Br J Gen Pract 2024;74:443–4.
Greenhalgh T, Payne R, McCabe F. Making remote healthcare safer. Int J Qual Health Care 2024;36:mzae023.
King K, Payne R. Teaching patient safety in remote consultations. Educ Prim Care 2024:36:2–5.
Leach H, Payne R, Hanson I, King K. Video consulting for GP trainees. InnovAiT. 2024;17:113–7. https://doi.org/10.1177/17557380231221099
Papoutsi C, Greenhalgh T. Innovation, Improvement, and Implementation – Conceptual Frameworks for Thinking Through Complex Change. In Kip H, Beerlage-de Jong N, van Gemert-Pijnen JEWC, Sanderman R, Kelders SM, editors. eHealth Research Theory and Development: A Multidisciplinary Approach. 2nd edn. Amsterdam: Routledge; 2024.
Papoutsi C, Greenhalgh T, Marjanovic S. Approaches to Spread, Scale-Up, and Sustainability. In Series: Elements of Improving Quality and Safety in Healthcare. Cambridge: Cambridge University Press; 2024. https://doi.org/10.1017/9781009326049
Payne R, Dakin F. The place of remote consultation in modern general practice. Br J Gen Prac 2024;74:7–8. https://doi.org/10.3399/bjgp24X735873
Payne R, Lodge A, Mackridge A, O’Keeffe D, Swann N, Clarke A, et al. After the teleconsultation. Br J Gen Prac 2024;74:422–5.
Payne R, MacIver E, Clarke A. Do new models of Primary Care risk exacerbating existing inequity? Br J Gen Pract 2024;74:436–7.
Greenhalgh T, Payne R. Digital maturity: towards a strategic approach. Br J Gen Prac 2025;75:200–2.
Payne R, Walker D, Raman K. Remote consulting. Innovait 5 May 2025. https://doi.org/10.1177/17557380251334349.
Saul H, Cassidy S, Swaithes L, Greenhalgh T, Payne R. How to make remote consultations safer. BMJ 2025;388:q2526.
Academic publications – book chapters
Bak Kirk U, King K, Payne R. Video Consultations. In De Murtas J, editor. Remote Consultation in Primary Care: A Step-by-step Approach to Remote Consultation and Triage. Amsterdam: Springer; 2025, in press.
Bak Kirk U, Rochfort A, Ferreira A, Payne R, Matillya N. Safety and Unintended Consequences. Chapter 5 in Neves A and Loranjo L, editors. Digital Health for Primary Care. London: Taylor & Francis; 2025, in press.
Greenhalgh T, Veinot T, Husain L. Understanding Emerging Digital Health Disparities. Chapter 22 in Marent B, editor. De Gruyter Handbook of Digital Health and Society. Amsterdam: Springer; 2025, in press.
Payne R, Bak Kirk U. Consultation Models. In De Murtas J, editor. Remote Consultation in Primary Care. Amsterdam: Springer; 2025, in press.
Payne R, Dykes L. Remote Assessment in Elderly and Frail Patients. In Brady M, Thompson S, editors. Remote Clinical Assessment. Class Publications; in press.
Policy briefing from Nuffield Trust
Getting the Best Out of the New World of Remote and Digital General Practice. Nuffield Trust, April 2024 (prepared for Parliamentary Briefing). www.nuffieldtrust.org.uk/sites/default/files/2024-04/RBD%202024%20event%20briefing_WEB%20%281%29.pdf
Blogs and web resources
Main RBD2 Study Website which includes research team, external advisory group and will house all of the publicly available resources to date.
www.phc.ox.ac.uk/research/groups-and-centres/interdisciplinary-research-in-health-sciences/remote-by-default-2/
Blogs and press releases (Nuffield Trust)
www.nuffieldtrust.org.uk/news-item/overhaul-of-training-needed-to-support-general-practice-staff-to-provide-remote-health-care
www.nuffieldtrust.org.uk/news-item/clinicians-practices-and-patients-all-have-a-part-to-play-in-dealing-with-risks-of-remote-consulting-new-study-reveals
www.nuffieldtrust.org.uk/research/getting-the-best-out-of-remote-consulting-in-general-practice-practical-challenges-and-policy-opportunities
Conference presentations and keynote lectures based on RBD2 findings
Greenhalgh T. How New Technologies Could Be Used to Reduce Inequalities (But Usually Aren’t). Keynote lecture, Nordic Congress of General Practice, Stavanger, Norway, June 2022.
Dakin F. Navigating Change and Crisis in UK General Practice: The Value of Relational Coordination in Teams. World Association of Family Doctors Annual Conference, Sydney, Australia, November 2023.
Hanson I. Training Needs of GP Trainees in Remote and Digital General Practice. World Association of Family Doctors Annual Conference, Sydney, Australia, November 2023.
Dakin F. Access and Triage in Contemporary General Practice: Inequities in Digital Candidacy and the Digital Facsimile. Digital Health Horizons Conference, Oxford, May 2024.
Dakin F, Greenhalgh T, Meier N. Relational Coordination and Relational Systems: How Teams Navigate Transformation and Crisis in UK General Practice, a Multi-method Qualitative Case Study Analysis. Organisational Behaviour in Healthcare conference, Oslo, April 2024.
Greenhalgh T. The Changing Nature of Healthcare Work. Opening Keynote lecture at Organisational Behaviour in Healthcare conference, Oslo, April 2024.
MacIver E, Clarke A, Greenhalgh T, Payne R. What Are the Challenges to Quality in Contemporary, Hybrid General Practice? A Multi-site Longitudinal Study. Society of Academic Primary Care 52nd Annual Scientific Meeting, Bristol, July 2024.
Paparini S, Spitters S, Swinglehurst D, Brenman N, Wherton J, Gill M, et al. How Digital Innovation in Primary Care Disrupts the Clinical Consultation. Qualitative Health Research Network Conference June 2024. Abstract in BMJ Open 2024;14. https://doi.org/10.1136/bmjopen-2024-UCL-QHRN2024.45
Payne R. Risks to Patient Safety in Remote Consulting. British Journal of General Practice Conference, April 2024.
Payne R, Greenhalgh T. Patient Safety in Remote Primary Care Encounters: Combined Safety I and Safety II Analysis. Society for Academic Primary Care South West Conference, Cardiff, March 2024.
Shaw S, Dakin F, Greenhalgh T, Van Dael J, Payne R, Ladds E, et al. Navigating the Future: Innovations in Primary Care Organisations. Symposium at Organisational Behaviour in Healthcare conference, Oslo, April 2024.
Funding
This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132807.
This synopsis provides an overview of the research award Remote by Default 2: the ‘new normal’? For other articles from this thread and for more information about this research, please view the award page www.fundingawards.nihr.ac.uk/award/NIHR132807.
About this synopsis
The contractual start date for this research was in September 2021. This article began editorial review in July 2024 and was accepted for publication in March 2025. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The Health and Social Care Delivery Research editors and publisher have tried to ensure the accuracy of the authors’ article and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this article.
Copyright
Copyright © 2025 Greenhalgh et al. This work was produced by Greenhalgh et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaptation in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/. For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited.