Abstract
This dissertation examines patient experiences of remote-first general practice models and identifies which population groups face systematic disadvantage under such arrangements. Employing a comprehensive literature synthesis methodology, this study analyses qualitative and quantitative evidence from peer-reviewed sources published between 2020 and 2025, coinciding with the rapid expansion of remote consulting following the COVID-19 pandemic. Findings reveal that whilst remote-first models offer convenience benefits—including reduced travel time and improved access for working-age adults—they simultaneously generate significant barriers for marginalised populations. Socially excluded groups, ethnic minorities with limited English proficiency, older adults, people with chronic conditions, those experiencing digital poverty, and individuals lacking private domestic space consistently report poorer access and diminished care quality. The evidence demonstrates that remote-first approaches, when implemented as default pathways without protected alternatives, risk widening existing health inequalities in primary care. This synthesis concludes that equity-oriented hybrid models, incorporating straightforward routes to face-to-face consultations and tailored support mechanisms, are essential to prevent the entrenchment of a two-tier primary care system. These findings hold significant implications for health policy, commissioning decisions, and clinical practice guidelines.
Introduction
The landscape of primary healthcare delivery in the United Kingdom and comparable high-income nations has undergone profound transformation since 2020. The COVID-19 pandemic precipitated an unprecedented acceleration in the adoption of remote consulting technologies, fundamentally altering how patients access general practice services (Khan et al., 2020). What began as an emergency response to infection control requirements has, in many contexts, evolved into a sustained model of service delivery characterised by digital and telephone triage as the default first point of contact—commonly termed “remote-first” or “total triage” approaches.
Remote-first general practice models represent a significant departure from traditional patterns of primary care access. Under these arrangements, patients seeking medical attention are typically required to complete online forms, navigate automated telephone systems, or await callback appointments before any clinical assessment occurs. Proponents argue that such systems enhance efficiency, optimise clinician time, and provide greater flexibility for patients who can consult from home or work without travel (Mathew et al., 2025). Indeed, for certain populations and clinical presentations, remote consulting offers genuine advantages that merit recognition and development.
However, the wholesale adoption of remote-first approaches raises profound questions about equity, access, and the fundamental nature of the therapeutic relationship in general practice. Primary care occupies a unique position within health systems as the most frequent point of contact between populations and healthcare services, and its accessibility significantly influences health outcomes across the life course. The National Health Service constitution enshrines principles of universal access and equity, yet emerging evidence suggests that remote-first models may inadvertently undermine these commitments by creating new barriers for already marginalised populations (Verity and Brown, 2023).
The academic and policy significance of this topic cannot be overstated. Health inequalities represent one of the most persistent challenges facing contemporary healthcare systems, with socioeconomic gradients in morbidity and mortality proving remarkably resistant to intervention (Marmot et al., 2020). Primary care has historically served as a potential equalising force, yet if access mechanisms themselves become stratified by digital capability, language proficiency, or housing circumstances, this compensatory function may be compromised. Understanding precisely how different patient groups experience remote-first models, and who bears the greatest burden of any associated disadvantages, is therefore essential for evidence-based policy development and ethical service design.
This dissertation responds to an urgent need for systematic synthesis of the rapidly expanding evidence base concerning patient experiences of remote-first general practice. By drawing together qualitative insights and quantitative findings from multiple research contexts, this work aims to provide a comprehensive overview suitable for informing clinical practice, health policy, and future research agendas. The focus on disadvantage and inequality reflects both the centrality of these concerns to healthcare ethics and the growing recognition that technological innovation in healthcare requires careful scrutiny through an equity lens.
Aim and objectives
Aim
This dissertation aims to critically examine how patients experience remote-first general practice models and to identify which population groups are systematically disadvantaged by such arrangements.
Objectives
To achieve this aim, the following specific objectives guide the analysis:
1. To synthesise existing evidence regarding patient experiences of remote-first general practice models, including perceived advantages and disadvantages across different dimensions of care.
2. To identify and characterise the population groups who face barriers to access or report diminished care quality under remote-first arrangements.
3. To examine the mechanisms through which remote-first models create or exacerbate disadvantage for vulnerable populations.
4. To evaluate the implications of current evidence for health policy, clinical practice, and the design of equitable primary care access systems.
5. To identify gaps in the existing evidence base and propose priorities for future research in this domain.
Methodology
This dissertation employs a literature synthesis methodology, systematically drawing together published research to address the stated aim and objectives. Literature synthesis represents an established approach within health services research, enabling the integration of findings from multiple primary studies to generate comprehensive overviews of complex phenomena (Grant and Booth, 2009). This methodological approach is particularly appropriate for emerging fields where evidence is accumulating rapidly and where policy decisions require timely synthesis of available knowledge.
Search strategy and source identification
The foundation of this synthesis comprises a curated collection of peer-reviewed publications identified through systematic searching of academic databases. Primary sources were located through searches of MEDLINE, CINAHL, Web of Science, and Google Scholar using combinations of terms including “remote consultation,” “digital triage,” “telephone consultation,” “general practice,” “primary care,” “patient experience,” and “access.” Date parameters were set to capture publications from 2020 onwards, reflecting the pandemic-accelerated expansion of remote consulting and ensuring contemporary relevance.
Inclusion criteria specified peer-reviewed publications examining patient experiences of remote or digital-first primary care access models in high-income country contexts. Both qualitative and quantitative study designs were eligible for inclusion, reflecting the value of methodological pluralism in capturing the complexity of patient experience. Sources were excluded if they focused exclusively on secondary or tertiary care settings, examined clinician rather than patient perspectives without reference to patient experience, or were published in languages other than English.
Quality assessment
Included sources were assessed for methodological rigour using established critical appraisal frameworks. Qualitative studies were evaluated against criteria derived from the Critical Appraisal Skills Programme (CASP) checklist, examining appropriateness of methodology, recruitment strategy, data collection methods, reflexivity, and analytical rigour. Quantitative and mixed-methods studies were similarly appraised for sampling adequacy, measurement validity, and analytical appropriateness.
Analytical approach
The synthesis employed a narrative approach to integration, identifying recurring themes and patterns across included sources whilst attending to contextual factors that might explain variation in findings. Thematic categories were developed iteratively through close reading of primary sources, with particular attention to experiences of access, perceived quality and safety, relational aspects of care, and differential experiences across population subgroups. Where sources reported conflicting findings, these tensions were examined for potential explanations related to methodological differences, population characteristics, or service configurations.
Limitations of methodology
Several limitations of this methodological approach warrant acknowledgement. Literature synthesis necessarily depends upon the quality and comprehensiveness of available primary research; gaps or biases in the underlying evidence base will be reflected in any synthesis. The rapid pace of change in remote consulting arrangements means that some findings may reflect specific pandemic-era circumstances that have subsequently evolved. Additionally, whilst efforts were made to identify relevant sources systematically, the possibility of relevant publications being overlooked cannot be entirely excluded.
Literature review
The emergence and characteristics of remote-first models
Remote-first general practice models emerged as a dominant feature of primary care delivery during the COVID-19 pandemic, though their roots extend to earlier policy initiatives promoting digital transformation in the National Health Service. Khan et al. (2020) documented the rapid reconfiguration of general practice during the initial pandemic period, observing that face-to-face consultations declined dramatically whilst telephone and video appointments became the primary mode of patient contact. This shift, initially conceived as a temporary infection control measure, has in many practices persisted as a permanent or semi-permanent feature of service organisation.
The defining characteristic of remote-first models is the requirement for patients to engage with triage processes—whether digital, telephonic, or both—before any possibility of face-to-face consultation arises. Duncan and Cheng (2021) examined public perceptions during the first six months of the pandemic, finding considerable variation in understanding of and satisfaction with new access arrangements. Their findings suggested that whilst some patients adapted readily to remote-first systems, others experienced confusion about processes and concern about care quality.
Terminology in this field requires clarification. “Remote-first” denotes systems where non-face-to-face contact is the default initial pathway, though face-to-face appointments may subsequently be offered. This differs from “total triage,” which implies comprehensive assessment of all patient contacts before allocation to appointment types, and from purely “digital-first” models that prioritise online over telephone access. In practice, considerable variation exists in how individual practices implement these approaches, creating a complex landscape that patients must navigate (Verity, Naidu and Brown, 2021).
Overall patient experience of remote-first care
The evidence regarding overall patient experience of remote-first models presents a nuanced picture characterised by both benefits and significant concerns. Morillon et al. (2025), in a mixed-method systematic review of patient perspectives on synchronous teleconsultation, identified convenience and time-saving as consistently reported advantages. Patients valued the ability to consult without travel, to fit appointments around work commitments, and to avoid waiting room delays. For straightforward clinical matters and follow-up of known conditions, many patients expressed satisfaction with remote consulting arrangements.
However, substantial evidence indicates that these convenience benefits are counterbalanced by concerns about quality, choice, and safety. Small et al. (2024) found that patients frequently perceived remote consultations as offering reduced quality compared with face-to-face encounters. Concerns centred on the impossibility of physical examination, the difficulty of conveying symptoms fully through verbal description alone, and uncertainty about whether conditions were being adequately assessed. These concerns were particularly pronounced for new symptoms, complex presentations, and mental health difficulties.
Kollmann et al. (2024a) examined experiences across multiple dimensions, finding that whilst access speed sometimes improved under remote-first systems, this advantage was frequently offset by complexity in navigating triage processes and uncertainty about whether and when face-to-face options would become available. Their research highlighted a consistent finding across multiple studies: patients generally view remote care as acceptable for minor or follow-up matters but express strong preferences for in-person options when presenting with serious, complex, or new health concerns.
The process of accessing care under remote-first arrangements emerges as a significant source of patient dissatisfaction. Verity and Brown (2023) documented experiences of complex and confusing systems, with patients reporting long waits on telephone lines, difficulties understanding online form requirements, and uncertainty about expected timescales for response. Duncan and Cheng (2021) similarly found that navigational challenges represented a major concern, with some patients uncertain whether their requests had been appropriately received and processed.
Relational dimensions of care
Beyond practical access considerations, remote-first models appear to affect the relational dimensions of primary care in ways that concern both patients and commentators. Humphrey et al. (2024) conducted qualitative research specifically examining the role of place in general practice consultations with marginalised patients. Their findings highlighted that the physical practice space serves functions beyond mere convenience—it provides a context for therapeutic relationship development, enables privacy that may be unavailable in domestic settings, and facilitates the non-verbal communication that underpins effective clinical assessment.
The concept of relational continuity—the ongoing therapeutic relationship between patient and clinician that develops over time—appears particularly vulnerable under remote-first arrangements. Grut et al. (2023), in qualitative exploration of primary care changes during the pandemic, found that both clinicians and patients perceived diminution in the quality of therapeutic relationships when consultations were primarily conducted remotely. The absence of physical presence was felt to impede rapport development and to make disclosure of sensitive issues more difficult.
Khan et al. (2020) noted that for mental health presentations specifically, remote consulting posed particular challenges. The therapeutic importance of physical presence, the value of environmental observation in clinical assessment, and the significance of the consulting room as a bounded, confidential space were all perceived as difficult to replicate through technological mediation. These concerns resonate with broader literature on the embodied nature of healthcare encounters and the relational foundations of effective primary care.
Populations experiencing systematic disadvantage
Perhaps the most significant finding across the literature concerns the differential impact of remote-first models on different population groups. Far from affecting all patients equally, remote-first arrangements appear to create systematic disadvantages for already marginalised populations, raising profound equity concerns.
Inclusion health and socially excluded groups
Verity and Brown (2023) conducted specific research into the experiences of inclusion health populations—homeless people, Gypsy/Roma/Traveller communities, sex workers, and vulnerable migrants—under remote-first access arrangements. Their findings documented multiple intersecting barriers. Digital exclusion was near-universal in these groups, with lack of smartphone access, inability to maintain telephone credit, and absence of reliable internet connectivity presenting fundamental obstacles to engagement with remote-first systems.
Beyond technological barriers, these populations faced language difficulties, distrust of systems requiring personal information disclosure, and concerns about safety and safeguarding that were poorly addressed through remote modalities. Verity, Naidu and Brown (2021) had earlier piloted research into the impact of total triage on vulnerable groups, finding strong preferences for in-person care and significant concerns about the adequacy of remote assessment for complex health and social needs.
Humphrey et al. (2024) extended this analysis by examining how the loss of practice space particularly affected marginalised patients. For individuals experiencing homelessness, the practice waiting room may represent one of few warm, safe spaces available. For those in precarious housing or unstable relationships, the practice provides privacy that home environments cannot offer. Remote-first models, by diminishing the role of physical practice attendance, inadvertently remove these ancillary benefits that may be particularly significant for the most vulnerable.
Ethnic minority groups with limited English proficiency
Small et al. (2024) conducted focused research into experiences of South Asian patients with limited English proficiency, finding that remote-first models created significant additional barriers for this population. Telephone consultations eliminated the non-verbal communication cues that facilitate understanding when language is imperfect, whilst online triage forms presented insurmountable literacy challenges for those with limited written English.
The psychosocial dimensions of care were particularly affected. Small et al. (2024) found that patients felt unable to convey the emotional and contextual aspects of their health concerns through telephone or digital modalities, leading to consultations experienced as reductive and unsatisfying. Professional interpretation services, whilst sometimes available for telephone appointments, were perceived as inadequate substitutes for the fuller communication possible in face-to-face encounters with appropriate support.
Kollmann et al. (2024b), examining experiences in low-income neighbourhoods with diverse populations, similarly identified language as a critical barrier to equitable remote care. Their findings highlighted that automated telephone systems, with recorded menus and callback arrangements, were particularly problematic for non-native English speakers who struggled to understand rapid automated speech and to navigate complex option sequences.
Socioeconomic disadvantage and digital poverty
Multiple studies identify socioeconomic factors as powerful determinants of experience under remote-first models. Saña et al. (2022), in cross-sectional survey research, found that residents of low-income neighbourhoods were significantly less likely to access remote GP care and, when they did access such care, reported it as less suitable for their needs. Lack of appropriate devices, insufficient data allowances, and competing demands on household digital resources all contributed to these disparities.
Barbara et al. (2023) documented changes in care utilisation during successive pandemic waves, finding evidence of socioeconomic gradients in adaptation to remote care arrangements. Patients in more deprived areas showed greater reductions in primary care contact, suggesting that remote-first models may have reduced overall access for populations with greatest health needs.
Kollmann et al. (2024b) identified that low-income patients faced not only technological barriers but also environmental ones. Overcrowded housing conditions meant that telephone or video consultations could not be conducted privately, limiting the ability to discuss sensitive health matters. The cost of telephone calls—particularly the long waits often required to reach practices—represented a material barrier for those on limited incomes. Allanson and Logan (2025), examining patient-reported experience data, found persistent associations between area deprivation and poorer reported experience of general practice access in the post-pandemic period.
Older adults and people with chronic conditions
Age emerges as a consistent predictor of differential experience with remote-first models. Kollmann et al. (2024a) found that older adults used remote care less frequently and rated it as less suitable when they did use it. Saña et al. (2022) similarly identified age as a significant factor, with older patients more likely to report that remote arrangements did not meet their needs.
For people with chronic conditions requiring ongoing management, remote-first models present particular challenges. Whilst some aspects of chronic disease management may be amenable to remote delivery, the complexity of many such conditions, the importance of physical examination in monitoring, and the value of relational continuity in supporting self-management all suggest limitations to remote approaches. Kollmann et al. (2024b) found that chronically ill patients expressed significant concerns about the adequacy of remote assessment and the difficulty of building therapeutic relationships through technology-mediated encounters.
Privacy and domestic circumstances
A recurring theme across multiple studies concerns the assumptions embedded in remote-first models about domestic circumstances. Grut et al. (2023) noted that telephone and video consultations implicitly assume that patients have access to private space from which to discuss health matters—an assumption that fails for those in overcrowded housing, shared accommodation, or unsafe domestic relationships.
Humphrey et al. (2024) specifically examined how privacy constraints affected the quality of consultations with marginalised patients. Their findings highlighted particular concerns about safeguarding, as patients experiencing domestic abuse or coercive control might be unable to disclose these circumstances when consulting from home in the presence or proximity of perpetrators. The practice consulting room, by contrast, offers protected space where such disclosures can safely occur.
Khan et al. (2020) raised similar concerns early in the pandemic, noting that remote-first arrangements might inadvertently reduce opportunities to identify safeguarding concerns that would become apparent through face-to-face contact. The non-verbal cues, demeanour observations, and environmental indicators available in physical consultations cannot be replicated through telephone contact and are substantially diminished even through video.
Populations potentially benefiting from remote options
The literature is not uniformly negative regarding remote consulting; for certain populations and circumstances, remote options offer genuine advantages that warrant recognition. Working-age adults with employment constraints frequently value the flexibility to consult outside traditional hours or without requiring time away from work. Parents of young children may find remote consultations more manageable than attending practice premises with dependent children. Rural residents for whom travel to practice represents significant burden may benefit from reduced journey requirements (Mathew et al., 2025).
Critically, however, these benefits appear contingent on specific conditions. Kollmann et al. (2024a) emphasised that positive experiences of remote care were associated with systems that were simple to navigate, well-explained, and flexible in offering alternatives when remote contact proved insufficient. Morillon et al. (2025) similarly found that satisfaction with teleconsultation depended substantially on whether face-to-face options remained easily accessible when clinically appropriate or patient-preferred.
Khan et al. (2020) observed that patients valued having choice between modalities rather than having remote contact imposed as default. Where remote options existed alongside maintained face-to-face access, they could enhance overall system responsiveness. Where they replaced face-to-face as default, they risked creating access barriers for those least able to navigate technological systems. Grut et al. (2023) reinforced this finding, noting that patient satisfaction depended heavily on perceived choice and control over consultation modality.
System design and implementation factors
The evidence suggests that patient experience under remote-first models depends not only on individual patient characteristics but also on features of system design and implementation. Practices vary considerably in how they structure remote access—some offer online booking alongside telephone options, some require mandatory form completion, some operate callback systems whilst others offer scheduled appointment slots.
Duncan and Cheng (2021) found substantial variation in public understanding of practice access arrangements, suggesting that communication about systems was often inadequate. Verity and Brown (2023) documented how system complexity particularly disadvantaged those with cognitive or literacy difficulties, who struggled to understand multi-step processes or to complete detailed online forms accurately. The provision of accessible alternatives—such as walk-in options for those unable to engage with telephone or digital triage—emerged as an important determinant of whether remote-first arrangements created absolute barriers or merely inconvenience.
NHS England has published guidance emphasising that practices should offer multiple access routes and ensure that remote arrangements do not create barriers for those unable to use them (NHS England, 2022). However, implementation of such guidance appears variable, and the evidence reviewed here suggests that many patients continue to experience remote-first systems as difficult to navigate and as limiting their choices regarding consultation modality.
Discussion
Synthesis of key findings
This literature synthesis reveals a complex picture of patient experience under remote-first general practice models. The evidence consistently identifies genuine benefits—convenience, time-saving, and flexibility—that accrue to some patients under remote-first arrangements. For working-age adults, those with mobility constraints, and patients managing stable conditions through routine follow-up, remote consulting can enhance access and efficiency. These benefits merit recognition in any balanced assessment of remote-first models.
However, the evidence equally consistently identifies significant concerns and harms that disproportionately affect already disadvantaged populations. Socially excluded groups, ethnic minorities with limited English proficiency, older adults, people with chronic illness, those experiencing digital poverty, and individuals lacking private domestic space all face systematic barriers under remote-first arrangements. These are not marginal concerns affecting small numbers; they describe substantial population groups whose needs may be poorly served by default remote pathways.
The mechanisms generating disadvantage operate at multiple levels. Technological barriers—lack of devices, connectivity, or digital skills—create access problems for those experiencing digital exclusion. Linguistic barriers—telephone menus, online forms, absence of interpretation—disadvantage those with limited English proficiency or literacy. Environmental barriers—lack of private space, unsafe home circumstances—constrain the feasibility and safety of remote consulting for those in precarious domestic situations. Relational barriers—reduced continuity, diminished rapport, impaired non-verbal communication—affect the quality of care for conditions requiring trust and disclosure.
Implications for health equity
The equity implications of these findings are profound. Health inequalities in the United Kingdom and comparable countries represent a persistent and concerning pattern, with socioeconomic gradients observable across virtually all health indicators (Marmot et al., 2020). Primary care has traditionally been conceptualised as potentially equalising—a universal service that can partially compensate for other disadvantages through accessible, responsive healthcare. If access to primary care itself becomes stratified by digital capability, language, housing, or other socially patterned factors, this compensatory function is fundamentally undermined.
The inverse care law, articulated by Tudor Hart (1971), observes that the availability of good medical care tends to vary inversely with the need of the population served. The evidence reviewed here suggests that remote-first models risk instantiating a digital version of this law: those with greatest health needs—who are often those with least digital capability, least English proficiency, and least domestic privacy—face the greatest barriers to accessing care under remote-first arrangements.
The COVID-19 pandemic exposed and exacerbated existing health inequalities (Public Health England, 2020). If the service configurations developed during the pandemic persist without modification, they risk entrenching these inequalities permanently. The groups experiencing poorest outcomes during the pandemic—ethnic minorities, those in deprived areas, people with disabilities and chronic conditions—are substantially the same groups identified as disadvantaged by remote-first access models. Policy decisions about future primary care access arrangements therefore carry significant implications for population health equity.
Clinical and safety considerations
Beyond equity concerns, the evidence raises important questions about clinical quality and safety under remote-first models. Patient concerns about the adequacy of assessment without physical examination are not merely subjective preferences; they reflect legitimate clinical considerations about diagnostic accuracy and safety. Whilst evidence on clinical outcomes under remote versus face-to-face consulting is beyond the scope of this synthesis, patient perceptions of reduced quality and safety warrant serious attention.
The findings regarding safeguarding are particularly concerning. Remote-first models may reduce opportunities to identify domestic abuse, child safeguarding concerns, or other circumstances where physical presence enables crucial observations. Patients unable to speak privately due to the presence of abusers or controllers may be unable to disclose circumstances that would become apparent in face-to-face consultation. The practice as a safe space, separate from domestic circumstances, serves protective functions that remote-first arrangements may inadvertently eliminate.
Mental health presentations emerge across multiple studies as particularly problematic for remote consulting. The therapeutic value of physical presence, the importance of environmental observation, and the significance of the consulting room as bounded confidential space all appear difficult to replicate through technological mediation. Given the high prevalence of mental health difficulties and their association with other dimensions of disadvantage, this limitation represents a significant concern.
Achievement of objectives
Returning to the stated objectives of this dissertation, the synthesis has successfully addressed each in turn. The first objective—to synthesise evidence regarding patient experiences—has been achieved through comprehensive review of qualitative and quantitative findings, revealing a pattern of conditional benefits alongside significant concerns about quality, choice, and navigational complexity.
The second objective—to identify disadvantaged population groups—has been fully addressed through identification of multiple intersecting categories of disadvantage: social exclusion, ethnic minority status with language limitations, socioeconomic deprivation, older age, chronic illness, low literacy, and lack of private space. These categories overlap substantially, suggesting that the most disadvantaged individuals may face multiple compounding barriers.
The third objective—to examine mechanisms of disadvantage—has been addressed through analysis of technological, linguistic, environmental, and relational pathways through which remote-first models create barriers. Understanding these mechanisms is essential for designing mitigations and alternatives.
The fourth objective—to evaluate implications for policy and practice—has been addressed through discussion of equity, clinical quality, and safety considerations. The evidence strongly supports the importance of maintaining accessible face-to-face pathways and designing systems that accommodate diverse needs and capabilities.
The fifth objective—to identify evidence gaps and research priorities—is addressed below in consideration of limitations and future directions.
Limitations of the evidence base
Several limitations of the current evidence base warrant acknowledgement. Much research was conducted during the acute pandemic period, when circumstances were exceptional and arrangements were rapidly evolving. Whether findings from this period fully generalise to post-pandemic remote-first models remains uncertain. Qualitative research, whilst providing rich insight into patient experience, cannot quantify the prevalence of different experiences or outcomes. Quantitative research, conversely, may capture trends whilst missing the textured understanding of how and why problems occur.
The evidence base shows some geographical concentration, with substantial research from the United Kingdom but less from other high-income countries that have also adopted remote-first approaches. Cross-national comparison could illuminate how different health system configurations mediate the relationship between remote-first models and patient experience. Similarly, research on specific practice-level factors that moderate patient experience remains limited; understanding what distinguishes practices where remote-first arrangements work well from those where they generate significant problems could inform quality improvement.
Conclusions
This dissertation has examined how patients experience remote-first general practice models and has identified which population groups face systematic disadvantage under such arrangements. The synthesis of available evidence supports several clear conclusions.
Remote-first models offer genuine benefits for some patients and some clinical circumstances. Convenience, flexibility, and time-saving are valued by working-age adults, parents, and others whose circumstances make practice attendance burdensome. For minor problems, stable conditions, and routine follow-up, remote consulting can enhance access and efficiency. These benefits should inform service design rather than being dismissed.
However, remote-first models, when implemented as default pathways without protected alternatives, systematically disadvantage already marginalised populations. Socially excluded groups face digital exclusion, language barriers, and environmental constraints that render remote access difficult or impossible. Ethnic minorities with limited English proficiency lose non-verbal communication and face insurmountable barriers in navigating automated systems and completing online forms. Older adults and those with chronic conditions find remote care less suitable and less satisfactory. Those lacking private domestic space cannot safely discuss sensitive matters through telephone or video consultation.
The cumulative effect of these individual-level disadvantages is a pattern of structural inequity. Remote-first models risk creating a two-tier primary care system in which the digitally capable receive convenient, efficient service whilst the marginalised face barriers that compound existing health disadvantage. This outcome would contradict fundamental principles of universal healthcare and would likely exacerbate existing health inequalities.
The policy implications are clear. Remote-first models require fundamental modification to ensure equity. Practices must maintain easily accessible routes to face-to-face consultation for those who need or prefer them. Triage systems must be designed with simplicity and accessibility as core requirements, not afterthoughts. Support for those with language, literacy, or digital difficulties must be actively provided rather than passively assumed. Walk-in and drop-in options may need protection as alternatives to telephone and digital triage. Practices in areas serving disadvantaged populations may require additional resources to maintain accessible services.
Future research should address several priorities. Longitudinal studies examining whether pandemic-era findings persist under more settled post-pandemic arrangements would strengthen the evidence base. Comparative research examining different implementation models could identify features associated with more equitable outcomes. Research focused on effective interventions—how practices can successfully combine remote efficiency with equitable access—would support quality improvement. Finally, research examining clinical outcomes, not merely experience, under different access models would address important questions about safety and effectiveness.
The transformation of primary care access during the COVID-19 pandemic represents both opportunity and risk. Remote consulting offers genuine possibilities for enhanced efficiency and patient convenience. Realising these possibilities whilst avoiding the entrenchment of new forms of healthcare inequity requires careful attention to equity in system design, implementation, and evaluation. The evidence synthesised here provides a foundation for such attention, identifying both the populations at risk and the mechanisms through which risk operates. Health systems that take this evidence seriously can design access arrangements that combine technological innovation with commitment to universal, equitable care.
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