Table 3. Examples of practices at different levels of digital maturity.

Digital maturity level	Examples
• Traditional	Range Park and Carleon both offer traditional forms of access and consultation types, which are considered more appropriate to the deprived populations served. For this reason, they take a reactive approach to policy initiatives that push the digital agenda. Both practices have mainly phone access, and with digital access either not available or not used. Despite modern premises, the IT infrastructure at Range Park is weak (“even the phone connection can be poor…”—GP).
•• Traditional with lone innovator	Rhian was an early digital adopter (one of the first practices in the country to have its own website, set up by the lead GP who is a keen digital innovator) but is now described by staff as lagging behind neighbouring practices, partly because of major infrastructural challenges (unsuitable premises dating from the 1970s and a legacy IT system that interfaces awkwardly with video and online consultation technologies and does not support analytics). Current technologies include MyHealthOnline, an online platform used for prescriptions and appointment bookings (which is not used much), and the My Surgery App which has a link on the surgery website and helps patients contact the surgery (there are plans to increase use). Rhian is thus quite advanced in terms of capability (digital technologies are installed) but lacks infrastructure and strategic readiness (perhaps chiefly because they are awaiting a move to new premises).
Between •• and •••	Newbrey was described by some interviewees as at level 2 but assessed by the researcher in residence as at or approaching level 3 (digitally curious). During the pandemic they adopted a telephone-first system for every patient with a very limited number of in-person consultations and a resulting adverse effect on clinician morale. A lone innovator GP attempted a video consultation service, but this did not catch on among their partners. The practice now makes widespread use of the accuRx online consultation tool and there is a GP-led triage system.
••• Digitally curious	Ogden East is trying out digital innovations but not yet using these as part of a fully-developed strategy. It has introduced a number of digital innovations which are in fairly widespread use. The practice has a telephone first triage system—all patients are initially assessed over the phone for need for further intervention. The practice has capability to use accuRx for video consulting but use has diminished since pandemic restrictions eased. Patients can book appointments through SystmOne or can complete a telephone call-back request online consultation form from the website, but most patients book their appointments by telephone. At Queens Road, staff view digital services as offering a potential solution to managing the demand from patients but they also express concern about unfettered access from easily-accessible online consulting platforms. There are multiple entry points into the practice (telephone, bookable appointments through the NHS app, accuRx online consulting platform; and in-person for people that cannot reach them remotely). Telephone lines are exceptionally busy and the accuRx platform is switched off when the practice reach capacity. Despite multiple access routes, in the last patient survey (2021) only 43% of patients were satisfied with access. River Road is currently experimenting with a system called Footfall for triage. Footfall is similar to other online consultation systems which patients can access on the practice website and which allows them to write down their presenting complaint and receive a reply from the practice by secure email. This is reported as having taken the pressure off reception phone lines. This practice initially started using video consulting using the Scotland-wide Attend Anywhere platform, but abandoned it because of poor infrastructure (inadequate computer and phone quality—both in the practice and in many patients’ homes). GPs have reverted to using pictures sent as phone or email attachments. Westerly had introduced a range of digital services prior to the pandemic and a few GPs had already trialled video consulting and accuRx. Because of concerns about digital exclusion when introducing online access and consultations, they reviewed several different providers and asked a small group of patients to test out two different services before choosing a system which included a voice-activated option preferred by some patients. However, this system was not funded by the Clinical Commissioning Group and was not used much by patients pre-pandemic, so a year later they switched to eConsult which was available fully funded. During the pandemic, they developed a new practice website and adopted a new telephony system to cope with vastly increased pressure on the phone lines.
•••• Digitally strategic	Camp St Group rated their own digital maturity as level 3 (one partner reflected that they are “not very sophisticated”), but there are signs that they are already at level 4—not because they have all the latest gadgets but because digital technologies are used creatively and strategically. They have used email for a long time to correspond with patients and are also now using online consultations (Systm1 accuRx) They use an automated response system to encourage people to use online consultations and have introduced workflows with staff who are trained to manage and triage the online consultations. They plan to invest in a new telephony system, aiming “to smoothe demand across the day”. Video was tried but withdrawn as a strategic choice because it was felt to meet very few patients’ needs. As in many practices, the GPs and support staff find online consultations frustrating (as the templates ask too many unrelated questions), so there is a novel plan to introduce a symptom sorter underpinned by artificial intelligence (Klinik). Fernleigh, an early adopter of technologies, use a range of approaches, including telephone triage and telephone consultations (with an in-person consultation arranged if required), accuRx text messaging and email, as well as eConsult online triage forms. Whilst video consultations are possible through accuRx and were used at the height of the pandemic, they are rarely used now (perhaps because most patients are elderly and have relatively low confidence with digital technologies).
•••• System- oriented	Towerhill is at or approaching level 5. It is strategically ambitious (with further digital developments a clear priority) and has very advanced infrastructure and a high level of digital capability—for example, use of the accuRx system for photography, patient text messaging and sending documents. Towerhill was an early adopter (and beta tester) of various digital tools and platforms, and is involved in digital health research (e.g. a locality data warehousing project which has an attached data analyst who can produce ‘dashboards’ on hospital admissions, referrals and more). The practice uses Teams for internal communication and health information exchange (hospital, mental health). They have appointment book interoperability using EMIS which allows them to book patients into linked community clinics (e.g. for ulcer dressings). Several partners are working to support digital innovation beyond the practice—for example, driving the introduction of a cloud-hosted telephone system (X-on) and a long-term condition management system across the Primary Care Network. Their Primary Care Network employs digital champions who are financially supported by the NHS.