Remote primary care is widely recognised as an promising solution to ensuring both patient and provider safety by preventing direct physical contact, hence reducing morbidity and mortality during the COVID-19 pandemic [16,36,37]. However, important safety concerns also manifested, predominantly concerning diagnostic uncertainty. In this context, previous literature also report GPs’ concerns about clinical risk [38] and the need to establish escalation protocols to support clinicians decide when a transition to urgent in-person follow-up care, or even to emergency services, is required [37].

Our results underline that remote digital tools may be an effective way of delivering primary care. In line with these findings, a Cochrane systematic review (2015) demonstrated the use of telemedicine strategies to be associated with increased access to care and improved clinical outcomes in single chronic diseases, particularly in type 2 diabetes [39]. However, the interventions were heterogenous and the external generalisability of these findings remain unclear. Future research will be needed to address questions such as for which patients, and for which conditions, do virtual care tools actually improve effectiveness.

Our participants highlighted that virtual care, particularly through remote triage, can reduce the number of unnecessary visits and thus have a positive impact on efficiency (i.e., minimising waste, including from an economic perspective). In fact, few telehealth evaluations have examined the association between outcomes and costs of virtual care. While some reviews have found that virtual care can decrease the use of acute hospital services [40–42], there is less evidence in the primary care context [43]. On the other hand, our participants raised concerns about potential overuse and misuse by patients, which could negatively impact the effectiveness of remote care. In a recent study in Canada (2020) evaluating the uptake of a platform for virtual visits in primary care, Stamenova et al. observed that many virtual visits appeared to replace face-to-face visits, yet patients did not overwhelm physicians with requests [44].

In what concerns timeliness of care, participants identified both potential advantages and disadvantages. Remote primary care has the potential to offer convenient access to a primary care provider without needing to take time-off work, arrange transportation, and spend time waiting for face-to-face visits. Participants were also concerned that barriers to the use of technology and difficulties inherent to a new mode of care delivery, could result in delays in diagnosis and treatment. There is sparse evidence on the subject. However, a recent study examined patient-initiated primary care visits in the Kaiser Permanente Northern California (a system with over four million members) and concluded that, on average, telephone visits were scheduled 50% sooner than office visits [45]. These findings have profound implications, given that timeliness of care is associated with improved health outcomes. [46].

Remote care has been promised to reduce inequities in access to care for decades, particularly in rural and geographically remote areas [47–49]. In line with previous literature, our results demonstrate the ability of remote care to overcome barriers for those who have physical limitations to attend a face-to-face meeting, but also highlight their potential to entrench existing inequities in access to care [50,51]. Published evidence shows that the transition to virtual primary care did not unfold in the same manner across communities [52]. Proactive efforts are therefore needed to identify and address both patient and provider‐related digital barriers so as to avoid that the widespread implementation of virtual care in a manner which reinforces disparities in health access amongst already underserved and excluded groups [52].

Equally, with regards to patient-centredness, a range of benefits and challenges have been identified. While participants consider that remote care can improve convenience and patient empowerment, participants also acknowledge that it can have both negative and positive effects on communication. Another important challenge is patient preference for face-to-face visits. Preference theory suggests that patients would prefer a virtual consultation if they perceive its benefits as outweighing its burdens [53]. Multiple factors may influence patients’ preference, including the situation of care (i.e., patient’s perception of their clinical status, treatment requirements, and care pathway), the expectations of care, the demand of care (e.g., social situation, consequences of choice), the capacity to allocate resources (e.g., patient’s ability to allocate financial, infrastructural, social and healthcare resources) [54] and patients digital health literacy [55,56]. These factors may combine or compete and may be dynamic throughout the patient’s journey.

The pandemic has a transformational impact in hastening the digital transformation, and in particular increasing awareness, trust, and adoption of remote care [16,57,58]. Challenges such as the lack of support, burnout, and remuneration issues, are balanced by a few benefits (i.e., remote working and a better control over schedule). However, to fully embrace the benefits postulated (e.g., greater flexibility to work remotely from home), healthcare systems must explore and implement the enablers required. Potential enablers include single sign-on, sharing of records across systems, electronic generation of form, and the creation of workspaces and secure interfaces without the need for laptops and VPNs [59]. While the rapid implementation of virtual consulting tools provides the ability to work more flexibly and from different locations, primary care leaders need to be supported and learn how to build effective teams via novel approaches [60].

At the health systems level, previous studies have indicated that implementation barriers largely depended on accreditation, payment systems, and insurance [61]. Prioritisation of financial investments into relevant infrastructure, greater emphasis on training and guidance for healthcare providers, and updates to the corresponding legal and regulatory frameworks supporting their use, are equally required. Overcoming institutional inertia is likely to be more feasible post-COVID-19, given that clinical culture is expected to have evolved substantially after a year of daily use of remote care delivery. In addition, as many of the existing guidance and policies on primary remote care were drafted and implemented during the emergency phase, the experience attained, and evidence collected offers an opportunity to refine, optimise, and update the relevant accompanying legal and regulatory frameworks.