Research and analysis

BDUK Hubs evaluation: connectivity outcomes in healthcare sites

Published 10 September 2026

Authored by Belmana, an independent contractor commissioned to run this evaluation on behalf of Building Digital UK (BDUK). Study conducted by Belmana and GC Insight.

1. Summary

Building Digital UK (BDUK) commissioned Belmana and GC Insight to conduct an economic evaluation of its Hub intervention, delivered through the BDUK Rural Gigabit Connectivity (RGC) Programme and Project Gigabit. The Hub intervention invested in connecting remote public buildings, such as schools, general practice surgeries and libraries, to gigabit-capable broadband.^{[footnote 1]}

An earlier phase of Hubs – the RGC funded connections – was evaluated in the RGC Hubs evaluation (Belmana, 2023). The recent GigaHubs programme started in 2022 as part of ‘Project Gigabit’, the UK Government’s £5bn national mission to deliver lightning-fast, reliable broadband for everyone in the UK.

BOX 1: Key Findings

This report evaluates the impact of gigabit-capable broadband connectivity on service delivery in rural GP surgeries. The key findings are:

• Broadband connectivity has an attributable effect on service delivery. Quasi-experimental analysis identifies a causal relationship between gigabit connectivity and changes in how GP services are delivered. Following connection, there is a statistically significant shift from telephone to video consultations, and higher attendance rates for appointments. These changes act as observable indicators of how improved connectivity influences service use.

• Direct measurable impacts are modest but robust. The observed changes in appointment mix and attendance are relatively small in magnitude but consistent across models, suggesting reliable – if incremental – operational benefits, including potential time savings from reduced missed appointments.

• Connectivity supports changes in service delivery when complemented by service design and organisational readiness. Qualitative evidence shows that improved broadband supports the effective use of digital systems such as e-consultations, electronic prescribing, cloud-based clinical platforms and Advice & Guidance (A&G), improving workflow efficiency and communication across care settings.

• Impacts are visible across specific care pathways. Digital tools enabled by connectivity are contributing to changes in pathways such as dermatology and cardiology, where remote triage, image sharing and specialist advice can reduce unnecessary referrals and improve timeliness of care.

• Connectivity can support place-based and community models of care. Evidence from Oxfordshire demonstrates how connected community sites (e.g. village halls) can support the delivery of NHS and social care services, aligning with wider system goals to shift care from hospital to community settings.

• Broadband is a necessary but not sufficient condition for transformation. The extent of impact depends on complementary factors including service design, workforce capacity, digital systems and patient digital access. Connectivity enables change but does not guarantee it.

These findings combine robust quantitative evidence of observable change in service delivery with qualitative insight into how impacts arise and should be interpreted accordingly when considering their implications for service change and wider system outcomes.

This report evaluates the impacts of broadband upgrades in rural health sites using a quasi-experimental research design and data from Ofcom’s annual Connected Nations Reports, BDUK, the ONS and NHS England’s Appointments in General Practice dataset. Depth interviews were conducted with general practitioners, members of staff at BDUK and Oxfordshire County Council and a volunteer at a village hall hub site, with evidence also drawing from a wider set of interviews conducted for the Hubs evaluation.

The report parallels a process review that highlights the theory of change underlying GigaHubs (Belmana, 2026a, 2026b); there are also studies that look at other types of Hubs, such as primary schools and libraries.

BOX 2: Evaluation Aims and Objectives

The overarching aim of the evaluation is to establish the connectivity impacts of Hubs. BDUK programmes have a standard set of overarching evaluation questions that must be assessed, in line with the Magenta Book and Green Book. Evaluation projects seek to answer or contribute to the overall understanding of these questions:

• What are the outcomes of the Hubs product across Rural Gigabit Connectivity (RGC) and in Project Gigabit?

• What has changed in individuals’/organisations’ behaviour for these outcomes to come about?

• How effective and efficient has the delivery of the programme been?

• What can we learn to improve future policy designs and implementation?

• Was the investment cost-effective?

This evaluation report addresses the first four evaluation questions in relation to health sites (the question ‘Was the investment cost-effective?’ is covered in a separate, upcoming Value for Money report).

2. Introduction

This report examines the impact of government support to connect GP surgeries and other healthcare sites to gigabit-capable broadband. It identifies evidence consistent with a causal effect of broadband connectivity on service delivery in GP surgeries, through measurable changes in appointment modes and attendance. The report then explores wider behavioural change beyond this indicator. While quantifiable impacts are modest, qualitative evidence suggests broader system-level transformation across care pathways and service delivery models.

These potential downstream effects on healthcare delivery and provision arise in a context where digital connectivity is emerging as a cornerstone of healthcare delivery, “driving innovations in patient care, medical data management and operational efficiency” (NHS England, 2025b), and is central to the Department of Health and Social Care’s 10-year health plan for England (2025).

3. Outcomes and Impacts of the Hubs Product

The findings are structured as a layered evaluation of impact, moving from infrastructure to organisational change, user outcomes and finally wider community and system effects. This reflects the evaluation’s theory of change and the logic underpinning the Hubs intervention. Improved broadband connectivity functions first as foundational infrastructure, enabling more reliable and higher-performing digital systems within health sites. These infrastructure improvements encourage the adoption of digital technology by health professionals and GP surgeries which in turn shapes organisational operations and service delivery. Finally, where connectivity gains are applied, patient access is widened, and care pathways are transformed.

BOX 3: Value for Money Pathways.

This evaluation report highlights evidence on the outcomes and impacts of health-site GigaHubs, which then feed into the overall evaluation’s assessment of value for money. These outcomes and impacts relate to the range of service, staff, system and patient effects linked to the expansion and provision of gigabit connectivity in health sites. The evidence can also help substantiate the pathways to benefit and estimate the scale that might be attributed to the pathway. This will be explored further in the upcoming VFM report.

These benefits can be distinguished between direct benefit pathways and contingent benefit pathways enabled by improved broadband connectivity but dependent on complementary conditions, such as the digital maturity of GP practices, the condition and availability of hardware and software, and patient digital access and inclusion. The pathways to the former may be the more direct effects at the health site, such as staff time saved through more reliable clinical systems, reduced non-attendance associated with increased use of video consultations and remote triage enabled through e-consultations. This report indicates evidence of the benefits more closely connected to improved connectivity in GP surgeries, including staff time saved, a reduction in non-attendance following a shift towards video consultations and the use of remote triage.

There were limited observed impacts associated with contingent benefit pathways (reduced disruption in prescribing workflows, improved telephone and triage workflow, asynchronous reviews and questionnaires, A&G referral efficiencies, patient travel/time savings and expanded patient access) These pathways may originate from better broadband but could be strengthened through targeted support and investment. The strength of evaluation evidence is more limited, partly because these pathways depend on a wider range of organisational, technological and patient-level factors, and because the pathway to impact is more complex and may take longer to emerge. However, this report provides evidence to help explain the mechanisms to impact, as well as the barriers and enablers shaping their realisation.

This layered structure (infrastructure → organisation → user → system) highlights both the enabling role of gigabit connectivity and the moderating conditions required to translate technical upgrades into sustained and inclusive public benefit. It can also be used to detail the pathways from the Hub product to value for money. Box 3 discusses this.

The methodology for this study is detailed in the Annex. The findings of this report should be interpreted according to the strength of evidence available for each theme. The analysis combines quantitative and qualitative methods, including the use of available datasets, survey evidence and in-depth interviews. The balance between these approaches varies across themes due to differences in data availability and the characteristics of the outcomes being assessed. Findings therefore differ in the extent to which they provide evidence of observed or attributable change, compared to evidence that explains how impacts may occur and under what conditions. This distinction should be considered when using the findings to inform interpretation, wider evaluation work and future evidence development. Section 3 of this report will set out further detail on how the findings of this study can be interpreted and used on this basis.

3.1 Theme 1: Broadband connectivity as foundational infrastructure

This section provides an overview of Hub connections to GP surgeries and characterises the health sites supported. It combines quantitative analysis with interview evidence to illustrate how improved connectivity has affected service delivery. Interview findings indicate how enhanced broadband is associated with more consistent access to care, reduced reliance on outdated connections, and improved operational efficiency. Interviewees also linked improved connectivity at GP surgeries to more resilient digital health services, including remote consultations, real-time access to patient records, and integration with NHS systems.

Hub connections in GP surgeries

Across the GigaHubs and RGC programmes, 252 GP surgeries were connected, including 38 funded through GigaHubs. While the qualitative analysis focuses on early impacts from GigaHubs, the quantitative analysis pools both programmes to increase sample size. Of the connected surgeries, 51 were in England, 79 in Northern Ireland, 94 in Scotland, and 28 in Wales. Some surgeries were located within the same output area, resulting in 244 output areas (OAs) where at least one GP surgery was connected.

Table 1 summarises the characteristics of supported areas, all areas containing GP surgeries, and statistically matched comparator areas.

Table 1: Characterising the GP surgery Hubs

Variable	Areas with GP surgeries
	Hubs	All GP surgeries	Comparator GP surgeries
Count of output areas	244	4798	244
Proportion rural (%)	61.1	13.5	61.1
Population density LSOA	917	3693	1496
Employment in LSOA	397	1228	604
Number of surgeries in OA	1.1	1.3	1.1
% premises Full Fibre available	24.1	38.9	32.7
Premises passed by BDUK funded projects	26	5	35
FScore	0.6	0.2	0.6
Average download speed, 2021 (Mbps)	54.8	79.9	65.0
No of connections >=30 Mbits/s	64.5	92.0	73.9

Source: BDUK data with data from Ofcom and ONS

Hub-supported areas with GP surgeries (244 OAs) were substantially more rural (61.1%) than the average across all GP surgery areas (13.5%), reflecting the programme’s focus on underserved locations. These areas also had fewer surgeries per OA (1.1 vs 1.3) and weaker baseline broadband connectivity. For example, only 24.1% of premises had access to full fibre, compared with 38.9% across all GP areas, and average download speeds in 2021 were significantly lower (54.8 Mbps vs 79.9 Mbps). These characteristics provide contextual evidence on the types of sites supported by the programme.

BDUK interviewees further contextualised this rural focus as part of engagement with NHS stakeholders, emphasising the need to address inequalities in service provision driven by connectivity gaps:

“More things are going to be online and [the NHS would be] offering the same level of service as you would to somebody in a rural area that you would in a built-up area or an urban area.”
(BDUK Product Manager)

For the quantitative analysis, comparator GP surgeries were identified from those not supported through the Hub product, but also in rural areas. A comprehensive list of UK GP surgeries was compiled using publicly available NHS and devolved administration data, and the OAs with a surgery formed the pool of areas from which comparators were drawn. Statistical matching was then used to select areas with similar characteristics, including rurality, broadband availability, and socioeconomic factors. As shown in Table 1, the matched comparators closely mirror Hub areas in rurality (61.1%) and other key variables. However, they generally exhibit slightly stronger baseline connectivity, including more premises passed by BDUK projects (35 vs 26), higher numbers of connections above 30 Mbps, and better overall broadband performance.

Use of broadband connectivity in GP operations

Interview evidence provides insight into how broadband connectivity underpins day-to-day operations in GP surgeries. Digital tools are now embedded across patient care and administrative processes. Two systems were consistently highlighted: Accurx, a communications platform supporting online consultations and patient interaction, and EMIS, a widely used electronic patient record system enabling appointment management, record-sharing, and clinical workflows.

These systems depend on reliable broadband and are integral to modern GP operations. Interviewees emphasised how connectivity has enabled operational improvements, particularly in communication and reception functions:

“Accurx has been a massive game changer too.”
(General Practitioner, Herefordshire)

“We did move to this cloud-based telephone system and…that has made telephone access much better…I know that our receptionist found that it really did help… with their workload actually, because patients weren’t hanging on the phone for as long as they had done previously and you know, getting very frustrated as a result…”
(General Practitioner, Herefordshire)

Interviews also highlighted that improving the speed and reliability of connections was crucial, as poor connectivity limited the performance of operational systems and the uptake of IT products that could deliver new services or efficiencies:

“[broadband connectivity] is essential for EMIS because EMIS doesn’t work without broadband. It’s remotely hosted.”
(General Practitioner, Somerset)

The operational benefits of these systems were further illustrated by BDUK staff:

“So if … you had a consultation, and you want to get a prescription through, not writing that down and handing it to somebody and then them having to wait, but actually it just going through the computer and then it being at the pharmacy by the time you leave the surgery… ”
(BDUK Product Manager)

Although the interviewees’ reliance on broadband connectivity has grown, a surgery’s demand on broadband also increased “dramatically” due to additional staffing:

“When I started there 30 years ago, there were four doctors. There are now four doctors, two nurse practitioners, a paramedic, all of whom are consulting patients…there’s two physios who… [are] not there all the time, but they consult patients… our use of access to EMIS has doubled essentially over the last 20-30 years.”
(General Practitioner, Somerset)

Why broadband connectivity improvements matter: Foundational infrastructure

Prior to broadband connection upgrades, GP Hub sites operated with lower broadband speeds and limited access to high-capacity digital infrastructure. These conditions constrained health sites’ ability to effectively implement and use cloud-based clinical systems and digital communication tools widely utilised across the UK. As key systems such as EMIS and Accurx rely on stable connectivity to access patient records, manage prescriptions and communicate with consultants, weaker connections increased the likelihood of service disruption.

However, interview evidence indicated that improved connectivity alone does not necessarily guarantee the full realisation of benefits. While faster and more reliable broadband reduces technical barriers to using digital systems, wider organisational factors, such as staffing, workflows, and increasing service demand, continued to shape demand on and use of connectivity.

The effects of improved broadband connectivity at this foundational level are best understood as conditional rather than uniform. The Digital Maturity Assessment, an annual self-assessment for all Integrated Care Boards and NHS Trusts in England, measures digital maturity against the NHS What Good Looks Like (WGLL) framework and sets out 28 domain areas across which digital maturity may vary (NHS England, 2026). Within the framework, connectivity sits within the “Ensure Smart Foundations” pillar (NHS England, 2021), providing the technical baseline on which digital systems depend. However, improvements to this pillar do not in themselves generate system-wide change.

In practices with lower levels of digital maturity, enhanced connectivity primarily reduces technical constraints, improving the reliability and performance of systems such as EMIS and Accurx and reducing disruption to day-to-day operations. In more digitally mature settings, the same infrastructure improvements provide a platform for wider transformation, enabling integration across systems and supporting more advanced digital workflows. This suggests that while connectivity is a necessary precondition for modern digital healthcare, its immediate effects at the infrastructure level vary depending on organisational readiness and capability.

3.2 Theme 2: Adoption of digital technology in GP surgeries

This section outlines the expected benefits of adopting digital health systems, quantifying the changes in appointment types following connectivity upgrades. By establishing the extent to which upgraded connectivity encouraged a switchover effect from phone appointments to video appointments, the analysis can assess some resource implications. However, the switchover effect, in being attributable to the Hub connection, also provides an indicator of adopting health technology dependent on broadband.

Expected benefits of digital health systems and technology

There were a variety of issues that the connection of GP hubs aimed to address, ranging from improving existing service provision at individual sites with weak connectivity, enabling new methods of service provision through digital communication and adapting to circumstances brought about by the Covid-19 pandemic. A BDUK staff member interviewed shared that:

“Most of the discussions that we had were around connecting to individual services and… individual GPs and surgeries to allow them to provide a better service…”
(BDUK Product Manager)

Another goal was to address outcomes associated with poor connectivity:

“If you have a really bad connection, [a surgery] wouldn’t be able to do prescriptions or [online] things like that. So, there were times where things will have to be more manual and obviously… that doesn’t make the service run very well for regular people.”
(BDUK Product Manager)

Aspects of this new and improved service could include digitally enabled communication between GPs and patients:

“…like a home visit with the healthcare assistant and then… [a] GP on the other end of an iPad.”
(BDUK Product Manager)

At the time of the Covid-19 pandemic, improvements in broadband connectivity were seen as crucial given the difficulties and risks of in-person appointments:

“But also, I think at that time there was the conversations around it now being way more critical because of the need for people to have consultations online, for people to interact with services in a less face-to-face way, basically, in a more remote way, and how they would sort of facilitate that…”
(BDUK Product Manager)

Improved connectivity and the mix of GP appointments

How fibre broadband installation at GP surgeries affected the mix of appointment types, specifically video, telephone, face-to-face, and home visits, was assessed using a fixed-effects model on appointments data, comparing the Hub surgeries with a control group of unsupported surgeries derived to be comparable by statistical matching. Monthly data is available on appointments at English general practices, and this is linked to other broadband and NHS data about areas with surgeries. The annex details the approach.

Public data on the type of appointments that each English GP surgery conducts differentiate between the broadband-dependent video conference (VC) and three other forms of interaction, including the telephone call. To assess the impact of fibre broadband installation on the distribution of GP appointment types, a quasi-experimental design was used. This approach compared changes in the share of appointment types( video conferencing, telephone calls, face-to-face consultations, and home visits) before and after the installation of fibre at surgeries, relative to a matched group of surgeries that did not receive the upgrade during the same period.

A range of models were employed to ensure robustness, assessing the intervention’s effects across comparison groups. Broadly, post-connection, analysis indicates a significant switch from telephone consultations to video conferencing at supported surgeries. This form of interaction has a higher attendance rate, so the switchover effect lowered the number of appointments missed^{[footnote 2]}.

The use of propensity score matching alongside panel regression models enabled a credible estimation of the causal impact of fibre connectivity on service delivery modes in GP practices, under the assumption of parallel trends between treated and matched control surgeries prior to the intervention. Please see the methodology annex for more details.

Table 2: Shares of appointment types after connection

Impact on share of:	Effect of connection	Range of estimates	Models Significant
Video conferencing	+3.4% (1.3%**)	2.8% (1.7%) to 3.5% (1.3%***)	8 out of 9
Telephone calls	-3.8% (2.0%*)	-4.6% (2.1%**) to -2.4% (2.0%)	3 out of 9
Face-to-face consultation	+0.6% (2.4%)	-0.2% (2.4%) to 1.7% (2.1%)	0 out of 9
Home visit	-0.3% (0.3%)	-0.6% (0.4%) to -0.2% (0.3%)	0 out of 9

50-70 surgeries analysed over 30 months (Nov 2022 - April 2025) Significance levels are 1% ( *** ), 5% ( ** ) and 10% ( * )

The most consistent and substantial effect was observed in the share of video consultations. Across the nine models, the installation of a fibre connection was associated with an average increase of 3.4 percentage points in the share of appointments delivered via video, with a standard error of 1.3 percentage points. This effect was robust across specifications, with eight out of nine models yielding statistically significant results. The estimates ranged from 2.8 to 3.5 percentage points, suggesting a consistent relationship between improved connectivity and the adoption of video-based care.

In contrast, the share of telephone appointments declined following fibre installation. On average, the estimated effect was a 3.8 percentage point reduction, with a standard error of 2.0 percentage points. Although this result was statistically significant in only three out of nine models, the range of estimates (from –4.6 to –2.4 percentage points) consistently pointed in the same direction, indicating a potential shift from telephone to video consultations rather than a change in remote care overall.

The analysis found no statistically significant impact on the share of face-to-face consultations or home visits. For face-to-face appointments, the average estimated effect was a modest increase of 0.6 percentage points, while home visits saw a small decrease of 0.3 percentage points. However, none of the models for these two appointment types produced statistically significant estimates, and the range of results was relatively narrow and centred close to zero. This suggests that, while fibre connectivity may encourage use of video technologies, it does not appear to have displaced traditional modes of in-person care.

This finding resonates with GP views about what video consultations offer:

“Video appointments, you can at least see the patient, but there’s no substitute for seeing them actually face to face… it’s marginally better than telephone, but not a lot. Patients don’t seem to want video consultations… they want a phone call, or they want to be seen face to face.”
(General Practitioner, Somerset)

“You can’t examine the patient… you don’t get the same rapport. You can’t pick up on their body language… face-to-face is really the best way of getting that.”
(General Practitioner, Herefordshire)

“You’re diagnosing people without necessarily having them in front of you. And you’ve got to be very careful because there’s a safety aspect to it… obviously patient safety has to be your priority. And if you haven’t got [patients] in front of you, you can’t generally examine them that well.”
(General Practitioner, Herefordshire)

This perspective reflects broader concerns about the practical and relational limitations of VC in routine consultations. The same GP highlighted that video consultations can be difficult to conduct within the time-pressured environment of primary care:

“It would take a while to get it set up… when you’re under a lot of time pressure… fiddling around trying to set up a video consultation is just not worth it.”
(General Practitioner, Herefordshire)

The quantitative analysis largely focused on a period after the Covid-19 pandemic, and this clearly was a driver for an increased use of video consultations, but interviewees noted a marked drop-off as the pandemic came to an end:

“So, there were a fair amount of video consultations and e-mail consultations and a lot more telephone conversations… then COVID gradually drifted away, and we’ve more or less lost the video consultations. We don’t do very many video consultations anymore.”
(General Practitioner, Somerset)

“So, we did a few [video consultations] in the pandemic and to be honest with you, we don’t do any now. I don’t think any of my colleagues do them.”
(General Practitioner, Herefordshire)

Taken together, the findings indicate, on the basis of the quantitative analysis, that the provision of fibre broadband at GP surgeries can facilitate a shift toward more digitally enabled consultations, particularly video appointments, without adversely affecting access to face-to-face or home-based care. These results support the view that broadband infrastructure plays a complementary role in enhancing service delivery in primary care settings, rather than substituting for conventional forms of patient contact.

Attendance effects and resource implications

One question is whether resource outcomes can be attributed to this change in the mode of appointments. This section explores the attendance effects, that is whether patients attend different types of appointments, as an indicator of one outcome. To assess this, an approach similar to the earlier modelling was used, with the additional consideration of how many appointments were flagged with a “did-not-attend” marker in the GP-level data, something that occurred in a low proportion of appointments. Each model compared the mean attendance rates for telephone versus video appointments across different matched samples. The models covered three comparator groups (all GP surgeries, those on the same telephone exchange, and those on the fringe of Hub coverage) and three specification variants for each.

Table 3 summarises the results, presenting the difference in average attendance rate between the video conference and telephone modes, and the associated statistical significance. Results were pooled across the supported surgeries and the matched surgeries in similar areas, and across all nine models, attendance at video appointments was consistently higher than for telephone appointments.

Table 3: Attendance effects – video vs. telephone appointments

EFFECT	Change	Models Significant	Median additional change	Range of additional change
Video vs. Telephone Attendance	0.026	9 out of 9	0.026***	0.020*** to 0.026***

50-70 surgeries analysed over 30 months (Nov 2022 - April 2025) Significance levels are 1% ( *** ), 5% ( ** ) and 10% ( * )

The mean attendance rate for telephone consultations ranges from 0.971 to 0.979, while the rate for video appointments ranges from 0.998 to 0.999, i.e. there was a consistency in the attendance rates across models. The difference in attendance ranged from 2.05 to 2.65 percentage points. This difference was statistically significant at the 1% level, with p-values consistently below 0.001.

This finding may reflect the additional structure or clarity that comes with video-based appointments, especially as its use is associated with the adoption of appointment management software. A platform might be used, with a more formalised pre-appointment process enabled by the platform integrating forms to allow a patient to provide more details integrated with the surgeries record management. This increased engagement as video appointments use digital platforms could offer a slightly more reliable format in terms of ensuring attendance.

A second point is then that this findings of increased video consultations is correlated with the surgery adopting a wider range of digital IT and be a proxy for this transformation.

That reliability could have measurable resource implications. The Unit Costs of Health and Social Care Manual (Jones et al., 2025) provides cost estimates of appointments at GP surgeries. GP costs per surgery consultation lasting 10 minutes are £45 when the appointment includes a doctor inclusive of other medical staff and indirect care staff costs; it is £37 with other staff also including indirect care staff costs. Some portion of these costs may form a proxy value for the attendances not missed because they were booked as video conference calls and, before the improved connectivity, would have been conducted by telephone.

The variation observed in the adoption of video consultations and other digital tools can be partly explained by differences in digital maturity across GP practices. As set out in Greenhalgh et al. (2022), practices range from “traditional” and “digitally curious” to “digitally strategic” and “system-oriented”, reflecting differences in readiness, capability and approach to digital change.

Within this framework, improved broadband connectivity can be seen as enabling, but not determining, adoption. In lower-maturity practices, connectivity improvements support incremental or experimental use of digital tools, which aligns with the relatively modest but consistent shift toward video consultations observed in the quantitative analysis. In higher-maturity practices, where digital tools are more embedded in workflows, the same improvements are more likely to support sustained behavioural change and more systematic use of digitally enabled consultation models.

Why connectivity improvements matter: Changes in appointment delivery

Weak and unreliable connectivity in GP surgeries limited the scope for digitally enabled service delivery, including the use of video consultations. Following upgrades, improved broadband supported a shift towards video appointments, with evidence indicating slightly higher attendance rates compared to telephone consultations.

However, changes in appointment delivery were partial and varied across practices. While improved connectivity enabled the use of video consultations, the extent to which these were adopted depended on whether practices integrated them into routine workflows and whether they were appropriate for different types of care.

This observed shift towards video appointments represents a direct benefit pathway, while wider use of digitally enabled care models reflects the option value created by improved connectivity. These findings suggest that connectivity can support measurable changes in service delivery, but its value depends on how far digitally enabled models are embedded in everyday practice.

3.3 Theme 3: Service delivery changes in GP surgeries

While the quantitative analysis identifies measurable behavioural change, the qualitative evidence helps explain how and why these changes translate into wider service transformation. This section considers the effects of improved connectivity on service delivery through digital triage systems, e-consultations, e-prescriptions and asynchronous telemedicine techniques like diagnostic questionnaires and routine medication reviews. It also goes beyond attendance effects to outline the clinical and operational improvements linked to video appointments.

Evidence beyond attendance

Qualitative evidence suggests that improvements in broadband connectivity can enhance care pathways and generate efficiencies in GP services, not only through reduced missed appointments but also through wider changes in how care is delivered. Digital health technologies, particularly video consultations, e-consultations and electronic prescribing, enable more efficient diagnosis, communication and patient management, reducing unnecessary follow-ups and administrative burden. A growing body of international evidence supports the use of video consultations in clinical settings, identifying both clinical and operational efficiencies. The literature focuses primarily on consultation modality, whereas later interview evidence highlights broader operational transformation.

Caffery et al (2025) provide a comprehensive review of 76 studies comparing video and telephone consultations across multiple medical sectors. Across this literature, video consultations are consistently found to be equal or superior to telephone consultations in clinical outcomes, with no studies reporting telephone use as clinically superior.

Evidence is particularly strong in contexts where visual assessment is important. In stroke care, video consultations supported higher rates of accurate treatment decisions (96–98%) compared to the telephone option (82–83%) (Meyer et al, 2008; Demaerschalk et al, 2012). Similarly, they enabled more reliable assessment of physical function in stroke rehabilitation (Li et al, 2020) and improved evaluation of pressure ulcers in spinal injury patients (Hill et al, 2009). These improvements can reduce unnecessary follow-ups and inappropriate referrals, generating downstream efficiency gains.

Video calls are also associated with service-level efficiencies. Studies summarised in Caffery et al (2025) show reduced follow-up interactions in mental health and dermatology services. For example, Ryan et al (2021) found pharmacist-led medication histories required fewer interactions via online (1.15 vs 1.47 via telephone). Enhanced patient engagement and retention have also been observed in programmes such as smoking cessation and substance use treatment, where online participation improved adherence and reduced attrition (Kim et al, 2018; Frost et al, 2022; Gainer et al, 2023).

Additional efficiencies arise from reduced travel requirements. In residential care and paediatric settings, video consultations enabled remote triage and review, reducing unnecessary in-person visits and transfers to acute care facilities (McCrossan et al, 2012; Hullick et al, 2022). This is particularly relevant in rural areas, where travel distances are greater and associated costs, both financial and in clinician time, are higher.

They can also support improved care coordination, enabling real-time access to specialist expertise. Studies in emergency paediatrics show reductions in unnecessary interfacility transfers, driven by improved triage accuracy (Marcin et al, 2023; Yang et al, 2015).

However, much of this literature is focused on specific clinical settings (e.g. hospitals, specialist services) and international contexts, with limited direct applicability to UK GP surgeries. While it provides strong evidence of efficiency gains from video consultations, it captures only part of the broader impact of digital connectivity in primary care.

E-consultations, e-prescriptions and telemedicine

Interview evidence suggests that the benefits of improved connectivity extend beyond video consultations to wider changes in care delivery, particularly through the adoption of digital workflows.

NHS England (2025a) reports that 99% of GP surgeries have a digital telephone system to facilitate triage. Enabled by reliable broadband, one practice described a shift to a fully digital triage model:

“I don’t do any on call. I’m a triage doctor. So, I’ll be sitting in a room in front of my computer and looking at all the e-consults as they come in and either allocating them appointments, or… messaging the patients, giving them some advice. Sometimes we actually have a dialogue with them through text, you know, issuing a prescription, potentially again sent electronically down to the surgery.”
(General Practitioner, Herefordshire)

This model was introduced in response to rising demand:

“…one of the reasons we introduced [a total triage system] because, you know, the demand for appointments with a GP was massively outstripping what we were able to provide.”
(General Practitioner, Herefordshire)

Broadband connectivity has also transformed prescribing practices:

“One big aspect that relies on broadband is prescribing, because now we do all of our prescribing electronically pretty much and very rarely issue scripts on paper…”
(General Practitioner, Herefordshire).

The time savings from e-prescribing are substantial:

“if I had to handwrite all the, you know, 90 prescriptions that I have to sign on a Tuesday… I wouldn’t be seeing any patients because it would take me all day”.
(General Practitioner, Herefordshire)

Correspondingly, in the GP surgery of the interviewee, e-prescriptions made “quite a big difference to [their] day-to-day work”.
(General Practitioner, Herefordshire).

This account aligns with wider NHS reporting. NHS England estimates that each repeat prescription ordered electronically saves GP practices 3 minutes of time, while patients save an average of 18 minutes per prescription request (NHS England, 2024).

E-reviews and asynchronous telemedicine

Broadband connectivity alongside cloud-based operating systems has enabled the advent of asynchronous telemedicine. This approach to medical treatment involves storing of data such as text and images collected through online services, to be transmitted and later interpreted by clinicians (Leighton et al, 2024). One asynchronous telemedical technique mentioned was the use of questionnaires to conduct otherwise administratively unfeasible routine medical reviews:

“I do things like a lot of medication reviews you can send out a questionnaire. So, we do a lot for, for example, we’ve got… over 1000 women on HRT (Hormone Replacement Therapy). There is no way that you can physically bring all of them in for an appointment every year to review how they’re getting on with their HRT.”
(General Practitioner, Herefordshire)

The use of questionnaire templates supported rather than substituted for GP-led medication reviews:

“So, I send out an Accurx template to them once a year and then… look at how they’ve replied and if they’re doing well that’s, you know, great, they’ve had their review and if … they need a discussion, then we can, you know, bring those people in… medication reviews do lend themselves to, you know, to digital pathways…”
(General Practitioner, Herefordshire)

This reflects the wider adoption of digital questionnaire systems in primary care. Accurx questionnaires are integrated in the NHS app and can be integrated on commonly used digital clinical records systems like EMIS, SystmOne, and Vision. Questionnaire templates allow practices to collect structured patient information remotely via SMS links, with the responses automatically added to the patient record. Available questionnaires include those for chronic conditions like asthma and diabetes, mental health questionnaires for adult ADHD, anxiety or depression, a Covid-19 triaging questionnaire, vital signs questionnaires for blood pressure or pulse, lifestyle and demographic questionnaires, acute questionnaires for conditions like lower back pain or a sore throat and medication review questionnaires for medications like HRT or the contraceptive pill.

Similar digital template questionnaires were also used by the same GP to diagnose and treat common ailments:

“… for example, if someone thinks they’ve got a urinary infection, I send them out a questionnaire… and I can usually be fairly confident about whether it’s, you know, urinary infection and I need to give them antibiotics.”
(General Practitioner, Herefordshire)

Aside from structured, template questionnaires, individual questions could also be asked via digital communication platforms:

“You can ask questions digitally using Accurx… that is accessed either on a computer or on a phone.”
(General Practitioner, Somerset)

The extent to which these digitally enabled service changes translate into sustained improvements in service delivery depends on the broader digital maturity of the practice. While connectivity enables the use of tools such as e-consultations, e-prescribing and asynchronous review systems, their impact appears to vary according to how far they are embedded within organisational workflows.

In lower-maturity settings, these tools may be used in a limited or ad hoc way, generating efficiency gains in specific tasks but leaving overall service models largely unchanged. In contrast, more digitally mature practices are better positioned to integrate these tools into redesigned workflows, enabling more fundamental changes to how care is delivered, including streamlined triage processes, reduced administrative burden and more proactive patient management.

This reinforces the interpretation that broadband connectivity is a necessary but not sufficient condition for service transformation: it enables new modes of delivery, but the scale of impact depends on complementary organisational capabilities, including digital leadership, staff capacity and workflow integration.

Why complementary conditions matter: Constraints on impact

These findings show that e-consultations, e-prescriptions, digital questionnaires and video consultations can streamline care pathways by enabling remote triage, faster prescribing and more efficient monitoring. Reliable broadband connectivity is a key enabling condition for these changes.

However, the realisation of these benefits depended on patient access and digital capability. The effectiveness of digital systems is shaped by patient demographics, device access, and connectivity outside the health site. As one GP noted;

“I suppose some of our older patients wouldn’t be able to access [Accurx]…”.
(General Practitioner, Somerset)

Variation in the use of e-consultations, e-prescriptions and asynchronous review systems can therefore be best understood as heterogeneity in organisational readiness and workflow integration, rather than variation in the intrinsic value of improved connectivity.

3.4 Theme 4: Digital technology and care pathways

This section examines how digital technologies, supported by improved broadband connectivity, may contribute to changes in care pathways within primary care settings. It explores how connectivity upgrades enable the integration of digital systems such as total triage platforms, e-consultations and A&G processes, and assesses how these tools influenced patient access and GPs’ communication with patients and consultants. By examining digital interactions between patients and GP surgeries, transformed referral processes and specialist consultation pathways, the section considers the extent to which digital technology enabled by broadband connectivity has expanded access to care. The digitally enabled processes discussed reflect broader shifts in healthcare delivery across the NHS, including efforts to manage more treatment within primary care settings and reduce unnecessary hospital referrals.

Patient access and digital inclusion

A BDUK member of staff involved in liaising with the Department for Health and Social Care and NHS during the Gigabit programme shared the importance of equal provision and access for policymakers:

“…one of the other sort of impacts to them that they were really chasing, I think, was… parity across systems…”
(BDUK Product Manager)

Greater connectivity and the integration of digital communication in healthcare provision was also linked in interview evidence to the widening of access to treatment for people with mobility issues and young people. A BDUK Product Manager suggested that connected GP surgeries benefited people who may face barriers to attending appointments in person:

“People who are unable to get out … [surgeries can] better service [them] through a different kind of connectivity.”
(BDUK, Product Manager).

Similarly, following the digitisation of a practice and the introduction of total triage, a GP saw an increase in younger patients contacting the surgery.

“I see all of these triage requests coming in, the e-consults coming in and it’s really interesting because there’s a lot of people who are in their teens or 20s or 30s who perhaps didn’t use to contact us, who feel very comfortable using the technology, who are now contacting us… I think [total triage] probably increased access amongst that age group.”
(General Practitioner, Herefordshire)

However, the interviewee also suggested that there may be too high a degree of access enabled by the surgery’s digital total triage system:

“The way we now have our triage system, it’s made us so accessible that actually sometimes you think we’re too accessible, so people will come to us at a very early stage with something that would probably resolve itself if they gave it a bit more time”.
(General Practitioner, Herefordshire)

This problem with total triage was echoed by the other GP interviewed, who described total triage as “exploding” GP surgeries’ workloads because “people can ask five questions a day rather than just the one that they previously asked”.

The same GP expressed further concerns with total triage systems that are digital first due to disparities in computer literacy:

“…if they’re not computer literate and there are still quite a few people who aren’t computer literate, then they’re going to struggle with that with other surgeries within [the Foundation Trust]. Some of them have gone to total triage, which means everything that comes in, comes in digitally, and… it’s all decided by the doctors as to what’s going to happen to it.”
(General Practitioner, Somerset)

On the digital divide, a GP emphasised the importance of ensuring access for older patients who tend to be less digitally literate and described the inclusion efforts made by her practice.

“We’ve tried very hard to mitigate against it, denying access for older people. So, what we’ve done with older people is… anyone who doesn’t feel that they can use [the total triage system] they can phone reception… and reception then does the triage form and then so it still goes through the triage system, but they can do it by phone.”
(General Practitioner, Herefordshire)

The interviewee did not observe any exclusion as a result of the surgery’s digital triage system:

“So, we’ve tried very hard, you know, to make sure that people aren’t excluded, and… I definitely don’t think we’ve had a reduction in the old age group getting through.”
(General Practitioner, Herefordshire)

A surgery’s shift to e-consultation through a total triage system was viewed as widening access, not only because of an increase in younger patients who may prefer digital methods of communication but also by reducing friction for patients trying to contact the surgery:

“…it’s going to be very difficult to accommodate everyone, make everyone happy… when you make such a big change. But I think the way we had it before where people were waiting on the phone for 40 to 60 minutes and probably some- a lot of them were giving up. I think that excluded a lot more people…”
(General Practitioner, Herefordshire)

Broadband connectivity was seen as not only enabling greater communication between GPs and patients via digital methods but also having the potential to support in-person communication. For example, a GP interviewee provided an example of the benefit of being able to access online videos in the surgery:

“…there’s a particular manoeuvre that you do to correct vertigo, and it requires me to move the patient in a particular way, so I show them on YouTube first. It wasn’t possible before YouTube was such a thing. But I can just show them the actual manoeuvre that I’m going to do on you. This is what it’s going to look like. So, they know what to expect.”
(General Practitioner, Somerset)

Clinician-consultant communication: Advice & Guidance and referrals

Both GPs interviewed emphasised the role of broadband connectivity in facilitating greater access and greater efficiency for referrals and consultations with specialists. Digital systems enabled interviewees to more easily refer patients who required referrals whilst reducing unnecessary referrals through remote communication with consultants. This occurred through advice and guidance (A&G), whereby “a GP requests guidance from a consultant through the NHS e-referral service” (Department of Health and Social Care, 2025, p. 39).

The integration of patients’ health records and the availability of fast, secure digital communication enabled surgeries to reduce unnecessary referrals, more easily complete necessary referrals and easily access the expertise of specialists through A&G.

One of the GPs interviewed described the intuition behind A&G:

“…the idea is that [specialist consultants] tell us what to do, advise us what to do and save us referring patients to them… where we can manage them purely in primary care.”
(General Practitioner, Herefordshire)

One of the benefits of A&G identified by the same interviewee was greater convenience for patients:

“I think the advantages are you know for the patients they may not need an unnecessary trip to the hospital. It’s pretty speedy.”
(General Practitioner, Herefordshire)

However, A&G entails GP surgeries completing new and additional tasks and offering new and additional care. A GP interviewed shared that A&G also increased the workload of their surgery as it involved taking on work that previously would have been managed through secondary care in hospital settings:

“Obviously because you’re taking workload away from secondary care from the hospitals, we’re getting more workload as a result because we’re managing more of these patients ourselves, which is why we’re paid to do it”
(General Practitioner, Herefordshire)

Notably, referral processes were also strengthened through broadband connectivity and digital technology:

“[W]ithout the access to good broadband, we wouldn’t be able to do a lot of the referrals we can do as seamlessly as we now can.”
(General Practitioner, Somerset)

For this GP, certain healthcare pathways were greatly enabled by digital developments in administrative processes:

“… [the referral process] for adult ADHD is all website-based. Now adult autism, ditto. And so, I can make those referrals, whereas previously they just wouldn’t have happened”
(General Practitioner, Somerset)

The effects of digitally enabled care pathways on patient access and system efficiency are similarly shaped by differences in digital maturity and service design. While improved connectivity enables the implementation of tools such as total triage, e-consultations and A&G, the outcomes associated with these pathways are not uniform across practices.

In more digitally mature settings, where digital tools are integrated into coherent service models and supported by inclusive design, these pathways can expand access, improve coordination with secondary care and reduce unnecessary referrals. However, where digital systems are introduced without sufficient attention to patient capability, workflow integration or demand management, they may generate unintended consequences, including increased workload or barriers for digitally excluded groups.

This highlights that the benefits of connectivity-enabled care pathways depend not only on the availability of infrastructure, but on how effectively practices translate that capability into inclusive and well-designed service models.

Treatment pathways using digital technology: Dermatology and cardiology

A GP interviewee explained that patients who previously would have been referred to a dermatologist for a face-to-face appointment, which would have involved them waiting for a year, could have a photo taken of their skin with a special device for looking at skin lesions, known as a dermatoscope. This photo could then be shared digitally with a dermatologist who would assess next steps. This A&G process, from beginning to end, would likely take only two weeks and would ensure that only patients who needed face-to-face appointments were referred.

“Well, for example, we do a lot of photographing of skin lesions and sending them to dermatologists in Bristol… when I routinely send a photo, I tell the patient to get back to me if they’ve heard nothing by two weeks, because I know that I will have an answer within two weeks. That answer may be that the dermatologist wants to see the patient, which won’t be within two weeks, but at least something will be happening.”
(General Practitioner, Somerset)

This experience is supported by broader statistical findings from the UK’s most widely used tele-dermatology platform, Consultant Connect; over a ten-year-period, patients avoid unnecessary dermatology referrals 63% of the time when photo technology and A&G are used (2025).

Another care pathway mentioned with reference to the utility of A&G was Cardiology:

“…our secretary does it on our behalf…they send an e-mail to a hospital department so Dermatology or Cardiology and they’ve got systems set up where they’ve presumably got consultants at the other end going through GP requests and then they’ll send us back written advice.”
(General Practitioner, Herefordshire)

Furthermore, the interviewee also found A&G useful for granting them access to remote support for interpreting cardiology-related test results:

“I do quite a lot of cardiology [A&G] here I’ve got a patient and they’ve had an ECG (Electrocardiogram) that perhaps that I’m a bit uncertain about, so I’ll … tell the consultant the history, send off the ECG and then the consultant will say ‘no, I’m not worried about this’. Well, that’s brilliant, because I can then reassure the patients and they’re not waiting for very long to hear back.”
(General Practitioner, Herefordshire)

The use of cardiology-related A&G within primary care is supported by recent NHS guidance. The Getting It Right First Time national review of NHS cardiology services across England (Clarke & Ray, 2021)positioned the provision of consistent e-Referral Service - Advice and Guidance as having a key role in the acceleration and expansion of three focus areas for cardiology set out by the Elective Care Transformation Programme. 78% of trusts studied in deep dive visits by the Data Analysis team reported regular use of ERS–Advice and Guidance to avert admission or clinical attendance (Clarke & Ray, 2021, p.31).

Oxfordshire: Wider-system and place-based impacts

Case study evidence indicates that improved broadband connectivity can facilitate health and social care provision outside traditional health sites. In the Oxfordshire GigaHubs project, the County Council used its own funds to expand the roll-out of GigaHubs beyond BDUK’s scope to include village halls and community centres. Oxfordshire County Council’s rationale was that improved connectivity would not only benefit community activities at these sites but also mean the sites could be used as bases for providing NHS and Adult Social Care services in these more remote areas.

An Oxfordshire County Council staff member touched on the NHS’ aim to shift from hospital to community:

“…the NHS is keen to do more locally. They’re keen to avoid people having to travel into the JR [John Radcliffe] hospital just to get a scan done, or to get stitches taken out…”

Broadband connectivity was suggested to be very important in the context of this goal:

“Communities centres can be part of that solution… we have a road map for that which, without the fibre being in there, would never be a starter.”
(Council Digital Infrastructure Team)

A volunteer at a connected village hall outlined an example of this shift, explaining how health-related community support hosted groups in their village hall post-connection:

“But the NHS come in here, and they do… there’s a Weight Watchers, but I think there’s also a mother and baby group that comes in. So, there are two or three different types of fairly large groups of NHS people that come in, and that’s quite a lot.”
(Village Hall Volunteer)

Although the volunteer acknowledged that there would have been a new profile of groups utilising the hall due to hiring arrangements ceasing during the Covid-19 pandemic, they also felt the faster broadband was a contributing factor to some of the new groups, including the NHS, deciding to hire the hall:

“…it’s good for them because it’s accessible, because of the [motorway] and the car park… So, I suspect they’re probably the ones who are benefiting the most from having reliable broadband because you’ve got lots of communities, lots of people coming from outside, they all want to be checking whatever they want to check on their phones…”
(Village Hall Volunteer)

Implementation constraints, challenges and limitations shaping impact

The interconnectedness of care systems to delivery over pathways constrains implementation and digital roll-out in individual GP surgeries as a discrete activity. Enabling primary care settings to operate within a wider connected digital set of platforms is often managed as a programme of interventions perhaps led out of an NHS body. The individual connection at a surgery, while possible from a broadband provision perspective, may then face hurdles for the site to take up and integrate the connectivity. For example, it was challenging to identify a suitable contact person who had the authority to make decisions regarding a site’s internet connection to liaise with at the hub sites. Oxfordshire County Council noted that this was a particular problem for Hubs based at NHS sites:

“[the NHS] is such a fragmented organisation. You know, the individual surgeries are individual businesses, individual practices, but they have to buy things that are to a standard that is set by the NHS Digital team, but they’re- the local oversight is through… Primary care trusts…”
(Council Digital Infrastructure Team)

“So, you had this kind of [situation of] no one person to speak to, to open doors. We had to engage and consult with numerous people to get them to understand what it was all about…”
(Council Digital Infrastructure Team)

This fragmentation was also noted by a BDUK member of staff who was involved in liaising with the NHS:

“…some of the other barriers were particularly in relation to the NHS were that GP surgeries are… not necessarily run centrally.”
(BDUK Product Manager)

“…but getting everyone together, getting signed up, getting to do all the things at the same time would have been a real struggle for them, I think, and in terms of resource and things like that.”
(BDUK Product Manager)

At the practice level, these same inter-dependencies associated with operating an integrated health care system with common digital resources created working-level risks. The interviewed GPs warned of the challenges and costs to medical treatment when broadband connectivity is lost. Broadband connection was vital for their surgery to access their clinical system EMIS.

“Well, everything we use is dependent on broadband technology, the computer system… EMIS (the surgery’s clinical system) is hosted remotely, which means if the Internet goes down, EMIS goes down.”
(General Practitioner, Somerset)

Similarly, there were difficulties in providing treatment when broadband connectivity is poor:

“we’ve had fairly infrequent…issues where if it does crash then you know we’re in quite a lot of difficulty because all of the patient notes are on our EMIS, our software system. Obviously, if the phones go down, then that’s a big problem as well…we’re very dependent on it, but fortunately it happens very rarely.”
(General Practitioner, Herefordshire)

Why complementary conditions matter: Digital pathways and access

Prior to the adoption of digitally enabled care pathways, patient access and clinician communication often relied on slower, more fragmented processes, contributing to delays, inefficient referral processes and weaker coordination between primary and secondary care. Tools such as total triage, e-consultations and A&G have improved access and supported more streamlined referral processes.

At the system level, connectivity creates option value for more integrated and place-based care pathways, but this value is dependent on service design, patient inclusion and coordination across primary, secondary and community care.

However, the benefits of these pathways depended on how they were implemented in practice. While reliable connectivity enabled these systems to function, factors such as digital inclusion, patient capability and service design influenced whether improved access translated into better patient experience and more efficient care.

4. Interpretation and Use of Evidence

BOX 4: Implications for rollout.

The evidence suggests that improved broadband connectivity creates two broad types of benefit for connected GP surgeries.

Realisable benefits: operational resilience. Improved connectivity supports more reliable use of cloud-based clinical systems, digital communication tools, e-prescribing, remote consultation platforms and digital patient record systems. These benefits are closest to the broadband upgrade and are therefore the most directly attributable, although their scale may vary by baseline connection quality and demand.

Contingent benefits: service change and pathway redesign. Wider benefits, including the use of video consultations, e-consultations, asynchronous reviews, Advice & Guidance processes, digitally enabled referral pathways, are dependent on organisations’ digital maturity, workforce capacity, workflow integration, existing service design and patient digital access.

Broadband should be treated as a foundational enabler in GP surgeries rather than a standalone intervention. It can reliably strengthen operational resilience, but wider option value is realised when connectivity is paired with digital maturity, compatible service design and patient inclusion support.

The findings in this report should be interpreted in line with the methods used to generate them (detailed in the Annex) and the extent to which the available data supports attribution, comparison and generalisation.

• Quantitative analysis of GP appointment data using a comparative design provides the strongest evidence in this study, enabling before-and-after assessment relative to matched comparator sites. These findings provide the most robust evidence of observable change associated with improved connectivity and should be used where the evaluation requires evidence of measurable behavioural change or direct programme effects.

• Qualitative evidence, including in-depth interviews and case studies, is used to explain how changes may have occurred and the conditions under which impacts are realised. This provides insight into mechanisms, operational context and the role of complementary factors such as digital maturity, service design and workforce capacity. These findings are not designed to demonstrate the scale or uniformity of impact, but to support interpretation of the quantitative results.

• Across themes, differences in evidence strength reflect data availability and coverage rather than the value of the findings. The report therefore combines evidence of observable change in specific service indicators with evidence that explains how connectivity may contribute to wider service transformation under different conditions.

The findings should be used to complement other evidence in the wider evaluation. Quantitative evidence can inform measurable benefit pathways and future value for money analysis, while qualitative evidence supports interpretation, identifies enabling conditions and constraints and informs programme learning.

Taken together, the evidence supports that improved connectivity is a necessary enabling condition for modern digital healthcare delivery. The extent to which this translates into wider outcomes depends on factors beyond connectivity alone and should be considered when applying the findings in policy, programme design and further analysis.

5. Conclusions

The report findings demonstrate that broadband upgrades functioned as a foundational enabler for modern rural healthcare infrastructure. Improvements in speed and reliability supported the operational resilience of GP surgeries by strengthening the effective use of cloud-based clinical systems, digital communication tools and remote consultation platforms. Drawing on NHS England’s WGLL framework and Greenhalgh et al.’s typology of digital maturity, the analysis interprets variation in impact through organisational readiness, workflow integration and service design. Across the four themes, the report traces how connectivity supports change from core digital infrastructure and appointment delivery through to patient access, care pathway coordination and place-based models of care.

The quantitative analysis of appointment data suggests a measurable change in the mode of consultation. Analysis of patient attendance data then suggests a consistent, albeit modest, benefit from video-based consultations over telephone, with higher attendance rates seen across all models. The increase in online consultations following connection is likely to be correlated with a GP surgery adopting digital platforms for appointment management, record keeping, e-prescriptions and telemedicine. Data to explore this quantitatively is not available. However, qualitative findings demonstrate that, once the broadband upgrade is being used, it can function as a critical enabling condition for modern healthcare provision and digital infrastructure. Day-to-day operations in connected surgeries are strengthened by administrative efficiencies and new forms of professional communication such as A&G.

At the organisational level, these infrastructure gains enhanced service reliability aligned with the Department of Health and Social Care’s Ten-Year Health Plan for England (2025). However, the extent to which improvements will have translated into broader service development may vary. Further evidence is needed to better understand how widespread and persistent the impacts of improved connectivity in health sites are. Future research on broadband connectivity could explore what factors shape digital service provision in health sites, whether benefits vary depending on patient population and how digital service provision in primary care may impact secondary care sites. This would help to better tease out the linkage from output to outcomes to impacts in the Theory of Change and allow for a framework which offers insight into variation in adoption and impact of digital connectivity in GP surgeries and other health sites.

Overall, the evaluation demonstrates that gigabit connectivity is a necessary condition for health sites to access the administrative and treatment-related benefits of A&G, e-prescriptions, video consults and other digitally enabled tools. There is also evidence of a significant behavioural change due to the Hub investment. The pathways of further impact are indicated qualitatively. However, sustained and equitable impact depends on complementary investment in equipment, staff skills and cross-sector coordination.

6. Annex: Methodology

Evidence gathered for this study included quantitative impact analysis focusing on GP appointments and identifying changes in the mix of consultation modes following a Hub connection. For GP Hubs, monthly appointment data for English general practices was used in a quasi-experimental design to assess the impact of fibre broadband installation on the distribution of GP appointment types. There has also been a series of depth interviews conducted with BDUK, project leaders, local authority officials, GPs and other stakeholders.

6.1 Analysing GP appointments after connection

To assess the impact of fibre broadband installation on the distribution of GP appointment types, the quasi-experimental design employed to look at broadband uptake and availability in the econometric strand to this evaluation (see Belmana, 2023) was used to identify a comparator group. The approach compares changes in the share of appointment types – video conferencing, telephone calls, face-to-face consultations, and home visits – before and after the installation of fibre at surgeries, relative to a matched group of surgeries that did not receive the upgrade during the same period.

Matching was conducted in a first stage using propensity score matching to identify a comparison group of surgeries with similar characteristics to those that received fibre through Hub investments. Matching was similar to the earlier modelling but focused on the 51 English GP surgeries and matched these only to comparable practices in England as detailed practice level appointment data is unavailable in the devolved administrations. Data about appointments is published soon after month end allowing analysis up to April 2025.

In the second stage, the analysis estimated fixed-effects panel regression models on the supported and matched sample, allowing for control of time-invariant differences between surgeries and common shocks across time through surgery and year fixed effects. The treatment effect was captured through an interaction term between a binary indicator for fibre receipt and the post-installation time period, identifying the average change in appointment share attributable to fibre connection. Robustness was assessed by estimating nine separate models, and standard errors were clustered at the surgery level to account for within-surgery correlation over time.

This method enables a credible estimation of the causal impact of fibre connectivity on service delivery modes in GP practices, under the assumption of parallel trends between treated and matched control surgeries prior to the intervention. It relied on area-level data to identify the comparator GP surgeries and the GP appointments data published by NHS England.

Characterising areas with GP Surgery Hubs

BDUK provided a range of data for the study. The Hub intervention data related to the 1,021 Hubs supported by mid-2022. Data covered the name, address and type of site, the time of the investment and connection, as well as the funding provided and the supplier that connected the Hub.

The Hubs are being connected in areas that are remote in terms of the broadband network. That provides a start to characterise where Hubs are being delivered, but there are also socioeconomic, broadband coverage/performance and public service delivery drivers for a Hub investment. This annex looks at the data that has been compiled to explore the Hubs connections. Various datasets are linked at an output area (OA) level:

Coverage and performance data: Ofcom publishes the Connected Nations reports on the UK’s communications infrastructure, focusing on coverage and performance of fixed broadband and mobile networks. This report uses the annual report data from Ofcom Connected Nations from 2017 up to 2025, including additional years since the analysis for the initial report.

Intervention data: BDUK also provided data – the Vouchers Data – covering the timing, supplier, value and location of the voucher support and whether it was supported under the GBVS or Rural Gigabit Connectivity Programme vouchers scheme. It also identifies whether the voucher was part of a project (where a supplier has aggregated a number of applications focused on a specific geographical area) or was a standard voucher (a standalone application from a household or business). The initial analysis has been updated using a more recent extract of the Vouchers Data, which includes the Project Gigabit vouchers that have been provided since the conclusion of GBVS and RGC in 2022.

Commercial viability data: Secondly, BDUK’s FScore Model provides an estimated relative cost to install fibre to the premise. The value is proportionate to cost, so that low values reflect premises that can be connected at low cost, while higher values indicate the opposite. The premises have further been characterised in terms of their viability, primarily to differentiate those that can be connected commercially in that the market would reach on its own without further public subsidy^{[footnote 3]}. This distinction approximates to the 20% of premises referred to as being F20 premises in the initial report.

Economic statistics: The modelling seeks to characterise areas in terms of their business population. For this, the ONS Business Register and Employment Survey has been used to provide data on employment at LSOA level for England and Wales (via Nomis). As well as total employment by LSOA, a variable measuring employment in digital sectors was constructed. This has been complemented by Data Zone level economic data for Scotland and higher geographies Northern Ireland. For OA level analysis, only LSOA level (and equivalent geographies in Scotland and Northern Ireland) data is available.

Other area characteristics controls: ONS population density estimates at LSOAs, the 2011 Rural Urban Classification for LSOAs and Indices of Deprivation were added. For OA level analysis, only LSOA level data is available. The Scottish and Northern Irish equivalent datasets have been integrated.

GP appointments in England data

The Appointments in General Practice dataset is a monthly statistical publication produced by NHS Digital, on behalf of NHS England. Data is sourced directly from GP clinical systems, including EMIS, TPP, Cegedim, Microtest/Eva Health, and others. The data is reported at individual GP practice levels, with aggregated counts of appointments in each category reported every month.

Data includes the number of appointments, the mode of delivery (e.g., face-to-face, telephone, online), the professional role of the clinician, time between booking and appointment, appointment duration, and attendance status. COVID-19 vaccination appointments were recorded separately through the National Immunisation Management System (NIMS), having been excluded from GP appointment totals after mid-2021 to improve data quality and interpretability. Since April 2023, appointment data has also been collected from Primary Care Networks (PCNs), though PCN coverage remains partial, with an estimated 80% of PCN appointments captured.

There were some limitations to this data:

• There was no GP level data available on attendance prior to November 2022, and many Hubs were connected throughout the period.

• The appointments data was limited to NHS England.

• Several categories had a high proportion of appointments with “unknown” attendance, or appointment mode.

• There is a likelihood that choice of meeting type is biased based on what the meeting entails, and this may have impacted attendance. For example, catchups over telephone may be more likely to be forgotten than video consultations with a specialist.

• Coverage was not universal: some practices do not submit data due to system incompatibility or low activity levels.

6.2 Approach to depth interviews

The aim of the qualitative evidence gathering is to understand the processes and pathways by which Hubs deliver impacts and provide a picture of the key impacts. Questions cover the challenges faced at each of the stages both to draw learnings and to test the logic of impact. Since many kinds of public buildings were connected, a key aim is to explore the impact on public services and compare them across projects.

Interview recruitment

The depth interviews were conducted continuously over the study period using a variety of routes to recruit interviewees. The focus of the depth interviews ranged from delivery and process matters to the achieved impacts at Hubs and understanding the outcomes across different kinds of Hubs and projects.

The interviews started with the BDUK evaluation team and the core BDUK officials involved in RGC and GigaHubs. Early interviews were with BDUK local delivery leads, officers that cover relationships with local authorities and liaison with projects. Officials were formally interviewed on more than one occasion during the study and workshops with several officials also helped to provide understanding.

Interviews with RGC and GigaHub project managers initiated the main qualitative evidence gathering about impacts. Some projects were led by central government departments and some by local authorities. The project managers referred the study team to contacts at Hubs, suppliers, officers working in areas related to online delivery, such as the local authority digital officers or those involved in education, health or library service at local authority level. The interviews at Hubs usually involved either the staff member responsible for site IT or taking a delivery role using connectivity. Interviewees sometimes covered a few different locations, such as the head of IT across a school trust.

Three strands of the qualitative evidence gathering recruited individuals that had been involved in one of the telephone surveys conducted for the study. During the fieldwork, surveys have been conducted with English schools, libraries and recipients of broadband voucher. Some of these surveys were for other studies, but all contained questions asking survey respondents whether they would be willing to be recontacted for a depth interview.

Interview methodology

The focus of the depth interviews at Hubs and Hub projects was on achieved impacts and understanding the outcomes across different kinds of Hubs and projects. They gathered in-depth evidence on the process of connecting public buildings, broadband use, need for faster broadband, broadband performance and the impacts of improved connectivity. Questions were designed to attribute where possible impacts to Hub investments, discussing context, needs as well as challenges.

The interviews typically took place online and lasted between 30-40 mins. Interviewees were asked for permission to record the interviews. Depth interviews utilised interview frameworks designed for the interviewee with around half a dozen different frameworks employed. These varied primarily by the type of interviewee.

Overall, by April 2026, 60 interviews were conducted with stakeholders, of which this report uses five interviews including two conducted with non-GigaHub General Practitioners based in post-upgrade non-urban GP surgeries.

7. References

Belmana (2023). BDUK Rural Gigabit Connectivity Hubs Evaluation. Report to BDUK authored with Hatch and Winning Moves. https://www.gov.uk/government/publications/bduk-rural-gigabit-connectivity-hubs-evaluation

Belmana (2026a). BDUK Gigabit Hub Evaluation: Process Review. Report to Building Digital UK authored with GC Insight. GovGigaHubs Process Review

Belmana (2026b). BDUK Gigabit Hub Evaluation: Theory of Change. Report to Building Digital UK authored with GC Insight. GovGigaHubs Process Review Theory of Change

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1. A gigabit-capable connection is a wired connection capable of download speeds of at least 1 gigabit-per-second, equivalent to 1,000 megabits per second. ↩

2. The associated Value for Money report will seek to value these effects. ↩

3. See paragraphs 108 and 109 of the Further Telecoms Infrastructure Review: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/732496/Future_Telecoms_Infrastructure_Review.pdf ↩