REMOTE-Neuro: co-produced recommendations to optimise remote neurology - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Neurol Open . 2026 Apr 15;8(1):e001518. doi: 10.1136/bmjno-2025-001518 Search in PMC Search in PubMed View in NLM Catalog Add to search REMOTE-Neuro: co-produced recommendations to optimise remote neurology Patricia Fuller Patricia Fuller 1 University of Southampton, Southampton, UK 2 National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Hampshire, UK Find articles by Patricia Fuller 1, 2 , Sarah Fearn Sarah Fearn 1 University of Southampton, Southampton, UK 2 National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Hampshire, UK Find articles by Sarah Fearn 1, 2 , Sally Dace Sally Dace 3 Patient and Public Involvement Representative, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Hampshire, UK Find articles by Sally Dace 3 , Amanda Wollam Amanda Wollam 3 Patient and Public Involvement Representative, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Hampshire, UK Find articles by Amanda Wollam 3 , Angeliki Zarkali Angeliki Zarkali 4 Dementia Research Centre, University College London, London, UK Find articles by Angeliki Zarkali 4 , Adam Cowan Adam Cowan 1 University of Southampton, Southampton, UK Find articles by Adam Cowan 1 , Sam Mountney Sam Mountney 5 The Neurological Alliance, London, UK Find articles by Sam Mountney 5 , Georgina Carr Georgina Carr 5 The Neurological Alliance, London, UK Find articles by Georgina Carr 5 , Sofia H Eriksson Sofia H Eriksson 6 Department of Clinical and Experimental Epilepsy, National Hospital for Neurology and Neurosurgery and Institute of Neurology, University College London, London, UK 7 The Association of British Neurologists, London, UK Find articles by Sofia H Eriksson 6, 7 , Christopher Kipps Christopher Kipps 1 University of Southampton, Southampton, UK 8 University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre, Southampton, UK Find articles by Christopher Kipps 1, 8, ✉ Author information Article notes Copyright and License information 1 University of Southampton, Southampton, UK 2 National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Hampshire, UK 3 Patient and Public Involvement Representative, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Hampshire, UK 4 Dementia Research Centre, University College London, London, UK 5 The Neurological Alliance, London, UK 6 Department of Clinical and Experimental Epilepsy, National Hospital for Neurology and Neurosurgery and Institute of Neurology, University College London, London, UK 7 The Association of British Neurologists, London, UK 8 University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre, Southampton, UK Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. Additional supplemental material is published online only. To view, please visit the journal online ( https://doi.org/10.1136/bmjno-2025-001518 ). None declared. ✉ Professor Christopher Kipps; [email protected] Received 2025 Dec 15; Accepted 2026 Mar 25; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13084783 PMID: 42007402 Abstract Objective To examine stakeholder experiences of remote neurology outpatient care and to co-produce an evidence-based framework to support safe, equitable and sustainable service delivery. Methods We undertook an inductive thematic analysis of free-text responses from three national surveys: a patient and carer survey conducted by the Neurological Alliance (2021; n=2463) and two surveys of neurologists conducted by the Association of British Neurologists (2020 and 2021; n=593). Findings were validated through co-production workshops and interviews with patients, carers and healthcare professionals in 2024 (n=43). Themes were triangulated and refined to generate stakeholder-endorsed recommendations. Results Participants valued flexible choice in consultation modality, recognising the accessibility and convenience of remote care, but expressed concerns about clinical quality, privacy and equity. Both patients and clinicians viewed remote care as a distinct skill set requiring tailored training and stronger digital infrastructure. Importantly, some participants perceived remote appointments as less legitimate than in-person consultations, a novel and under-recognised challenge with implications for engagement and health equity. Five domains aligned with National Health Service (NHS) transformation principles were identified: (1) patient-centred care, (2) neurology and specialist area considerations, (3) clinical safety and quality, (4) capacity and sustainability and (5) operational efficiency. These findings informed the REcommendations for optimising Modality, Operational efficiency, Training and Equity in NEUROlogy (REMOTE-Neuro) framework. Conclusions Remote care continues to offer significant benefits to both patients and clinicians. However, several years postpandemic, there are still unresolved issues which limit its effective integration with face-to-face care. Practice implications REMOTE-Neuro provides a co-produced set of recommendations to optimise remote neurology practice. Grounded in over 3000 stakeholder perspectives and aligned with NHS transformation priorities, it offers a practical roadmap for implementation in neurology and a transferable model for other specialties. Keywords: CLINICAL NEUROLOGY, HEALTH POLICY & PRACTICE WHAT IS ALREADY KNOWN ON THIS TOPIC Remote consultations are now a routine component of neurology outpatient care; however, there is limited evidence on how to integrate remote and face-to-face (F2F) modalities safely, effectively and equitably. WHAT THIS STUDY ADDS This large, multidataset, co-produced study presents an evidence-based framework to optimise remote neurology services. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY The REcommendations for optimising Modality, Operational efficiency, Training and Equity in NEUROlogy framework provides actionable, co-produced recommendations that directly operationalise National Health Service outpatient transformation priorities. It offers a practical structure to guide service design and future evaluation of hybrid neurology models. Introduction The COVID-19 pandemic necessitated a rapid shift to remote healthcare delivery. Despite historical concerns about the limitations of remote neurology appointments, increasing evidence indicates that remote appointments, when appropriately triaged, can be both safe and effective with clear advantages to patients, clinicians and the wider healthcare system. 1 , 8 What remains unclear is how best to combine face-to-face (F2F), telephone, video and asynchronous communication in ways that optimise safety, equity and efficiency. Most existing studies are based on small samples from single centres and tend to present either the patient or clinician perspective. 6 , 8 At UK national level, strategic initiatives such as Getting It Right First Time provide valuable and detailed service-wide recommendations for neurology. 9 Broader programmes including the NHS Long-Term Plan, 10 the Outpatient Recovery and Transformation Programme 11 and the Topol Review 12 promote digital innovation and more personalised outpatient care across the NHS. In parallel, WHO and NHS England endorse co-producing new models of care with service users. 13 What is missing so far is a single framework to bring these strands together in a way that reflects the lived realities of those delivering and receiving remote neurology care. To address this gap, we synthesised three national surveys comprising over 3000 stakeholder perspectives and convened a series of iterative co-production workshops with patients, carers and healthcare professionals (HCPs). These workshops validated and enriched the national findings and informed a co-produced set of REcommendations for optimising Modality, Operational efficiency, Training and Equity in NEUROlogy (REMOTE-Neuro framework). By integrating lived experience with clinical insight at scale, the framework delivers practical and stakeholder-endorsed recommendations for optimising remote neurology care. Methods Study design This study followed a two-phase, mixed-methods design. Phase I involved an inductive thematic analysis of national survey data. Phase II comprised a series of stakeholder workshops, interviews and focus groups to validate findings and co-produce practical recommendations. Data sources and participants Views of patients, carers and clinicians were captured from: Neurological Alliance ‘My Neuro Survey’ (2021) : free-text reflections on remote consultations provided by 2463 respondents living with neurological conditions. Association of British Neurologists (ABN) Work-Practice Surveys (2020, 2021) : quantitative and qualitative data on service delivery, remote-care modalities and condition-specific suitability from 225 neurologists in 2020 and 368 in 2021. Patient and carer co-production workshops : three in-person workshops held between January and November 2024 with a purposive sample of 17 neurology patients and four carers. HCP interviews and focus groups : 43 HCPs from the Wessex region, including 20 neurologists and trainees, 12 Parkinson’s, four neuromuscular, two multiple sclerosis and five epilepsy specialist nurses and allied health professionals. Data analysis Free-text responses from the national surveys were coded independently by four researchers (PF, SF, AZ, AC) using the inductive thematic analysis by Braun and Clarke. 14 Themes were developed collaboratively and refined through team discussion to enhance rigour and credibility. Descriptive statistics from the ABN surveys were used to contextualise and triangulate the qualitative findings. Themes were compared across datasets to identify areas of convergence and divergence. Data adequacy was assessed to ensure sufficient depth and diversity of perspectives. 15 The analysis team brought mixed disciplinary expertise (clinical neurology, public health and qualitative research) and lived-experience perspectives, and reflexive discussions considered how researcher backgrounds shaped theme development. Co-production and validation Draft themes were reviewed with patients, carers and HCPs during phase II workshops, interviews and focus groups to confirm relevance, refine interpretations and translate findings into practical recommendations. Recommendations were developed iteratively, ensuring they reflected stakeholder priorities and real-world feasibility. Final themes and recommendations were mapped to national priorities outlined in the NHS Long-Term Plan 10 and the Outpatient Recovery and Transformation Programme. 11 Results Participants ( table 1 ) comprised patients, carers and HCPs from across the UK. The Neurological Alliance survey responses were received from 2463 adults living with a variety of neurological conditions (mean age 59 years; one-third with multiple diagnoses). ABN surveys represented 593 neurologists, predominantly consultants, 66% male, with a modal time in practice of 11–15 years. Local co-production participants had lived experience of several different neurological conditions, including multiple sclerosis, Parkinson’s disease, dementia, epilepsy, migraine, Huntington’s disease, peripheral neuropathy and dystonia, average age 63.4 years. Interviews and focus groups with local clinicians captured perspectives from all main neurology subspecialties. Table 1. Demographic characteristics of participants: (A) Association of British Neurologists Work-Practice Surveys (2020: n=225; 2021: n=368), (B) Neurological Alliance ‘My Neuro Survey’ (2021; n=2463). (A) Domain Category 2020 n (%) 2021 n (%) Sex Male 118 (64.5) 156 (67.5) Female 61 (33.3) 72 (31.2) Prefer not to say 4 (2.2) 3 (1.3) Age (years) 25–30 2 (1.1) 2 (0.9) 31–36 14 (7.7) 14 (6.1) 37–42 30 (16.4) 50 (21.7) 43–48 38 (20.8) 52 (22.5) 49–54 41 (22.4) 48 (20.8) 55–60 39 (21.3) 47 (20.4) 61–66 17 (9.3) 15 (6.5) ≥67 2 (1.1) 3 (1.3) Role Consultant 165 (90.2) 209 (90.5) Trainee 18 (9.8) 22 (9.5) Years as consultant 1–5 26 (15.7) 44 (21.1) 6–10 29 (17.5) 35 (16.8) 11–16 39 (23.5) 49 (23.4) 17–22 43 (25.9) 45 (21.5) 23–27 15 (9.0) 21 (10.1) ≥28 14 (8.4) 15 (7.2) Type of centre Neurosciences centre 118 (64.5) 187 (81.0) Neurology centre 23 (12.6) 29 (12.6) District general hospital 42 (23.0) 78 (33.8) (B) Domain Category N (%) Age (years) Mean (range) 58.9 (25–93) Neurological condition (top 10) Multiple conditions 817 (33.2%) Multiple sclerosis 345 (14.0%) Epilepsy 172 (7.0%) Parkinson’s 147 (6.0%) Dystonia 120 (4.9%) Myasthenia 118 (4.8%) Functional neurological disorder 92 (3.7%) Myalgic encephalomyelitis 83 (3.4%) Migraine 75 (3.1%) Other 59 (2.4%) Open in a new tab Themes were organised into five domains aligned with NHS transformation principles ( figure 1 ). Exemplar quotations and the full set of stakeholder-endorsed recommendations are presented in online supplemental files . Figure 1. Schematic representation of the REcommendations for optimising Modality, Operational efficiency, Training and Equity in NEUROlogy framework showing the five domains and associated subthemes. Neurology and specialist area considerations include: ‘When face-to-face is essential’, ‘When remote care works’, ‘Subspecialty considerations’, ‘Accessibility gains’, ‘Communication nuances’ and ‘Perceived value’. QI, quality improvement. Open in a new tab Patient-centred care This theme captured the value patients ascribed to remote appointments, but also their concerns around quality, privacy and digital equity. Two subthemes emerged: choice of appointment modality and barriers to remote care. Choice of appointment modality Many patients emphasised having a genuine choice of all modalities, not just between F2F and telephone. For initial consultations or when new or concerning symptoms arose, they often preferred an in-person visit that allowed a comprehensive assessment including physical examination where necessary. When their condition felt stable, video or telephone follow-ups were generally acceptable. Remote options were valued for their convenience, lower cost and ability to bridge gaps between in-person reviews. However, staff found managing multiple communication routes at times inefficient and confusing, as patients might use all modalities for a single issue. Barriers to remote care While remote options were appreciated for their convenience, specific concerns coalesced around five main areas: quality of care, technological challenges, appointment systems, privacy and equity. Concerns about appointment systems and technology, although central to patient experience, are presented under ‘Capacity and sustainability’ and ‘Operational efficiency’ themes. Concerns about care quality Some patients and carers doubted that clinicians could deliver a truly holistic assessment at a distance. They felt anxious about relying on self-report, afraid they might overlook subtle symptoms and only relaxed once a F2F review reassured them that nothing had been missed, misdiagnosed or underestimated in its impact. In the absence of other clues, communication and rapport were viewed as much more difficult remotely, with the consultation often feeling a little impersonal and rushed. Neurological symptoms could also be difficult to articulate remotely and sometimes it was just much easier to explain in person. Some patients also acknowledged that being remote allowed them to be selective about what they disclosed, a limitation also recognised by HCPs. Concerns about privacy Privacy could be a concern for patients at both ends of the conversation. Not everyone had access to a suitable private location for a remote appointment. Many preferred seeing that the clinician was in a private space to avoid requesting a further F2F appointment to discuss sensitive issues. Concerns about equity There was general concern among patients and carers that not everyone would be comfortable using technology or have the competence and access to do so. Neurologists, too, were conscious that the increasing use of digital care could further marginalise underserved groups; in the 2021 ABN Work Practice Survey, 21% of respondents were aware of Trust/Board targets for F2F versus remote appointments. Neurology and specialist area considerations This theme explored the unique clinical and contextual factors influencing how remote care is delivered in neurology. It highlighted the accessibility benefits of remote care and concerns about the perceived informality of remote care, which risked undermining value if not clearly framed and supported. When face-to-face is essential Free-text responses from the ABN surveys highlighted a strong preference for F2F appointments for most new patients and where there was a need for examination, assessment or treatment; to ease communication; in the presence of complexity or known vulnerability; to facilitate involvement of a carer or other HCP or to respect patient preferences. Clinicians fully supported patient choice, but this had to be clinically safe and appropriate. Quantitative findings (2021 ABN survey) revealed that over 90% of neurologists preferred F2F assessments over remote formats, with approximately 60% of all consultations conducted in person, 30% by phone and 10% by video. F2F consultations were preferred for the following neurological problems: weakness (94.5%), gait dysfunction (87.6%), cognitive impairment (81.7%), tremor (74.3%), sensory complaints (70.2%; table 2 ). Table 2. ABN work practice survey 2021 (n=368): (A) condition-specific suitability for remote appointments, (B) preferred remote modality, (C) preference for F2F versus remote, (D) current practice. (A) Neurological problem Well-suited, n (%) Poorly suited, n (%) Weakness 4 (2.0) 206 (94.5) Sensory complaints 34 (16.9) 153 (70.2) Headache 177 (88.1) 21 (9.6) Tremor 45 (22.4) 162 (74.3) Gait dysfunction 20 (10.0) 191 (87.6) Cognitive impairment 27 (13.4) 178 (81.7) Transient loss of consciousness 168 (83.6) 31 (14.2) (B) Setting Phone, n (%) Video, n (%) General neurology 124 (57.4) 92 (42.6) Subspecialty 93 (49.7) 94 (50.3) (C) Setting F2F, n (%) Remote, n (%) General neurology 217 (96.0) 9 (4.0) Subspecialty 176 (90.3) 19 (9.8) (D) Setting F2F, n (%) Phone, n (%) Video, n (%) General neurology 219 (63.4) 211 (32.0) 165 (8.3) Subspecialty 197 (60.2) 188 (33.9) 145 (12.6) Open in a new tab ABN, Association of British Neurologists; F2F, face-to-face. When remote works well Free-text ABN responses identified headache, transient loss of consciousness (TLOC), seizures and sleep disorders as being well-suited for remote appointments, even for new referrals. Quantitative responses supported these views (headache 88.1%; TLOC 83.6%), although opinions on seizures and sleep were not elicited nor the differentiation between new referrals and follow-ups. Preferences for remote modality were split relatively evenly between phone and video across both general and subspecialty clinics. Remote appointments were considered more suitable for follow-up patients, although much depended on the particular patient, how well they were known to the team and other triage-related factors discussed above. Subspecialty considerations With the exception of headache, seizures, sleep disorders and TLOC, there was less consensus around the suitability of other new and follow-up remote appointments (see quotes in the online supplemental files ). Views differed both within and across subspecialties, reflecting, inter alia, the characteristics of each patient population and clinician preferences. Accessibility gains Both patients and HCPs recognised remote consultations as transformative for accessibility and convenience, particularly for conditions with a wide geographical catchment and for patients with mobility issues, clinical vulnerabilities, severe disabilities, psychosocial issues and those reaching end-of-life. A quick triaging phone call was useful to direct patients to the appropriate subspecialty, and clinicians also appreciated the real-world insights gained from home-based assessments of environment and function, in which patients were relaxed and comfortable. Communication nuance Patients with communication challenges felt that remote consultations could still be effective when tailored to their needs. For example, individuals with speech impairments sometimes preferred F2F appointments for ease, while others found video calls using the chat function helpful. For sensitive conversations, many patients favoured F2F, but some found it more comfortable to receive such information at home, where they could have support and more space to process their emotions privately. Perceived value Clinicians felt that some patients treated remote consultations as having less value than in-person appointments, for example, answering calls while out shopping. Clinical nurse specialists reported being typically unable to reach three patients in a morning clinic, with some asking for a call back later; a formal complaint was later traced to a series of telephone reviews that the patient had not recognised as ‘proper’ appointments. Clinical safety and quality This theme highlighted the foundational elements required to deliver safe and effective remote care and the practical constraints imposed by the system. Importance of a robust triage process HCPs stressed the critical importance of robust triage. It was felt to be a time-consuming and onerous activity not always fully captured in job plans but improved by being consultant-led. Not all units and staff used a formal triage process to provide uniformity of care. Private space availability HCPs highlighted significant challenges in shared workspaces. When multiple staff members were on remote calls simultaneously, it became harder to hear patients clearly and to preserve their dignity and confidentiality. Rapid access slot provision Crucially, HCPs did not always feel confident that they would be able to see patients F2F in the time scale they felt was required after concerns had been identified remotely. Although the ready availability of rapid-access clinic spots was deemed essential for a safe remote service with adequate safety-netting, in some trusts this was compromised by the loss of clinic rooms during the pandemic that had not been returned. Audit and quality improvement Ongoing audit and feedback cycles were considered essential to ensure pathways remained responsive and evidence informed. Capacity and sustainability This domain looked beyond technology to the workforce, training and co-produced resources that could make virtual appointments sustainable over time. Co-produced resources for patients and carers Patients and carers said technical glitches such as poor connectivity or uncertainty about what to do if a call failed could erase some of the advantages of remote care. Neurological symptoms could further limit their ability to troubleshoot in real time. In our co-design workshops, participants asked for co-produced, well-signposted resources that demystified the process and reframed remote care as an empowering option rather than a lesser substitute. Suggestions included co-produced ‘how-to’ guides and decision trees to facilitate choice of appointment type. Training and support for staff HCPs were conscious that in a rapidly evolving healthcare landscape, they needed to be kept up-to-date with best practices in remote neurology. Investment in staff training would value and motivate them, allow them to care for patients in the way they aspired to and would positively influence workforce recruitment and retention. Yet, current arrangements could fall short. HCPs acknowledged that shifts in diagnostic processes, missed training opportunities due to technical failures and trainers working remotely were changing teaching and training. This needed to be recognised by new and innovative training methods for students and staff. Clinicians reported managing digital systems and related admin beyond their job plans, with much of the innovation driven by individual efforts, not formal roles or resourcing. Importantly, succession planning was often lacking, despite clear signposting, meaning that the departure of key staff left vulnerabilities in knowledge and systems. Defining and assessing remote care competencies Both HCPs and patients viewed remote care as a distinct skill set requiring specific competencies. HCPs noted challenges in building rapport, assessing disability and managing risk without visual cues or physical examination, while also needing to troubleshoot technical issues. Patients highlighted the importance of clinician skill in overcoming communication limitations, particularly the loss of non-verbal cues. For example, in the absence of visual clues and an explanation, the sound of a HCP typing could be misinterpreted as lack of interest; patients could not see concern or interest in a phone consultation, so they valued the HCP verbally acknowledging that they had noted down a particular symptom or concern; patients often perceived telephone consultations as rushed, while HCPs needed to ask more questions to replace what would be obvious in a F2F consultation. Operational efficiency This theme highlighted the systemic and logistical barriers that undermined the effectiveness of remote care and eroded confidence in the system. Administrative friction Patients reported receiving short-notice or repeatedly altered appointments, sometimes in the wrong modality; re-booking could be opaque and cancellations could create long gaps between support and care, followed by an appointment cluster. Not all patients received warning of on-the-day appointment delays, which proved especially difficult for those with bladder issues, limited privacy or work constraints. Some units have solved this problem for their patients by using the chat function to warn of any delays in real-time. Clinicians reported similar frustrations. If a video link had not been issued, the first 10–15 min were lost to phoning the patient, emailing a link and coaching them onto the platform. Out-of-date contact details compounded delays. Streamlined booking and reliable contact data were seen as low-cost fixes that could raise confidence in virtual care. Digital infrastructure Many clinicians were frustrated at digital infrastructure quality and reliability, with ‘clunky’ laptops, multiple platforms and slow, bolt-on upgrades that lengthened every task. Processing a single consultation could require up to ‘28 mouse-clicks’; often over-booked clinics had to be juggled manually because the scheduling software simply reported that clinics were full. Time for innovation Clinicians were keen to build patient-facing materials, for example, videos, portal pages, ‘what to expect’ guides or visual ‘walk-throughs’, which would set realistic expectations and demonstrate how remote visits fit into holistic care. Yet most felt too stretched to create or update these tools in the absence of protected time. To aid comparison of stakeholder views across domains, a structured summary of key patient/carer and clinician perspectives is presented in table 3 . Table 3. Summary of patient, carer and clinician perspectives. Domain Patient and carer perspective Clinician perspective Patient-centred care Strong preference for a genuine choice between F2F, telephone and video for all appointments. Preferred F2F for initial consultations, new or worrying symptoms. Valued remote care for stable conditions and discussion-based reviews. Felt increased responsibility when self-reporting remotely, with concern that symptoms might be missed or underestimated. Recognised potential for selective symptom disclosure, particularly by telephone. Aware that remote models could widen inequities. Supported patient choice where clinically appropriate and safe. Acknowledged limitations of remote self-reporting. Recognised risk of exacerbating pre-existing inequities through digital expansion. Observed that some patients perceived remote care as less legitimate than F2F care. Neurology and specialty-specific considerations Reported difficulty articulating complex neurological symptoms remotely. Noted that communication challenges did not necessarily preclude remote care. Valued accessibility gains of remote appointments, particularly for disability, fatigue or long travel distances. Strong preference for F2F assessment in most new consultations. Considered many follow-up appointments suitable for remote delivery. Identified headache, TLOC, seizures and sleep disorders as particularly amenable to remote assessment. Reported less consensus across other subspecialties. Valued real-world assessment in home environment. Clinical safety and quality Valued reassurance that remote concerns could be escalated promptly to F2F review. Reported privacy concerns in both home and clinical remote settings. Identified robust triage as essential for safe hybrid care. Reported challenges conducting remote consultations in shared workspaces. Noted that timely access to rapid access F2F slots was not consistently available. Capacity and sustainability Requested clear, well-signposted co-produced resources to help normalise and navigate remote care. Viewed remote care as a distinct skill set. Identified need for training and defined remote care competencies. Valued clinician competence in remote communication. Operational efficiencies Experienced cancellations and opaque re-booking processes leading to gaps in care. Reported outdated contact details and missing video links. Worked across multiple, poorly integrated platforms. Reported lack of warning about on-the-day appointment delays. Described connectivity failures that undermined confidence. Described the administrative burden increasingly shifting to clinicians. Identified IT reliability as a source of stress and risk. Reported limited protected time for service development and innovation. Open in a new tab F2F, face-to-face; TLOC, transient loss of consciousness. Discussion This study presents REMOTE-Neuro, a co-produced set of stakeholder-informed recommendations to optimise remote neurology care. The findings highlight the lived experiences and priorities of those delivering and receiving care, revealing areas where communication, clinical pathways and support systems could be strengthened. Addressing these areas has the potential to benefit patients through more responsive, personalised care and to support clinicians by reducing inefficiencies and enhancing professional development and support. Patient-centred care Flexible choice of appointment modalities was a major theme. While prior studies have recognised the benefits of remote consultations for patients with mobility issues or logistical barriers, 36 7 16 , 20 our findings indicate that in neurology, modality decisions are also influenced by condition-related and symptom-related communication needs. Patients and carers therefore favoured hybrid models with sufficient flexibility to accommodate clinical context and changing needs over time. Our data also surfaced a relatively unexplored issue: that some patients may perceive remote appointments as inherently less valuable. This has important implications, as it may deter engagement or reduce the quality of information shared. Our co-production workshops recommended co-producing materials that normalise remote care and support self-efficacy, particularly for those with lower health or digital literacy. This approach has worked well for surgical schools. 21 , 23 Importantly, patients still worry about quality of care, privacy and equity. These issues have been previously documented both in neurology and across other specialties, 36 7 16 , 20 suggesting that familiarity with remote models has not fully translated into confidence. In particular, shifting responsibility for technical setup, privacy management and troubleshooting onto patients risks transferring systemic burdens to individuals, where they can be less visible and less easily addressed, with potential to widen existing health inequalities. Aligning with NHS England’s emphasis on reducing inequities in access and outcomes and the Topol Review, REMOTE-Neuro therefore advocates routine audit of remote pathways to identify digital barriers and mitigate unintended exclusion. 24 Neurology and specialist area considerations Clinicians supported choice, but this had to be clinically appropriate. Consistent with smaller studies, 1 4 7 20 our large national dataset revealed a clear consensus that most new patients should be seen F2F, while many follow-ups could be seen remotely. Neurological problems such as headache, seizures, TLOC and sleep disorders, where diagnosis is predominantly history-driven and investigation-supported, were considered potentially suitable for remote assessment, even in new referrals, provided triage and follow-up systems were robust. However, beyond these general trends, there was less consensus on condition-specific criteria for remote versus F2F care. As such, there is a clear need to develop more detailed guidance for each neurological subspecialty to support consistent practice. Clinical safety and quality Triage was identified as the critical foundation for remote care but was often described as time-consuming and inconsistently supported by formal structures or job plans. Given the broad consensus around triage, a standardised framework with automation for low complexity cases could be explored. This might streamline processes, reduce variability, support safety and alleviate clinician burden, as has been demonstrated elsewhere. 25 Equally essential are clearly defined and transparent pathways for rapid transition to a F2F appointment when required. Such safeguards are fundamental to maintaining patient safety and preserving trust within hybrid models. Capacity and sustainability Improving remote care requires sustained investment in people as well as technology. In a specialty already affected by burnout and attrition, 26 upgrading IT infrastructure and streamlining scheduling systems could ease pressure on an overstretched workforce. These improvements might also help reduce missed appointments currently averaging 11.7% in neurology. 9 Sustainable remote neurology requires protected time for clinicians to maintain remote-care skills, support trainee learning and work with patients to co-produce and update resources that help them navigate and make effective use of remote appointments. Co-production participants emphasised this shared responsibility: both patients and staff need the skills and support to engage with and benefit from remote consultations. Operational efficiency Despite national initiatives, 27 digital disparities and fragmented infrastructure continue to undermine the effectiveness of remote care, with wide variation across the country. Our findings show that practical challenges, such as outdated platforms, inefficient workflows, poorly integrated appointment systems and limited private spaces, interact to create systemic friction that erodes trust and demoralises both patients and clinicians. These barriers have direct implications for clinical safety and may limit the effective integration of hybrid pathways. They may also influence the perceived value of remote consultations and undermine wider system goals, including efforts to reduce unnecessary outpatient visits. Limitations This study has several limitations. First, participants may over-represent digitally engaged or motivated individuals. Inconsistent demographic information across datasets limited subgroup analysis. Additionally, some perspectives may reflect pandemic-specific conditions, although our recent local validation confirmed continuing relevance. Conclusion REMOTE-Neuro is a co-produced, stakeholder-informed framework to optimise remote neurological care. Although developed within neurology, its structure and methodology provide a transferable model for other specialties and health systems navigating hybrid models of care. Our data also highlight an important and under-recognised challenge: patient perceptions of value. If remote care is seen as second tier, this structural vulnerability will impact trust and engagement. Exploring and addressing this legitimacy gap is likely to be just as vital as any technical upgrade. The framework offers practical guidance for clinicians, service leads, commissioners and digital transformation teams. Even modest actions, such as offering greater choice of appointment format, ensuring private spaces for remote consultations and sharing co-produced patient information, can increase patient trust and reduce avoidable pressure on clinicians. Rather than serving as a rigid checklist, REMOTE-Neuro is designed to be adapted through local co-design and aligned with available infrastructure. It prioritises what matters most to staff and patients to enable continuous and meaningful quality improvement over time. Future work should examine value perceptions across contexts, evaluate implementation and assess the impact of rapid-access F2F appointments and automated triage pathways on safety and engagement. Supplementary material online supplemental file 1 bmjno-8-1-s001.pdf (475.5KB, pdf) DOI: 10.1136/bmjno-2025-001518 Acknowledgements We would like to thank the patients, carers, healthcare professionals and members of the University Hospital Southampton Outpatient Transformation team who contributed their insights and time to this project. We are grateful to the Neurological Alliance and the Association of British Neurologists who shared their surveys with us and our PPI contributors, whose collaboration shaped the design, analysis and outputs of this study. The funder had no involvement in the study design; in the collection, analysis and interpretation of the data; in the writing of the report or in the decision to submit the paper for publication. The funder did not influence the results or outcomes of the study despite author affiliations with the funder. Footnotes Funding: This study was funded by the University Hospital Southampton Small Grant Scheme award (D3-GRT0709). Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent for publication: Not applicable. Ethics approval: This study was approved by the Ethics Committee: East Midlands—Derby Research Ethics Committee (IRAS 287057). Participants gave informed consent to participate before taking part in the study. Data availability free text: The data that support the findings of this study are available from the Neurological Alliance and the Association of British Neurologists, but restrictions apply to their availability, as they were used under licence for the current study and are not publicly available. Data are, however, available from the authors on reasonable request and with the permission of the Neurological Alliance and the Association of British Neurologists. Data availability statement Data are available on reasonable request. References 1. Tan SY, Gunawardana N, Roberts RC. The Lasting impact of the COVID-19 pandemic on outpatient neurology consultations. BMJ Neurol Open . 2024;6:e000608. doi: 10.1136/bmjno-2023-000608. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. Watila MM, Duncan C, Mackay G. Evaluation of telemedicine for new outpatient neurological consultations. BMJ Neurol Open . 2022;4:e000260. doi: 10.1136/bmjno-2021-000260. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 3. Seigel CR, Martin H, Bastin G, et al. Patient acceptance of teleneurology across neurologic conditions. J Neurol. 2024;271:2850–8. doi: 10.1007/s00415-024-12200-y. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 4. Stavrou M, Lioutas E, Lioutas J, et al. Experiences of remote consulting for patients and neurologists during the COVID-19 pandemic in Scotland. BMJ Neurol Open . 2021;3:e000173. doi: 10.1136/bmjno-2021-000173. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 5. Gandelman-Marton R. Potential feasibility of a remote first visit in the epilepsy clinic. Epilepsy Behav. 2023;146:109358. doi: 10.1016/j.yebeh.2023.109358. [ DOI ] [ PubMed ] [ Google Scholar ] 6. Ezeamii VC, Okobi OE, Wambai-Sani H, et al. Revolutionizing Healthcare: How Telemedicine Is Improving Patient Outcomes and Expanding Access to Care. Cureus. 2024;16:e63881. doi: 10.7759/cureus.63881. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 7. Courtney E, Blackburn D, Reuber M. Neurologists’ perceptions of utilising tele-neurology to practice remotely during the COVID-19 pandemic. Patient Educ Couns. 2021;104:452–9. doi: 10.1016/j.pec.2020.12.027. [ DOI ] [ PubMed ] [ Google Scholar ] 8. Kehagia AA, Chowienczyk S, Helena van Velthoven M, et al. Real-World Evaluation of the Feasibility, Acceptability and Safety of a Remote, Self-Management Parkinson’s Disease Care Pathway: A Healthcare Improvement Initiative. J Parkinsons Dis . 2024;14:197–208. doi: 10.3233/JPD-230205. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 9. Geraint Fuller Neurology - getting it right first time. [01-May-2024]. https://gettingitrightfirsttime.co.uk/medical_specialties/neurology/ Available. Accessed. 10. NHS The NHS long term plan. [01-May-2024]. https://www.longtermplan.nhs.uk/ Available. Accessed. 11. NHS England Outpatient recovery and transformation programme. https://www.england.nhs.uk/outpatient-transformation-programme/ n.d. Available. 12. Topol E. The topol review: preparing the healthcare workforce to deliver the digital future. [01-Jun-2024]. https://topol.hee.nhs.uk/ Available. Accessed. 13. World Health Organisation WHO global strategy on integrated people-centred health services 2016-2026. [30-Jan-2025]. https://interprofessional.global/wp-content/uploads/2019/11/WHO-2015-Global-strategy-on-integrated-people-centred-health-services-2016-2026.pdf Available. Accessed. 14. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101. doi: 10.1191/1478088706qp063oa. [ DOI ] [ Google Scholar ] 15. O’Reilly M, Parker N. ‘Unsatisfactory Saturation’: a critical exploration of the notion of saturated sample sizes in qualitative research. Qual Res. 2013;13:190–7. doi: 10.1177/1468794112446106. [ DOI ] [ Google Scholar ] 16. Leach H, Eccles A, Chew-Graham CA, et al. Patient experiences of remote consulting with chronic fatigue syndrome/myalgic encephalomyelitis and fibromyalgia: a qualitative study. BJGP Open. 2025;9:BJGPO. doi: 10.3399/BJGPO.2024.0079. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 17. LeRouge CM, Garfield MJ, Hevner AR. Patient perspectives of telemedicine quality. Patient Prefer Adherence. 2015;9:25–40. doi: 10.2147/PPA.S67506. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 18. Kruse C, Karem P, Shifflett K, et al. Evaluating barriers to adopting telemedicine worldwide. a systematic review. 2018:24. doi: 10.1177/1357633X16674087. [ DOI ] [ PMC free article ] [ PubMed ] 19. Ford J, Reuber M. Exploring patients’ views on telephone consultations in the seizure clinic: A qualitative interview study. Epilepsy Behav Rep . 2024;28:100705. doi: 10.1016/j.ebr.2024.100705. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 20. Patel UK, Malik P, DeMasi M, et al. Multidisciplinary Approach and Outcomes of Tele-neurology: A Review. Cureus. 2019;11:e4410. doi: 10.7759/cureus.4410. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 21. Fecher-Jones I, Grimmett C, Ainsworth B, et al. Systematic review and narrative description of the outcomes of group preoperative education before elective major surgery. BJA Open . 2024;10:100286. doi: 10.1016/j.bjao.2024.100286. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 22. Howell J, Stocker M. Patients go home sooner after Hip and knee replacements using standardized guidance in Epic. [10-Jun-2024]. https://issuu.com/britorthopaedic/docs/boa_jto_v11_i01_final_draft4/s/19884812 Available. Accessed. 23. Wynter-Blyth V, Moorthy K. Prehabilitation: preparing patients for surgery. BMJ . 2017:j3702. doi: 10.1136/bmj.j3702. [ DOI ] [ PubMed ] [ Google Scholar ] 24. NHS England Inclusive digital healthcare: a framework for NHS action on digital inclusion. 2025 25. Transformation directorate Using intelligent automation to improve the triage and referral management pathway. [10-Jun-2024]. https://transform.england.nhs.uk/key-tools-and-info/digital-playbooks/gastroenterology-digital-playbook/using-intelligent-automation-to-improve-the-triage-and-referral-management-pathway/ Available. Accessed. 26. Kipps C, Kinton L, McCarron M, et al. Clinician burnout: results of an ABN survey of British neurologists. J Neurol Neurosurg Psychiatry. 2022;93:A11. doi: 10.1136/jnnp-2022-ABN.32. [ DOI ] [ Google Scholar ] 27. Deloitte Closing the digital gap: shaping the future of UK healthcare. [01-May-2024]. https://www2.deloitte.com/content/dam/Deloitte/uk/Documents/life-sciences-health-care/deloitte-uk-life-sciences-health-care-closing-the-digital-gap.pdf Available. Accessed. Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials online supplemental file 1 bmjno-8-1-s001.pdf (475.5KB, pdf) DOI: 10.1136/bmjno-2025-001518 Data Availability Statement Data are available on reasonable request. Articles from BMJ Neurology Open are provided here courtesy of BMJ Publishing Group ACTIONS View on publisher site PDF (1018.4 KB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top