Safety netting: what does it actually mean?

GP Insight | March 2019

Safety netting summary table

• Likely time course of current symptoms• When and why to come back if symptoms do not resolve• Specific red flag symptoms or changes to look out for• The reasons for tests or referrals, including the suspicion of cancer if appropriate

• If a diagnosis is uncertain

What to communicate to patients

• Ensure that you have current contact details for patients undergoing tests or referrals

• Ensure patients know how and when to obtain their results• Have a system for communicating abnormal test results to patients

• Have a system for contacting patients with abnormal test results who fail to attend for follow up

• Put in place systems to document that all results have been viewed, and acted upon

• Have policies in place to ensure that tests ordered by locums are followed up

• Highlight repeat consultations for unexplained recurrent symptoms

• Make sure practice staff involved in logging results are aware of reasons for urgent tests and referrals

• Conduct learning events for patients diagnosed as a result of an emergency admission

• Conduct an annual audit of new cancer diagnoses eg NCDA

Actions for practices

• Check the patient understands the safety netting advice (take into account language/literacy barriers)• If symptoms do not resolve, carry out further investigations even if previous tests are negative• Consider accuracy of diagnostic tests and possibility of false negatives, eg chest X-ray, etc

• Consider referral after repeated consultations for the same symptom where the diagnosis is uncertain (eg three strikes and you are in)

• Code all symptoms and urgent referrals• Detail any safety netting advice in the medical notes

Actions for GPs

Safety netting summary flowchart Patient communication GP consultation Practice process/system Education

Together we will beat cancer

Consider referral/investigations OR planned/patient-initiated review

Practice system for communicating abnormal test results to patient

Check up to date patient contact details

Tell patient: ∞ Reason for tests ∞ Who will make follow-up appointment ∞ When to return for results

Cancer suspected

No investigations/referrals but cancer is possible

Repeated consultations for same symptoms?

Patient presents/ re-presents to GP

Urgent cancer referral/investigations

Abnormal results

Normal results

Cancer confirmed

Cancer excluded

Cancer excluded

New or recurring symptoms

ReferencesSuspected cancer: recognition and referral NICE guideline. Published: 22 June 2015.Safety netting to improve early cancer diagnosis in primary care: development of consensus guidelines. Final Report. 4th May 2011. Clare Bankhead et al.

Practice system to check and log: ∞ Patient appointment attendance∞ Patient receives results ∞ Results viewed and acted on (including investigations ordered by locums)

∞ Log safety netting advice in notes and code symptoms∞ Process for follow-up including who will book the follow up appointment

Communicate to patient:∞ Uncertainty ∞ When to come back if symptoms persist∞ Red flag symptom/changes

Also consider... Keep up to date with referral guidelines for suspected cancer Conduct an annual audit of new cancer diagnoses Carry out a Learning Event of every delayed diagnosis of cancer

Consider further tests/investigations

Inside:safety netting

summary poster

Together we will beat cancer

Are you worried about missing a cancer diagnosis?Patients often present with symptoms that could indicate a new cancer diagnosis. Some will be easily recognised as potentially serious and acted upon, but many will be non-specific or vague eg fatigue, weight loss or abdominal pain. The non-specific nature of cancer symptoms is a key challenge to early diagnosis and part of the reason why so many cancers are diagnosed at a late stage, when the chance of a successful outcome is lower. Safety netting is an important process to help manage diagnostic uncertainty and support more timely diagnosis of cancer.

The concept of safety-netting in health has been around for over 30 years. It’s a set of steps and actions that can be taken at the consultation and practice level to ensure patients are monitored until their symptoms and signs are explained and results acted upon. It has been shown to be relevant at each step of diagnostic process in primary care and at the interface with secondary care.

We do safety netting in different

ways and don’t talk about it, so it can be difficult to know exactly what is being done, and to identify and share good practice. We need to share best practice and generate evidence for which types of safety netting are most effective and for whom. Formal ways of collecting and analysing such data are being explored.

Dr Brian Nicholson

A key part of safety netting includes communicating any uncertainty in the diagnosis to the patient and being

clear about when a re-consultation is appropriate1. This could include information about which symptoms to look out for, or the timeline for seeking help again if symptoms haven’t resolved. In some cases, immediate booking of a follow-up appointment, and monitoring of attendance to that appointment, is necessary.

Safety netting also incorporates good coding of symptoms and actions taken, which can support practice-level systems to track primary care tests and follow-up actions. Practice-level systems should also monitor onward referrals while clinical decision making should consider the possibility of false negative test results among patients with persistent symptoms.

The combination of face-to-face safety netting and systems could

be really powerful. A simple request to book a follow-up appointment could be supported by a system to identify patients who have not attended for their follow-up within a specified timeframe.

Dr Brian Nicholson

1. The Inner Consultation. 1987. Dr Roger Neighbour. Radcliffe Publishing Ltd

Safety netting is also relevant in the context of screening, not only to help track patients with abnormal screening results but also to consider cancer in patients with relevant symptoms regardless of a recent normal screening result.

Reported challenges to safety netting include patient co-operation, complexity and changes in the local health care systems, resistance to change, and lack of training.

GPs can make the case for safety

netting using learning events (formerly called SEAs) from their own practice. A practice-wide non-judgemental and open dialogue can aid learning and embedding improved practices into safety netting systems. Online resources and support from the CRUK Facilitator Programme can also be helpful.

Dr Ishani Patel

Together with our patients, we

benefit from clear, shared systems to ensure that consultations, tests and subsequent actions are linked to rapid, appropriate management. Recently our secretaries suggested having a safety net prompt around requests for advice and guidance from secondary care – which is now routine.

Dr Pawan Randev

What 3 things can you do? (from Dr Pawan Randev)

• Consider what the consequence of a patient not attending a test/appointment/follow up would be

• For normal results with persisting symptoms, continue to review (eg false negatives can be common in CXRs for patients with lung cancer; symptomatic FIT negative patients can continue to have symptoms)

• Ask yourself if there is a robust system of following up investigations and patients in your practice

More information and resources• Request support locallyCancer Research UK’s facilitators work across the UK to provide facilitated support to over 5,700 GP practices. Facilitators in your local area are happy to talk to you about how we can help improve cancer outcomes.

They also offer a free one-hour facilitated workshop on safety netting to help your practice team review and reflect on the strengths of safety netting in your practice and any areas for improvement.

Call 0203 469 5272 or email facilitators@cancer.org.uk

• Order copies of Your Urgent Referral Explained leafletFor patients who have been urgently referred with suspected cancer, to help them prepare for appointments and tests. cruk.org/publications

• Download the NICE Guidance desk easel cruk.org/NICE

• Visit CRUK webpage on safety netting cruk.org/safetynetting

• Sign up to receive Cancer Insight emailsOur newsletters provide you with best practice information on important cancer-related topics, as well as the latest evidence, training materials, practical tools and patient resources. cruk.org/cancerinsightGP

• Sign up to National Cancer Diagnosis Audit Read past results and take part in the upcoming NCDA. cruk.org/NCDA

Further readingNicholson BD, Mant D, Bankhead C. BMJ 2016;355:i5515. Can safety netting improve cancer detection in patients with vague symptoms?

Evans J, Ziebland S, MacArtney JI, Bankhead CD, Rose PW, Nicholson BD. Br J Gen Pract 2018; 68 (672): e505-e511. GPs’ understanding and practice of safety netting for potential cancer presentations: a qualitative study in primary care.

Hirst Y, Lim AWW. Br J Gen Pract 2018; 68 (670): e333-e341. Acceptability of text messages for safety netting patients with low-risk cancer symptoms: a qualitative study.

Jones D, Dunn L, Watt I, Macleod U. Br J Gen Pract 2019; 69 (678): e70-e79. Safety netting for primary care: evidence from a literature review.

Cancer Research UK is a registered charity in England and Wales (1089464),Scotland (SC041666) and the Isle of Man (1103). CIGP22

Safety netting summary table

• Likely time course of current symptoms

• When and why to come back if symptoms do not resolve

• Specific red flag symptoms or changes to look out for

• The reasons for tests or referrals, including the suspicion of cancer if appropriate

• If a diagnosis is uncertain

What to communicate to patients

• Ensure that you have current contact details for patients undergoing tests or referrals

• Ensure patients know how and when to obtain their results

• Have a system for communicating abnormal test results to patients

• Have a system for contacting patients with abnormal test results who fail to attend for follow up

• Put in place systems to document that all results have been viewed, and acted upon

• Have policies in place to ensure that tests ordered by locums are followed up

• Highlight repeat consultations for unexplained recurrent symptoms

• Make sure practice staff involved in logging results are aware of reasons for urgent tests and referrals

• Conduct learning events for patients diagnosed as a result of an emergency admission

• Conduct an annual audit of new cancer diagnoses eg NCDA

Actions for practices

• Check the patient understands the safety netting advice (take into account language/literacy barriers)

• If symptoms do not resolve, carry out further investigations even if previous tests are negative

• Consider accuracy of diagnostic tests and possibility of false negatives, eg chest X-ray, etc

• Consider referral after repeated consultations for the same symptom where the diagnosis is uncertain (eg three strikes and you are in)

• Code all symptoms and urgent referrals

• Detail any safety netting advice in the medical notes

Actions for GPs

Safety netting summary flowchart

Patient communication GP consultation Practice process/system Education

Together we will beat cancer

Consider referral/investigations OR planned/patient-initiated review

Practice system for communicating abnormal test results to patientCheck up to date patient

contact details

Tell patient:

∞ Reason for tests

∞ Who will make follow-up appointment

∞ When to return for results

Cancer suspected

No investigations/referrals but cancer

is possible

Repeated consultations for same symptoms?

Patient presents/ re-presents to GP

Urgent cancer referral/investigations

Abnormal results

Normal results

Cancer confirmed

Cancer excluded

Cancer excluded

New or recurring symptoms

References

Suspected cancer: recognition and referral NICE guideline. Published: 22 June 2015.

Safety netting to improve early cancer diagnosis in primary care: development of consensus guidelines. Final Report. 4th May 2011. Clare Bankhead et al.

Practice system to check and log:

∞ Patient appointment attendance

∞ Patient receives results

∞ Results viewed and acted on (including investigations ordered by locums)

∞ Log safety netting advice in notes and code symptoms

∞ Process for follow-up including who will book the follow-up appointment

Communicate to patient:

∞ Uncertainty

∞ When to come back if symptoms persist

∞ Red flag symptom/changes

Also consider...

Keep up to date with referral guidelines for suspected cancer

Conduct an annual audit of new cancer diagnoses

Carry out a Learning Event of every delayed diagnosis of cancer

Consider further tests/investigations