Download safety netting summaries
Safety netting is an important tool that can be used to support management of diagnostic uncertainty, helping ensure patients are re-evaluated in a timely and appropriate manner.
Safety netting is a diagnostic strategy or consultation technique to help manage diagnostic uncertainty. It helps ensure patients undergoing investigations for, or presenting with symptoms which could indicate serious disease, are followed up in a timely and appropriate manner. The term safety netting encompasses a wide range of actions and procedures. These include actions used at an individual GP-patient consultation level and procedures implemented at a practice level. Safety netting is particularly important for suspected cancer, where symptoms are common and often non-specific.
The concept of safety netting was first introduced by Roger Neighbour, who considered it a core component of the general practice consultation. Neighbour broke down the process into 3 key questions:
1. If I’m right what do I expect to happen?
2. How will I know if I’m wrong?
3. What would I do then?
Despite this work being widely cited, there has been little progress on how to interpret and apply diagnostic safety netting in practice.
- Neighbour, R. The inner consultation. Oxford, England: Radcliffe Publishing, 2004.
There is no peer-reviewed evidence on the effectiveness of safety netting in primary care for patients with suspected cancer. The limited literature that does touch on safety netting is largely based on significant event analysis (SEA)* of cancer diagnosis, recommending safety netting as a key action for improving the diagnostic process[1,2].
Although there's no firm evidence, safety netting is regarded as an essential component of primary care consultation and as such is recommended as part of the NICE guidelines for suspected cancer referral, Scottish cancer referral guidelines, and 2015 cancer strategy for England.
“Safety netting is recognised as an important tool when a patient isn’t deemed to be high risk, but cancer can’t be ruled out. It empowers patients to seek further advice if symptoms are changing. Safety netting can also help prevent patients from ‘ping-ponging’ between GP and hospital, test after test, until a diagnosis can be made. There’s still some confusion about this practice, GPs need more support to implement it. - Dr Richard Roope, Cancer Research UK’s GP expert[5, 6, 7].
*Significant event analysis (also called significant event audit) is a quality improvement technique, used to reflect and learn from individual patient cases.
- Mitchell, E., Rubin, G. & Macleod, U. Understanding diagnosis of lung cancer in primary care: qualitative synthesis of significant event audit reports. BJGP 2013 doi:10.3399/bjgp13X660760.
- Mitchell, E., Rubin, G., Merriman, L. & Macleod, U. The role of primary care in cancer diagnosis via emergency presentation: qualitative synthesis of significant event reports. BJC 2015. doi:10.1038/bjc.2015.42
- Evans J, Ziebland S, MacArtney JI. GPs’ understanding and practice of safety netting for potential cancer presentations: a qualitative study in primary care. BJGP 2018 doi:10.3399/bjgp18X696233
- Nicholson BD, Goyder CR, Bankhead SR. Responsibility for follow-up during the diagnostic process in primary care: a secondary analysis of International Cancer Benchmarking Partnership data. BJGP 2018 doi:10.3399/bjgp18X69581
- Nicholson BD, Mant D, Bankhead C. Can safety-netting improve cancer detection in patients with vague symptoms? BJGP 2016 doi:10.1136/bmj.i5515.
University of Oxford consensus guidelines
An unpublished study led by researchers at the University of Oxford used GP expertise to develop consensus guidelines for safety netting patients in primary care with suspected cancer.
We have developed summaries of the consensus guidelines to aid implementation.
Table style - summarises advice for communicating with patients, as well as safety netting actions for GPs and GP practice
Flowchart style – summarises safety netting actions through the diagnostic journey
Workbook – practical tool to enable GP practices to reflect on their own safety-netting practice. It includes a summary of the safety-netting guidance and shares examples of good practice.
Research in progress
CRUK’s Early Diagnosis Advisory Group (EDAG) have funded the University of Oxford to do some peer-reviewed research to follow up on this work. The study will investigate current safety netting practice and develop comprehensive safety netting recommendations. The project is due to report towards the end of 2017.
National guidelines for suspected cancer referral
The NICE guidelines for suspected cancer referral suggest that those at higher risk of cancer but who do not meet referral criteria are recommended for safety netting.
Cancer strategy for England
The 2015 cancer strategy recommends that NHS England should incentivise the establishment of processes by GP practices to ensure safety netting of patients, including support for training.