Safety netting

nurse.png	Some cancer symptoms are easily recognised, where timely management and referral for suspected cancer may be straightforward, but this is not always the case. Patients presenting with non-specific symptoms can cause diagnostic uncertainty and be difficult to manage, which can result in longer primary care intervals and later stage diagnosis [1]. For example, abdominal pain is a common symptom associated with multiple cancers as well as benign diagnoses [2,3]. Safety netting is an essential process to help manage uncertainty in the diagnosis and management of patients by providing information for patients and organising follow-up after contact with a health professional.
small_-_png-icon_notepad_tick_cyan_cmyk.png	Patients need to be informed of when, why and how to book a follow-up appointment should their symptoms persist, worsen or change.
small_-_png-icon_headshoulders_x3_magenta_rgb_0.png	Safety netting may be performed at the time of the contact between health professional and patient, or may happen after the contact through active monitoring and administrative systems to manage results and referrals [1].
small_-_png-icon_warning_grey_rgb.png	People who are referred on a suspected cancer pathway should be aware that further investigation is due to possible cancer, to help the patient understand the risk of cancer associated with their symptoms and the importance of attending their future appointment. Careful and balanced communication is important to avoid unnecessary patient distress. For example, when known, it may be appropriate to inform patients of their individual risk of cancer and that a referral has been made to rule out a cancer diagnosis.

References

1. Jones, D., et al., Safety netting for primary care: evidence from a literature review. British Journal of General Practice, 2019. 69(678): p. e70-e79.
2. Koo, M.M., et al., The nature and frequency of abdominal symptoms in cancer patients and their associations with time to help-seeking: evidence from a national audit of cancer diagnosis. J Public Health (Oxf), 2018. 40(3): p. e388-e395.
3. Renzi C, Lyratzopoulos G, Hamilton W, Rachet B. Opportunities for reducing emergency diagnoses of colon cancer in women and men: A data-linkage study on pre-diagnostic symptomatic presentations and benign diagnoses. European journal of cancer care. 2019;28(2):e13000.Safety netting of primary care tests

Retrospective clinical reviews showed that 1 in 4 cancers diagnosed in England (2014) had an avoidable delay to their diagnosis, with nearly half (49%) of delays happening in primary care [2]. The authors suggest that avoidable delays attributed to patient factors (for example presence of comorbidities), which occur after presentation, may benefit from improved safety netting or communication to patients.

Broadly, the evidence [1-3] suggests that the key components of safety netting fit within:

• Patient symptom follow-up
• Diagnostics, including the possibility of false negative results.
• Referral for further investigation

One study found that patients who are being referred for further investigation may feel a lack of transparency in the referral process, be concerned about being ‘lost in the system’ and not knowing what to expect [1]. The research also suggested that GPs providing information and reassurance regarding a referral is considered by a patient to be as important as the speed of their referral. Therefore, it's important to ask patients what they'd like to know about their referral.

All three aspects of safety netting are addressed within the existing suspected cancer guidelines:  

• NICE NG12 guideline for suspected cancer recognition and referral (2023)  

• Scottish Cancer Referral Guidelines for Suspected Cancer (2019)   

While the Northern Ireland Cancer Network (NICaN) provide primary care guidance for suspected cancer referrals for GPs practicing in Northern Ireland, safety netting advice is not included. As safety netting is an important component of timely referral and management of suspected cancer, all information provided on this page and in wider resources is applicable UK-wide.  

References:

1. Jones, D., et al., Safety netting for primary care: evidence from a literature review. British Journal of General Practice, 2019. 69(678): p. e70-e79.
2. Swann R, Lyratzopoulos G, Rubin G, Pickworth E, McPhail S. The frequency, nature and impact of GP-assessed avoidable delays in a population-based cohort of cancer patients. Cancer epidemiology. 2020;64:101617.
3. Nicholson BD, Mant D, Bankhead C. Can safety-netting improve cancer detection in patients with vague symptoms?. BMJ. 2016;355:i5515. Published 2016 Nov 9. doi:10.1136/bmj.i5515

Patients need to be informed of when, why and how to book a follow-up appointment should their symptoms persist, worsen or change.

• Consider the likely time course of current symptoms (e.g. cough, bowel symptoms, pain)
• Tell patients when to come back if symptoms do not resolve in the expected time course, and the specific warning/ red flag symptoms or changes to look out for
• Check the patient understands the safety netting advice (considering language and/or health literacy barriers). It may be useful to consider sending text message reminders to reaffirm your safety netting advice for patients [4].
• Consider referral after repeated consultations for the same symptom where the diagnosis is uncertain (e.g. three strikes and you are in)
• Code all symptoms, diagnostic tests, referrals and set up appropriate diary alerts
• Detail safety netting advice in the medical notes (as understood by the patient)
• Make use of clinical IT systems that alert you of repeat consultations for unexplained symptoms

Primary care tests

Cancer referral Guidelines recommend several investigations for patients presenting with suspected signs and symptoms of cancer, including chest x-ray (CXR) and FIT (for symptomatic patients). However, a negative test result does not always rule out cancer, especially among patients with unresolved symptoms

• Communicate to the patient the reasons for the test and importance of coming back if symptoms continue, even after a negative test result
• Code all diagnostic tests and retain (or explicitly pass on) responsibility over initiated investigations until results are reviewed and acted upon appropriately
• Consider the accuracy of diagnostic tests and what the result adds to a patient’s clinical picture. For example,  there is evidence to suggests a CXR false negative rate of up to 23%¹·². A negative CXR result could potentially give false reassurance to the patient and their GP. It is important to monitor and safety net symptomatic patients who receive a negative CXR result, until symptoms are explained or resolve. For further information, see our FIT key differences infographics for England.
• The threshold to determine a positive result is much lower for symptomatic patients than it is for patients in the bowel screening programme who are presumed to be asymptomatic. Therefore, health professionals and patients should not be reassured by a recent negative screening result if a patient presents with possible symptoms of bowel cancer.
• Inform patients about how to obtain their results and have a system for contacting patients with positive test results and for those who fail to attend for follow up
• Have a system to document that all results have been viewed, acted upon appropriately and followed up
• Be aware of practice policies in place to ensure that tests/ investigations ordered by locums are followed up
• Ensure practice staff involved in logging results are aware of reasons for urgent tests and referrals

Referrals

Patients who are urgently referred for suspected cancer should be aware that their investigation is due to possible cancer, to help the patient understand the risk of cancer associated with their symptoms and the importance of attending their future appointment. Careful and balanced communication is important to avoid unnecessary patient distress, for example, when known, it may be appropriate to inform patients of their individual risk of cancer and that a referral has been made to rule out a cancer diagnosis.

• Ask your patient what they would like to know about their referral
• Explain to patient’s that they are being referred on a suspected cancer pathway, and what to expect at their next appointment
• Communicate the importance of attending appointments
• Check the patient understands the safety netting advice (considering language and/or literacy barriers)
• Code referrals and set up appropriate diary alerts
• Detail safety netting advice in the medical notes (as understood by the patient)
• Obtain up to date contact details for patients undergoing tests or referrals

References

1. Stapley, S., D. Sharp, and W. Hamilton, Negative chest X-rays in primary care patients with lung cancer. Br J Gen Pract, 2006. 56(529): p. 570-3.
2. Bradley, S.H., M.P.T. Kennedy, and R.D. Neal, Recognising Lung Cancer in Primary Care. Adv Ther, 2019. 36(1): p. 19-30.

In line with the PCN requirements, practices in England must use the relevant SNOMED code for Safety Netting. Only those codes included in the supporting Business Rules will be acceptable to allow CQRS calculations. A PCN’s Core Network Practices will therefore need to ensure that they use the relevant codes and if necessary, re-code patients.  

Ensure you use the new SNOMED code for: Delivery of safety netting for patients on urgent referral pathway for suspected cancer. You can search for this by putting in ‘cancer safety netting’ into your code browser and will find the code 1239431000000107.  

However, to make the best use of this, we would advise using safety netting templates which incorporate this SNOMED code and allow you to tick the relevant section on the templates, as well as set a date for any reminders.  

Have a look at your PCN’s use of the official SNOMED codes for Safety Netting compared to other PCNs, using the PCN dashboard. 

To review the effectiveness of your safety netting processes in practice you could undertake the following actions:

• Conduct Learning Events for patients diagnosed via an emergency presentation.
• Conduct an annual audit of new cancer diagnoses (e.g. internal practice audit or if you have participated in the National Cancer Diagnosis Audit) you can check your cases in your report.

For a summary table of all of the tops tips and a flow chart that incorporates safety netting into practice please see Safety netting table and flow chart

Current safety netting practices vary among GPs and between primary care practices [1-3]. Research is under way to further investigate barriers and opportunities for improving safety netting.

For example, NG12 doesn’t specify whose responsibility it is ultimately to ensure symptom follow-up – GPs or patients.

Current clinical IT systems hold a great potential to streamline safety netting into everyday patient care. The impact of an EMIS integrated safety netting toolkit for symptoms of cancer is currently being evaluated through the Early Detection and Diagnosis Committee.

References

1. https://www.cancerresearchuk.org/funding-for-researchers/applying-for-fu... for primary care: evidence from a literature review. British Journal of General Practice, 2019. 69(678): p. e70-e79.
2. Swann R, Lyratzopoulos G, Rubin G, Pickworth E, McPhail S. The frequency, nature and impact of GP-assessed avoidable delays in a population-based cohort of cancer patients. Cancer epidemiology. 2020;64:101617.
3. Nicholson BD, Mant D, Bankhead C. Can safety-netting improve cancer detection in patients with vague symptoms?. BMJ. 2016;355:i5515. Published 2016 Nov 9. doi:10.1136/bmj.i5515

1. What is the main advantage of safety netting today over how it used to be done in the past?

2. Not every practice has a safety netting protocol in place. What is your advice to GPs interested in motivating their practice to establish one?

3. How do you negotiate responsibility between patients and practice, in relation to the follow-ups? And in relation to attending the two week wait appointments for suspected cancer? 

4. Are there other safety netting actions that tends to get overlooked but have a potential for speeding up cancer diagnosis?

5. What are the three safety netting actions each GP can do, regardless of their IT or practice-level environment?

6. In your view, what can be done to improve safety netting evidence and practice? 

7. Finally, what is the most recent safety netting measure introduced in your practice?

CRUK’s Safety netting summary table provides a summary of key safety netting actions and patient communication tips to support primary care health professionals in practice.  

CRUK’s Safety netting flow chart illustrates the key steps primary care professionals can take to manage patients with potential cancer symptoms.  

CRUK’s Lung Cancer and FIT Symptomatic web pages provide site-specific safety netting advice.    

MacMillan’s Primary care top 10 tips: safety netting provides selected safety netting tips, with a rationale and what to consider within each tip.  

Pan London suspected cancer safety netting guide offers tips on how to use clinical IT systems to pro-actively recall DNAs, how to track patients’ attendance of tests and investigations and how to set up reminders to follow-up low-risk patients.  

Macmillan Safety netting and coding training module is an e-learning course primarily aimed at GPs and GP trainees, although other primary care clinical staff may find it valuable too. The content of this course is designed to improve the clinician's quality of coding and safety netting in the context of cancer.  

The ‘Shared Safety Net Action Plan’ journal article includes two helpful printouts for health professionals to use with their patients, including a visual body poster where key safety netting information can be added, and taken away by the patient.