Case study: how can effective safety netting support timelier diagnosis across the pathway?
The case study below demonstrates how implementing effective safety netting, including the use of e-safety netting tools, at key touchpoints in the primary care pathway can support timelier diagnosis. It also shows how a patient could be at risk of a longer time to diagnosis in the absence of these actions.
This case study can be used to support GP and practice training around safety netting. It’s been developed with Dr Sarah Taylor, Cancer Research UK GP and Greater Manchester Cancer Alliance Associate Medical Director for Early Diagnosis and Primary Care.
John is 62 and a non-smoker.
-
John’s initial presentation: Experiencing persistent fatigue and work-related stress. No other symptoms reported at this time. He has a history of asthma.
-
GP’s initial impression: Likely stress-related fatigue, does not meet criteria for investigation at this time.
-
John’s subsequent presentation: ongoing fatigue, and a new cough persisting for more than 3 weeks.
-
GP’s impression: national cancer referral guidelines recommend John warrants a chest x-ray.
Opportunity |
With effective safety netting |
Without effective safety netting |
| Patient education and communication |
On initial presentation to the GP, John is given clear guidance that if the fatigue continues, or if they notice any other concerning symptoms, to return to the GP within a set timeframe (3 weeks). John is provided with written reference of the safety netting advice. |
On initial presentation to the GP, John is reassured the fatigue is likely stress-related advised to ‘wait and see’. There is no advice provided on when to re-present, and in what circumstances. No supporting information is reviewed or offered. John assumes the fatigue is normal. |
| Documentation and use of e-safety netting tools | The agreed action is documented on the system by the GP The practice use an e-safety netting tool to check whether John makes a follow up appointment. | No record of the GP’s advice is made on the system and no tools are used to track whether John makes a follow up appointment. |
| Outcome | John returns to his GP practice 3 weeks later, with worsening fatigue, and has since developed unexplained shortness of breath. The GP refers John for an urgent direct access chest x-ray. This comes back negative after 2 weeks. | John returns to his GP practice 3 months later, with worsening fatigue, and has since developed unexplained shortness of breath. The GP refers John for an urgent direct access chest x-ray. This comes back negative after 2 weeks. |
Opportunity |
With effective safety netting |
Without effective safety netting |
| Patient education and communication |
John is given a clear explanation of the results of the CXR, and the limitations of the test. He’s told that although his test is reassuring, it doesn’t completely rule out cancer, especially if his symptoms continue or worsen. He’s advised to return if her symptoms persist beyond a further 3 weeks, or he develops any new or worsening symptoms. John and the GP agree to book a follow-up appointment in 3 weeks. |
John is reassured that the CXR is negative and that his ongoing symptoms may be related to an exacerbation of his asthma. There’s no explanation of the limitations of CXR and no advice provided on when to re-present, and in what circumstances. |
| Documentation and use of e-safety netting tools | The agreed action is documented via a template and coded in the system, so that the practice admin team are alerted to send John a text to remind him of his follow-up appointment. | Safety netting is not documented or coded in the system. |
| Outcome | John attends his follow up in 3 weeks time, with worsening symptoms and a new cough. As the GP is still concerned, they decide to refer John for an urgent suspected cancer referral. | John attends the GP 2 months later, with worsening symptoms and a new cough. As the GP is now concerned, they decide to refer John for an urgent suspected cancer referral. |
Opportunity |
With effective safety netting |
Without effective safety netting |
| Patient education and communication |
John clearly understands the GP’s concerns and why they’ve completed the USC referral (the GP explained that it is unlikely he has cancer, but important to rule out). John receives a clear run-through of what to expect – that he should receive the appointment within 2 weeks, and if not to contact the practice. He is asked if he understands, given the opportunity to ask questions and provided a leaflet explaining his urgent suspected cancer referral. John is also given clear instructions with timeframes on what to do if his symptoms worsen/if new symptoms develop. |
John is told he is being sent to a lung specialist but without any clear explanation, he’s told it’s just “routine”. John is unaware of the urgency or reason for the referral, and delays attending the appointment as he doesn’t want to take the time off work. |
| Documentation and use of e-safety netting tools | The referral is coded appropriately and tracked using an e-safety netting tool. | The referral is not coded appropriately, so the practice is unable to track whether there are any delays in John’s referral or appointment. |
| Outcome | John is seen within 2 weeks and is diagnosed with lung cancer. | John’s appointment is delayed by 4 weeks but he is eventually investigated and diagnosed with lung cancer. |
John's overall outcome
With effective safety netting
John’s journey from initial presentation to diagnosis was around 10 weeks, which could potentially lead to John being diagnosed at an earlier stage with more treatment options available.
Without effective safety netting
John’s journey from initial presentation to diagnosis was around 30 weeks, which could potentially lead to John being diagnosed at a later stage and experiencing worse outcomes.