Safety netting

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Safety netting is a diagnostic management strategy that aims to ensures patients are monitored throughout the diagnostic process until their symptoms or signs are explained and results have been acted upon or their symptoms are resolved.

A review of safety netting literature suggests that:

“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. This aims to empower patients and protect healthcare professionals. 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]

Retrospective clinical reviews showed that one in four 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

All three aspects of safety netting are addressed within the existing suspected cancer guidelines (see NICE, NG12 (2015) and the Scottish Cancer Referral Guidelines for Suspected Cancer(2019))*.  

*While the Northern Ireland Cancer Network (NICaN) provide primary care guidance for suspected cancer referrals for GP’s 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

CRUK safety netting table - A list of safety netting top tips for primary care practices, by roles and responsibilities. Also available as a flow chart, from patient’s first reported symptoms to diagnosis.

CRUK Safety Netting Workbook - A self-assessment checklist that can support to aid discussions around safety netting principles and best practice.

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

Pan London suspected cancer safety netting guide - 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. 

NICE NG12 guidance - recommendations for safety netting

Scottish Referral Guidelines for Suspected Cancer – recommendations for safety netting

How you can use clinical IT systems to support Safety Netting in practice:

A number of clinical IT systems have safety netting tools embedded. Below are links to further information about EMIS and SystmOne safety netting tools.

If your PCN practices use EMIS, or EMIS Web, please signpost them either to:

  • the newly released EMIS Safety Netting 2020 Template and training resources, including a written user guide and two training videos: one for clinical staff and one for admin staff. Please note: PCNs outside of the Cheshire and Merseyside Cancer Alliance may want to see IT support locally
  • EMIS Web electronic safety netting toolkit for cancer developed by the UCHL Cancer Collaborative, which has a video guide, a user guide and an admin user guide.

SystmOne Safety netting tool - See a video user guide for SystmOne here

RCGP/MacMillan comprehensive guideline, tools and a template for conducting learning events at the practice level

National Cancer Diagnostic Audit  - A UK-wide audit of cancer diagnosis linking clinical data from primary care and secondary care and cancer registry data. 

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].

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

Top tips for safety netting symptoms:

  • 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].
  • Ensure the patient is followed up until their symptoms are explained, resolved or they are referred for further investigations, even in the event of a negative test result.
  • 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 recurrent signs/symptoms.

The NICE guidelines (NG12) recommend health professionals:

  • Ensure that patients who are safety-netted know which signs and symptoms to look out for and when they should return for re-evaluation.
  • Plan a review for patients with signs and symptoms that are associated with an increased risk of cancer, but who do not meet the criteria for referral or other investigative action.
  • The review should have a timeframe agreed with the patient or be patient-initiated based on GP’s advice on when to seek further medical help.

The Scottish Cancer Referral Guidelines (SRG) recommend health professionals :

  • Understand that for people whose presenting symptoms persist, it is not acceptable to simply exclude cancer without providing an assessment of the likely underlying cause.
  • Use a ‘watch and wait’ strategy when patients are not referred, where patients should be aware of which symptoms to monitor and when to return.
  • Detail in referral documentation when a ‘watch and wait’ strategy was not appropriate due to a patient’s high level of anxiety. Both guidelines rely on patients’ health literacy. Checking patient understanding or giving written instructions may be appropriate.

References:

  1. Pearson, C. Using linked primary care data to investigate diagnostic pathways of cancer patients presenting with non-specific but concerning symptoms. https://www.cancerresearchuk.org/sites/default/files/cancer-stats/24/24._clare_pearson.pdf
  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
  4. Hirst Y, Lim AWW. Acceptability of text messages for safety netting patients with low-risk cancer symptoms: a qualitative study. Br J Gen Pract. 2018;68(670):e333-e341. doi:10.3399/bjgp18X695741

Research states that avoidable delays to cancer diagnoses in England (2014) were mostly experienced during the test request/performance phase of a diagnosis (reported in a quarter of delays), and in the context of primary care led investigations [1].

Suspected cancer guidelines recommend several investigations for patients presenting with signs and symptoms of cancer, including Chest X-Ray (CXR) and FIT symptomatic [NG12 body poster / SCRG body poster]. However, a negative test does not always rule out cancer, especially among patients with unresolved symptoms. Also, receiving a negative test result for one cancer site may not exclude the possibility a different cancer, especially for patients with non-specific symptoms.  For example, depending on patient’s age, gender and accompanying symptoms, under NICE NG12 unintentional weight loss can prompt parallel investigations, including an urgent chest X ray, FIT, CA-125, upper GI endoscopy, CT/USS, haematology and OGD.

Lung and Chest X-Ray
   
 

A CXR can give up to 1 in 5 false negative results [3]. This may lead to over reassurance of patients and their GPs, and potentially delay the diagnosis of cancers or other serious conditions - careful communication of test results and safety netting advice to patients can help these associated risks of a false negative results. If respiratory symptoms persist, or there is suspicion of cancer based on GP suspicion, GP’s should follow-up with their patients until the patient’s symptoms are explained or resolved. 

Bowel and FIT
   

An important difference between FIT for symptomatic patients compared to FIT in bowel cancer

screening is that the threshold to determine a positive result is much lower for patients with symptoms, and so healthcare professionals and patients should not be reassured by a recent negative screening result if symptoms are unexplained. Ultimately, a previous negative FIT result (from a symptomatic test or from bowel cancer screening) does not rule out bowel cancer, and due to symptom overlap across cancer sites, a patient’s risk of having a non-bowel cancer should also be considered, for example ovarian cancer.

For further information on FIT in screening compared to FIT symptomatic, see our FIT key differences infographics for England, Scotland and Wales here.

Top tips for safety netting primary care tests:

  • 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 (e.g. false negative rates for chest x-rays for lung cancer and different thresholds in FIT for screening vs. FIT for symptomatic patients)
    • If a negative test result is received, ensure the patient is followed up until their symptoms are explained, resolved or they are referred for further investigations
  • 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

The NICE guidelines (NG12) recommend health professionals to:

  • Ensure that the results of investigations are reviewed and acted upon appropriately, with the healthcare professional who ordered the investigation taking or explicitly passing on responsibility for this.
  • Be aware of the possibility of falsenegative results for chest Xrays and tests for occult blood in faeces

The Scottish Cancer Referral Guidelines (SRG) recommend health professionals to:

  • Be aware that where diagnostic tests are undertaken, the clinician requesting the test has a responsibility for acting on the result and ensuring that the patient receives this.
  • Understand that if there is significant concern, awaiting the results of any investigation should not delay referral (in reference to gynaecological cancers)

The SRG also include safety netting guidance within site-specific recommendations:

  • Refer patients urgently for suspected cancer if any unexplained signs and symptoms of lung cancer persist for longer than six weeks, despite a normal chest X-ray.
  • Understand that a negative rectal examination, or a recent negative bowel screening test, should not rule out the need to refer a patient for urgent suspected lower GI cancer

References:

  1. 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.
  2. 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.

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 GP’s providing information and reassurance regarding a referral is considered by a patient to be as important as the speed of their referral. Therefore, it is important to ask patient’s what they would like to know about their referral

Patients who are referred for suspected cancer should be aware that their 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.

Patient information leaflets can aid GPs in patient communication and support at the time of referral. Health professionals also need to consider the literacy level and any language barriers the patient may have to ensure the patient understands the information they are being given.

When a referral is made for a patient, GPs and practice staff can minimise delay by ensuring that the patient contact details are up-to-date and that safety netting processes are in place. For example, practices may choose to run automated, regular checks in their clinical IT system of outstanding actions from symptom follow-up, primary care tests and suspected cancer referrals Introducing part-time GPs and locums to the safety netting protocols will also allow for smooth continuity of care for patients.

Top tips for safety netting referrals:

  • 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 (where appropriate, signpost to CRUK’s Urgent Referral Explained leaflet)
  • 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

The NICE guidelines (NG12) recommend health professionals to:

  • Discuss with people with suspected cancer their preferences for being involved in decisionmaking about referral options and further investigations including their potential risks and benefits.
  • Explain to people who are being referred with suspected cancer that they are being referred to a cancer service. Reassure them, as appropriate, that most people referred will not have a diagnosis of cancer and discuss alternative diagnoses with them.
  • Provide information on the possible diagnosis in accordance with the patient’s wishes for information.
  • Provide information to people with suspected cancer, which should include:
    • where the person is being referred to
    • how long they will have to wait for the appointment
    • how to obtain further information about the type of cancer suspected or help before the specialist appointment
    • what to expect from the service the person will be attending
    • what type of tests may be carried out, and what will happen during diagnostic procedures
    • how long it will take to get a diagnosis or test results
    • whether they can take someone with them to the appointment
    • who to contact if they do not receive confirmation of an appointment
    • other sources of support
  • Provide information that is appropriate for the person in terms of language, ability and culture, recognising the potential for different cultural meanings associated with the possibility of cancer.
  • Have information available in a variety of formats on both local and national sources of information and support for people who are being referred with suspected cancer.
  • Assess a person’s need for continuing support while waiting for their referral appointment. This should include inviting the person to contact their healthcare professional again if they have more concerns or questions before they see a specialist.
    • If the person has additional support needs because of their personal circumstances, inform the specialist (with the person's agreement).

The Scottish Cancer Referral Guidelines (SRG) recommend health professionals to:

  • Understand that it is good practice for the referrer to consider ways of supporting the person to attend investigations, consultations or reviews and addressing any concerns they may have about their referral.
  • Have systems in place to ensure people are not lost to follow up
  • Should you be informed about a downgraded urgent referral, take the opportunity to explain why an urgent suspected cancer referral was requested, as vital information may have been omitted from the referral or may have become available since the referral was made.
    • Keep the patient informed about any change in referral priority

References:

[1] Piano M, Black G, Amelung D, Power E, Whitaker KL. Exploring public attitudes towards the new Faster Diagnosis Standard for cancer: a focus group study with the UK public. Br J Gen Pract. 2019;69(683):e413-e421. doi:10.3399/bjgp19X702677

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.
  • Invite a CRUK Facilitator to facilitate a Safety Netting workshop in your practice or with your Primary Care Network where you can work through real safety netting examples.

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

Active areas of research

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– GP’s or patient’s. 

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 CRUK’s EDAG funding stream.

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

The combination of face-to-face safety netting and IT 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)

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?

GPs can make the case for safety netting using learning events (formerly called Significant Event Analysis) 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).
Practices can start by looking at the list  of questions on CRUK website to identify potential gaps in their practice. If you want to set up a system, EMIS Web has a template and video. For SystmOne some practices use scheduled tasks and templates are available, here is a short video by CRUK Strategic GP Rawan Pandev

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? 

This requires clinical judgement. Some patients respond to leaflets and clarity of purpose of the referral ie to exclude cancer. Others may need clear verbal information. Many of us use clinical system integrated text reminder systems. As GPs , we do have a role in following up non-attenders for 2 week wait appointments. In my practice all such referrals are safety netted by secretaries. (CRUK Strategic GP Rawan Pandev)

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

Proactive safety netting should be extended to suspected cancer referral attendance (combined with e-referrals), direct access diagnostics and vague symptoms. Also tracking patient attendance and outcomes for blood tests/ imaging/ endoscopy/ suspected cancer outpatient appointments using the relevant electronic healthcare record functionality or API /plug-in software. (Dr Ishani Patel)

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

Each GP can consider “what if this patient does not attend for this test/appointment/follow up?” What could be the consequence? Results reported as normal, but persisting symptoms, merit continuing review by the GP. An example is normal first CXRs in patients in lung cancer (up to 25% of lung cancers in some series). Ask yourself if there is a robust system of following up investigations and patients in your practice. It can help to look at past Learning Events (previously called SEAs) to see if this has been an issue in the past. (CRUK Strategic GP Rawan Pandev)

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

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)

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

We introduced a safety net prompt to help track advice and guidance requested from secondary care – this was suggested by our secretaries and has become routine for us. (CRUK Strategic GP Rawan Pandev)

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