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Many people see their GP with symptoms that could either get better without treatment, or be a sign of serious illness; their diagnosis is uncertain. Research explored how GPs and patients can work together to develop follow-up plans (a process known as safety-netting). New recommendations could help GPs manage uncertain diagnoses.
To avoid unnecessary referrals, GPs may adopt a ‘watch and wait’ strategy when someone has an uncertain diagnosis. This strategy should come with a clear follow-up plan so that people understand the possible causes of their symptoms, how to look after themselves and what to do if symptoms persist. This is good safety-netting.
Without good safety-netting, watch and wait carries risks. For example, late cancer diagnoses have been linked to poor safety-netting. However, professional guidance on safety-netting is lacking. This is a knowledge and practice gap.
A new study explored the best ways to deliver safety-netting advice. It suggests that people are more likely to follow advice if they are involved in developing the follow-up plan. They need to understand:
- why they are receiving this advice
- what actions are required, and by whom.
The lack of time within primary care consultations is well known. This may need to be addressed for clinicians to have long enough to develop a safety-netting plan. Professionals may also need training to develop the appropriate communication skills.
The issue: a lack of guidance on giving safety-netting advice
Safety-netting advice is given to patients when the cause of their symptoms, or how their illness will progress, is uncertain. It is a common practice; many GPs use it at the end of every consultation. But research has shown that GPs vary in their understanding and delivery of safety-netting. The advice is also inconsistently recorded in medical records.
Patients do not recognise safety-netting as an established part of consultations. They may not understand what the clinician is trying to communicate and can feel that their symptoms are being ignored or dismissed.
For some conditions, such as cancer, there are professional guidelines on giving safety-netting advice. But for other conditions, the lack of evidence-based guidelines could be putting patients at risk.
New recommendations on giving safety-netting advice
This review included 95 studies and other documents (including web sources, clinical guidelines and books) on clinicians’ understanding and communication of safety-netting advice. Most documents (61%) were from the UK, and from in-hours primary care. The research team set up an expert panel including primary care professionals and patient representatives to help interpret the findings.
The expert panel made specific recommendations on safety-netting advice, which is given when a diagnosis is uncertain or could change.
How to offer safety-netting advice
- Build safety-netting into the entire consultation; it should not be rushed at the end.
- Use simple terms and avoid jargon and abbreviations (but include appropriate technical terms); tailor advice and address potential sources of anxiety (for instance being young or a first-time parent).
- Consider grouping chunks of information to help the patient remember the advice.
- Give people the opportunity to share their expectations and concerns, and address these in the safety-netting plan.
What advice to give: the safety-netting plan
- Explain and discuss uncertainties and the follow-up plan.
- Offer an initial diagnosis, explain how long you expect symptoms to last (or how they might change), give practical tips for self-care and symptom management (which give people a sense of control) and instructions for when they should be concerned.
- Personalise someone’s risk based on their characteristics (such as age or medical history) and not on population data. The plan should also be personalised and address factors that might make an individual less likely to follow advice (for instance if they have had a previous missed diagnosis).
- Give the patient the opportunity to ask questions and to share in decision-making.
- Actively check the patient’s understanding.
- Acknowledge the patient’s ability to make judgements about their own health, and to change their mind about a plan.
Other resources, follow-up and documentation
- Enable the patient to review safety-netting information via online resources, for example, which could be audio or visual.
- Invite the patient to return for further medical advice even if it is for the same symptom(s); reassure patients that this is a valid course of action.
- Accurately include the safety-netting advice in medical records so that other clinicians seeing the patient will know what care was given.
Why is this important?
Clear safety-netting advice helps keep patients safe and ensures timely follow-up and diagnosis. In previous research, people with delayed cancer diagnoses said GPs did not tell them about possible causes of their symptoms or what to do if symptoms persisted. Patients need to know about the potential severity of an undiagnosed illness and the importance of follow-up. Accurate communication should make these points clearly and avoid giving people a false sense of security.
The researchers hope their recommendations will encourage clinicians to engage people in developing follow-up plans. People are more likely to follow safety-netting advice if they understand why it is being given, what the actions are and who is responsible for each. Longer appointment times could improve safety-netting, but are unlikely to be implemented at present.
The researchers say their recommendations could be included in medical school training. They hope their findings will also inform continuing professional development for GPs.
The recommendations need to be validated in further research, but the researchers say that they can be implemented now in in-hours primary care. In other settings, such as pharmacies and out-of-hours primary care, further research is needed.
Many of the recommendations also apply to remote consultations, which have increased since the pandemic. But future research is needed to look at whether people’s understanding and acceptance of safety-netting advice are different when given in an online consultation. Further research is also needed to explore how to deliver safety-netting advice to people with multiple conditions.
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This Alert was based on: Friedemann Smith C, and others. Optimising GPs' communication of advice to facilitate patients' self-care and prompt follow-up when the diagnosis is uncertain: a realist review of 'safety-netting' in primary care. British Medical Journal Quality and Safety 2022;31:541-554.
A review of other studies looking at safety-netting in primary care: Jones D, and others. Safety netting for primary care: evidence from a literature review. British Journal of General Practice 2019;69:e70-79.
The Royal College of General Practitioners includes some suggestions for safety-netting when consulting remotely.
Funding: This study was funded by the NIHR Research for Patient Benefit programme and the University of Oxford’s Medical Sciences Division Covid-19 Research Response fund.
Conflicts of Interest: The study authors declare no conflicts of interest.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.