Safety-NETting for Timely Diagnosis (NETTD) in primary care: A realist review of the context and mechanisms of effective safety-netting
Patients who consult GPs or other primary health care professionals (PHCPs) often leave the consultation with instructions to seek further advice or return if symptoms persist. This important practice is called ‘safety-netting’ and is widely used by PHCPs to reassure patients who may recover at home, while catching those whose illness becomes serious and needs further attention.
Despite the importance and widespread use of safety-netting, there is little training available in how it should be used, no formal recording or monitoring procedures, no agreement on what information should be given to patients or in what format, and no guidelines for how, for whom and in what setting safety-netting should be used.
We are doing a realist review to answer the question: How, why, for whom, in what contexts, is safety-netting used appropriately?
Why is this important?
Safety-netting is a part of a large proportion of the consultations that happen every day and as such it impacts the care of many patients. Safety-netting in primary care is important when there is diagnostic uncertainty or the underlying cause of vague symptoms could be serious, allowing patients in need of further investigation to receive it with minimal delay. Inadequate safety-netting is, however, a recognised cause of diagnostic error in NHS primary care, and a contributor to both unnecessary re-consultations and delayed diagnosis. A factor in this is the scant guidance on how it should be delivered, recorded, and followed-up. This has led to inconsistencies in practice reported by clinicians and patients alike.
Realist reviews are well suited to answering questions where their complexity benefits from a range of information sources to fully understand the issue. We use an iterative process, working with an expert group made up of lay people and PHCPs, to gather published and grey literature and create a theory of safety-netting that encompasses a wide range of information sources. This iterative process allows the theory to evolve until it addresses the needs of the spectrum of patients and primary care contexts in which safety-netting is used.
How might patients benefit?
This research will produce an evidence-based theory of safety-netting that can be used to guide practice and improve patients’ experiences immediately and in the future. The theory can be developed into a practical guide to safety-netting and evaluated through further research, impacting primary care research and practice into the longer term.