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Safety-NETting in general practice for diagnosing or ruling out CAncer (CASNET): an interview study with patients and General Practitioners in Oxfordshire.

This study has been completed - summary of results

Background

GPs use a technique called safety-netting to ensure their patients come back to the surgery for a follow-up appointment. This is very important when patients have symptoms that could lead to an important diagnosis such as cancer. Safety-netting can be done in a variety of ways, such as the GP giving advice about which symptoms to look out for and after how long to come back, or by the GP practice having computer systems that highlight abnormal test results and patients who have not attended their appointment. Safety-netting is recommended in national guidelines but there are no clear descriptions of which are the most effective ways to safety net.

Initial objectives

  • To elicit GP and patient views on safety netting for suspected cancer in primary care.
  • To explore current safety netting practices based on accounts and real life examples of GPs and patients involved in monitoring for suspected cancer in primary care.
  • To further understand factors that may influence the success or failure of safety netting in primary care.

Methods

In-depth, face-to-face interviews were conducted with 25 qualified GPs and 23 adult patients in Oxfordshire between November 2016 and July 2017. We developed flexible interview topic guides from our knowledge of the literature, secondary analyses of International Cancer Benchmarking Project survey questions related to safety netting, and patient interviews from a recent study of the bowel or lung cancer diagnostic process (via the Health Experiences Research Group’s qualitative data archive). Interview data were analysed thematically.

Results

GPs’ understanding and practice of safety netting for potential cancer presentations

This analysis has been published in the British Journal of General Practice (http://bjgp.org/content/early/2018/05/07/bjgp18X696233 ).

We report that English GPs are certain that safety netting is a key component of “good clinical practice”. However, they are unclear about which aspects of clinical practice are considered to be safety netting, and they tend not to discuss their approach to safety netting with their colleagues. We found that, in the absence of guidance or training on safety netting, the bespoke personal strategies that GPs use, and describe as safety netting, are often developed from past mistakes or system failures. Safety netting is therefore, at present, a reactive, rather than a proactive, process. Safety netting varies according to the perceived risk of cancer, the perceived reliability of each patient to follow advice, GP working patterns and time pressures. Some GPs described documenting less for patients they considered at low risk and those they felt confident of seeing again. Those GPs working part-time described being aware of the need to document their actions in case the patient consulted a different doctor next. Locums said they handled risk differently, choosing to safety net more meticulously or referring at a lower threshold to ensure that patients are followed up in their absence. For these reasons, we highlight the need for clear structured documentation of the safety netting conducted to facilitate continuity of care and follow-up for patients. Increasing workload, short appointments, and a reluctance to over-burden hospital systems or create unnecessary patient anxiety, have together led to a strategy of selective active follow-up of patients perceived to be at higher risk of cancer or less able to act autonomously. This appears to have left patients with low-risk-but-not-no-risk symptoms of cancer with less robust or absent safety netting despite this group of patients experiencing delays in diagnosis.

How GPs and patients share the responsibility for follow-up

This analysis is in preparation for publication.

Drawing on ideas of transactional and dependent sharing from the shared decision-making literature, we have explored the various ways in which responsibility for symptom follow-up is shared between GPs and patients.

GPs’ and patients’ views of safety netting recommendations

We have used GP and patient feedback.to refine the safety netting recommendations previously published in the BMJ. Most discussion surrounded the practicalities of communicating all abnormal and normal test results, developing a reliable method for highlighting unexplained recurrent symptoms, and achieving consistent documentation of safety netting.

Conclusions

We found that GPs would benefit from clearer guidance on which aspects of clinical practice contribute to effective safety netting (for cancer). Our interviews suggest that a practice system based on a proactive standardised approach to safety netting is, at present, lacking and prevents safety netting from being conducted robustly for all patients. To this end, further research is required to develop and evaluate which interventions produce the most efficient returns in terms of reduced workload and delays in (cancer) diagnosis. Potential solutions may include improved methods of communicating safety netting actions, automated fail-safe systems to ensure safe follow-up is conducted, and novel strategies for delegation of responsibilities between members of the health care team. Further research to better understand why patients do not follow the advice given or fail to re-consult for persistent or worsening symptoms is also required.

For further information contact Brian Nicholson (brian.nicholson@phc.ox.ac.uk )

CASNET