Sample characteristics
Overall, 24 GPs agreed to take part in the focus groups. Due to time restrictions two were unable to attend their intended focus group sessions and had telephone interviews instead (both audiorecorded). Groups 2 and 4 each had one participant drop out at the last minute. Most groups were a mixture of GPs from different practices, except groups 4 and 5. In total, 20 GPs attended one of the five discussion groups, with a minimum of two and maximum of seven GPs per group. Almost half of the participants were female, and aged 29–59 years, with an average of 8 years as an active GP; 27% were involved in research, and 55% were employed full time. Table 1 outlines sample characteristics.
Table 1. Characteristics of the GP sample
Potential role of txt-netting
GPs identified several cancer safety-netting pathways that could benefit from an automated text message (Figure 1). GPs agreed that a key function could be to raise symptom awareness among patients. This would comprise a simple message advising what to look out for, and what actions to take if symptoms persist. For patients with low-risk cancer symptoms (that is, not red-flag symptoms), the purpose of a text message will be to reaffirm what was discussed during the consultation, and to check if symptoms resolve within a given time period (watchful waiting) and/or with treatment:
‘We have different sections in our EMIS. You have problem, you have history, examination … You might have a safety net, and then if that could be automatically incorporated into a text that you send out, then you could write straight into the message what you want to be sent out to the patient. That way you know that what was discussed in the consultation has been reinforced with a text message so the patient can go back and use it as a reference maybe 2 weeks down the line. “Okay, that’s what was discussed. Do I have that? I don’t.”’
(Group 2, male 1)
‘If there’s sort of just one text, one standard text, which you are going to have, then I would probably say “Please book an appointment if you are not better.” Yes. And if you can have another one for “Please remember to have your tests”, that would be good, too.’
(Interview 1, female)
Figure 1. Potential pathways for use of txt-netting in primary care.
GPs thought that a text message could help improve follow-up processes by rapidly identifying patients who need further assessment. GPs opined that this would be particularly useful when a patient’s symptoms do not warrant urgent referral or immediate investigation, and for patients who are more likely to slip through traditional safety-netting approaches (for example, due to language barriers). They also thought that txt-netting could help to ensure that patients review their symptoms in a timely manner, and would encourage patients to return. However, GPs highlighted that there may still be workload implications for patients requiring follow-up:
‘It would be useful, I think, if it was like: “Yes, it’s resolved”, because then we can kind of close that off. If it’s: “No, it’s not resolved”, then we still need to proactively help them book in somehow, either for a phone follow- up or a clinical follow-up, or whatever.’
(Group 5, male 1)
‘“If your symptoms aren’t better, please book another appointment now”, then that actually would be really handy, because I do think that one of the really difficult things is people can never remember how long they’ve had something.’
(Interview 1, female)
Two further suggested uses of text messages for safety netting that were outside of watchful waiting were identified: to confirm that urgent cancer (2-week wait) referral appointments are received and attended, and to send reminders for walk-in appointments to investigate symptoms (for example, a chest X-ray). Many GPs reported that they currently use manual, paper- based systems, such as personal diaries, to track patients with urgent cancer referrals:
‘If there was just an automated system that would offer a text message if somebody had not attended a 2-week wait appointment, whether it was because they didn’t attend, or whether because the hospital themselves messed up the appointment in some way administratively, or a letter didn’t get through, but just to know that there was an automated text would support me so much in my practice, and quite a proportion of people miss their 2-week wait appointments. It’s shocking.’
(Group 3, male 4)
‘We have a lot of DNAs, do not attends, in our local hospital, and … [unclear] … would be a big proportion of our budget, but also sort of waste the resources, and we get do not attend cancer referrals. So we’ve gone to the effort of thinking this patient has cancer, sent them a letter, but they haven’t attended. We never really find out why that is, but we have to chase them up on that. So it would be great if we had that in a simple text message, I suppose.’
(Group 4, male 1)
Potential barriers to txt-netting
GP preferences for txt-netting
GPs expressed a wide range of preferences for how txt-netting should be applied, and for text message content. Some wanted to be able to tailor text message content, whereas others preferred generic wording (recognised as more time efficient). Some GPs preferred a patient-managed approach, relying on patients to self-assess and book follow-up appointments, whereas others preferred a GP-managed approach, in which GP practices would contact patients who replied to the text message to confirm ongoing symptoms, that is, two-way messaging:
‘I would prefer to send out the text myself, knowing the patient, and to write what specifically I am concerned about. Because you kind of know what you’re worried about at the end of your consultation, and the specific things to that patient that you’d want to question about.’
(Group 4, male 1)
‘I think if I could generate a text message to remind somebody to do something, or to review somebody … if we could have a little text library, in EMIS, or MJog, whatever it is, and you could choose that text, that text, that text, and they’re standardised texts, so you don’t have GPs writing them. You’ve got to make it quick and easy for GPs, and you’ve got to also be able to make it a handover system, so … there’s no point in GPs spending a lot time doing admin work, they’d probably need to be doing clinical work.’
(Interview 2, female)
GPs also highlighted the need to automate txt-netting to maximise efficiency:
‘I think that would be a huge undertaking to remember to send all those text messages in 2 weeks. I know that I wouldn’t be able to encompass that on my workload. So I think the most efficient way would be, as you close your consultation, that message would go off.’
(Group 1, female 1)
Patients’ understanding of text messages
The challenge of accurately conveying safety-netting advice within a single text message was discussed as a key barrier:
‘I question whether or not one generic message would be enough. So it would be wanting them to understand that: “The consultation we had today left me with a bit of concern, so I would like to see you again.”’
(Group 2, female 1)
This led GPs to question whether or not txt-netting would be flexible enough to work in practice, particularly for patients with comorbidities and multiple symptoms. There were concerns that this would lead to issues with patients’ understanding of the text message:
‘We think it’s their haemorrhoid, but we want to make sure that it’s resolved in 2 weeks, and so we waited 2 weeks to ask them: “Have you seen this resolved?”’
(Group 5, female 2)
‘They might be like, “Which one?” They might be thinking about their cough, or …’
(Group 5, female 1)
‘I can see problems. If it’s getting better, is that resolved, or does it have to be completely better? You can see how you could interpret it differently. We know what we mean, but that doesn’t necessarily come across in 144 characters.’
(Group 5, male 3)
Timing of text messages
Concerns were also raised about the appropriate timing of text messages, and how this would change depending on the nature of the symptom. GPs also pointed out that timely review could be negated by the time needed to make and receive appointments:
‘Remember, they’re going to get the text in 2 weeks, but actually they’ve got to book an appointment, so it might be another 2 weeks before they actually come in.’
(Group 3, male 3)
Ethical considerations of txt-netting
Several ethical considerations were raised in relation to txt-netting. These included patients without access to a mobile phone, and the incomplete or inaccurate nature of mobile phone numbers in primary care records. GPs also referred to sub-populations in their practices who could be marginalised by txt-netting (for example, older or tech-novice patients). This was discussed as a potential pitfall of mobile health interventions:
‘Here, people aren’t so … they’re not as phone friendly. They’re not as tech savvy, mobile. I’ve had patients I’m trying to get onto the phone to type in numbers and they’ve been like, “I don’t know how to work my phone.’”
(Group 4, male 2)
All focus group discussions raised the importance of patient consent and confidentiality when sending text messages with potentially sensitive information, such as symptoms:
‘If you’re with your mates in the pub or whatever, and you have your phone there. Suddenly it flashes: “Has your rectal bleeding improved?”’
(Group 5, female 2)
Patient consent to txt-netting was considered by GPs to be essential:
‘If you are sending text messages, that phone may be available to other members of the family. You may need to check with them. Other family members may not be aware about these worrying symptoms that this patient has. They might not want other people to know about it, so do they really want a text that is going to be on the phone that other people can read, potentially? It might pop up when someone else has the phone. You might need to think about whether that’s appropriate.’
(Group 5, female 1)
‘It’s a patient choice if they want to be safety netted. I might see a 90-year-old who has a potential cancer risk. They might not care any more that they have cancer. Why do they need safety netting?’
(Group 2, male 1)
Attitudes to txt-netting
Although there were concerns about implementation of txt-netting in practice, the use of technology for safety netting in general was welcomed, and was recognised as currently underused in primary care, with many GPs relying on manual, paper-based systems. To some extent, they suggested that text messages are already used to safety net (for example, appointment reminders or reporting of tests results). Txt-netting was perceived as a useful concept worth exploring further, most viewing it as an additional tool for patient management:
‘I think it’s an option we should be using. I think there’s probably a lot of scope within IT that we’re not using. I think with cancer and safety netting, the more systems we have, which we could use, if we need … the more tools we have we can pick up when there’s a problem. If texting is one of them, then that’s great.’
(Interview 2, female)
‘It’s just another tool in your armoury, I suppose. You can do verbal safety netting, you can do, maybe, written safety netting. Text messaging would just be another tool.’
(Group 2, male 2)
