In-depth, face-to-face interviews were conducted between 16 November 2016 and 14 June 2017 with 25 qualified GPs working in Oxfordshire (see Table 1 for participant characteristics). GPs’ understanding of safety netting and how they carried it out in practice were explored. Direct quotes from the interviews are presented here, with hesitations and repetitions removed to aid readability.
What is safety netting?
The authors did not ask GPs to define safety netting in their interview, yet a key theme of ‘What is safety netting?’ emerged. Reflecting on their clinical practice revealed some taken-for-granted interpretations and behaviours:
‘It’s such a throw-away phrase, occasionally you even find in the notes, “Patient safety netted”, and actually stepping back to think what are we trying to communicate, what does it mean? And if it means that much and it’s important, how do we do it? It’s been really interesting … to step back and think this is a word I use almost every day but actually what does it mean?’
(GP01, female [F], aged 45 years, part-time [PT])
Participants commonly recognised safety netting as a ubiquitous element of (good) clinical practice. GP02 said:
‘I think of safety netting as a part of every single consultation … It’s just something you do.’
(GP02, F, aged 52 years, PT)
The same GP also said that most patients should go away from consultations about new symptoms ‘… with an idea of what the doctor thinks is going on and, therefore, what should probably happen next, and also what to do if that isn’t what happens.’
(GP02, F, aged 52 years, PT)
However, GPs often struggled to isolate a clear description of safety netting, revealing uncertainty over which aspects of practice contributed to safety netting. For instance, after describing how they would explain their thinking to a patient when ordering tests — a behaviour often regarded as part of safety netting — GP14 said:
‘That’s not quite safety netting is it?’
(GP14, F, aged 44 years, PT)
And GP01 said:
‘I don’t know if that counts as safety netting, that’s probably not.’
(GP01, F, aged 45 years, PT)
The authors were struck by the competing narratives about safety netting, what it is, how it is done, and where the responsibility lies. Contradictions were sometimes evident within the same GP’s account. At one point in his interview GP15 said:
‘… we probably have different concepts about what safety netting means … [and] I think we do it all very differently within our consultations …’
(GP15, male [M], aged 38 years, full-time [FT])
He explained that in the absence of a practice policy for how it should be done:
‘… it’s left up to the GP to decide what they wish to record in the notes and how they wish to recall the patient back if they’ve asked them to do something.’
(GP15, M, aged 38 years, FT)
However, later GP15 also suggested that if he wrote ‘I have safety netted’ in the notes his colleagues would know what they meant. When the interviewer queried this, the GP responded:
‘I guess my assumption is if one of my colleagues has written that, that they’ve safety netted in the same way I have.’
(GP15, M, aged 38 years, FT)
Factors affecting safety-netting practice
Workload
Time pressure was commonly cited as a barrier to safety netting. GPs consulting in 10-minute appointments particularly felt this was insufficient to deal with everything thoroughly, especially where patients had complex needs or consulted about multiple problems:
‘Time’s always a barrier to everything. But actually, I think if there’s a patient you’re concerned about I do spend quite a bit of time safety netting and making sure people understand the importance of it. So, I mean time is all well and good, but I don’t keep to my 10 minutes because it’s not enough.’
(GP18, F, age 44 years, PT)
Several explained that actively following up every patient would be impossible because it would (unnecessarily) create extra work and anxiety for the patient:
‘I don’t know how you would start with keeping a note of all those patients you were slightly worried about, because it would soon be longer than your arm and, you know, I think at the end of the day patients do have to take some responsibility for following up on symptoms.’
(GP21, M, aged 48 years, PT)
Patients perceived as young and intelligent or with the capacity to advocate for themselves were considered reliable enough to follow safety-netting advice and consult again at an appropriate interval. For such patients, a key ingredient of safety netting was often a reliance on them to take responsibility for re-consulting:
‘The best safety net is an informed patient who can advocate for themselves. And we’re quite fortunate with our population that most of our patients are reasonably intelligent and in control of their lives.’
(GP19, M, aged 49 years, FT)
By contrast, GPs suggested they, and the wider practice team, retained more responsibility for patients who were: unknown to the GP; vulnerable due to advanced age, cognitive or mental health issues; or reluctant or unable to engage with the diagnostic process. For these patients, GPs reported booking a follow-up appointment there and then, while the patient was still present, to increase the likelihood of the patient returning, or involving carers or relatives with consent. Some GPs used personal reminders or asked administrative staff to contact the patient if they did not attend:
‘You just have to remember that there are some patients who take no responsibility for themselves because they can’t … They’re in the minority, but then you have to put in place a system for safety netting that’s watertight.’
(GP04, M aged 53 years, PT)
Though a strategy of selective follow-up was deemed necessary to control their workload, GPs accepted it was not ideal due to the increased likelihood that patients might fall through the net:
‘I accept that there’s a risk to all these things. If you don’t have a system of checking on everything then it’s possible that someone will slip through the net. But on the other hand, if you spend all day every day checking on everything you’ll never get any work done. So, it’s got to be a balance.’
(GP19, M, aged 49 years, FT)
In deciding whether and when patients warranted a referral for cancer investigations, GPs reported a responsibility to ease the current strain on specialist care and to ensure investigation was in the patients’ best physical and psychological interests. Limited time and resources resulted in a balance being struck, using robust safety netting as backup:
‘I think as well the balance of resources in the NHS, and the kind of gatekeeping role we have as GPs. Now whether that’s something that’s going to continue or not … in the existing climate and the way the government seems to be working things, I don’t know. But I think it’s something I take quite seriously.’
(GP12, M, aged 37 years, FT)
Low concern about cancer
Safety-netting practice varied depending on the GP’s level of concern that cancer might be causing a patient’s symptoms:
‘I never don’t use safety netting at some level. I think the question is how much do you use? And I think that depends on what I think the risk is.’
(GP09, M, aged 52 years, PT).
However, GPs struggled to explain their rationale for deciding which cases raised concern:
‘It’s then picking the cases where there’s a possibility or a real chance that it might be relevant, versus the ones where I think, actually, it’s just run of the mill stuff. And deconstructing that decision-making process is really hard. I’m not sure I could even tell you how I do it.’
(GP12, M, aged 37 years, FT)
GP15 described a patient with bowel symptoms who he had not actively followed up because ‘… I wasn’t worried about cancer at the time’.
Eventually they referred the patient non-urgently for investigations that led to a cancer diagnosis. With hindsight, the GP wondered whether they had safety netted well enough, saying:
‘I guess because I wasn’t worried about cancer then maybe I’d safety netted a bit more casually than I would have if I had, for example, seen a woman who I felt a breast lump, which I felt was benign but I wanted to see her again in a month.’
(GP15, M, aged 38 years, FT)
GP21 had been surprised when a male in his 20s whose gastric symptoms he had been investigating turned out to have stomach cancer, saying:
‘I mean it’s so rare in that age group. But it does happen … But you can’t go and scope every 25-year-old with these kind of symptoms.’
(GP21, M, aged 48 years, PT)
Similarly, GP04 had been caught out after dismissing a lump on a patient’s nose, which was later diagnosed as an amelanotic melanoma. The GP said:
‘It hadn’t occurred to me that it could be cancer at the time.’
(GP04, M, aged 53 years, PT)
Others had learnt from experience that they needed to be mindful of the potential risk of cancer even when they would not naturally suspect it:
‘You always have to be prepared to be wrong-footed by something that you’re not expecting.’
(GP23, F, aged 38 years, PT)
GP08 (M, aged 50 years, FT) explained that safety netting ‘… should aim to rule out the worst-case scenario’. GP16 suggested that GPs might not take safety netting seriously enough until they had experienced something going wrong:
‘I think your attitude to safety netting changes once you’ve done it wrongly. I think that’s the way we learn: hard and fast. And people that haven’t had that I don’t know whether they can take it as seriously, all the documentation and everything.’
(GP16, F, aged 39 years, PT)
Work patterns and documentation
The detail that GPs said they wrote in the clinical record varied widely. At one end of the spectrum GP18 explained:
‘I write as much as I can remember. So, I write the history of all the questions that I remember asking them, and the full examination, and hopefully a plan, so that if somebody sat and read that they would understand what level of assessment had been done.’
(GP18, F, aged 44 years, PT)
At the opposite end, GP05 revealed:
‘Although I’m saying all these things to you, I don’t always write it down.’
(GP05, F, aged 53 years, PT)
The GP had not previously considered the implications of that, saying:
‘… so I suppose it does present a problem if someone else picks up the case and not knowing whether you’ve mentioned it or not.’
(GP05, F, aged 53 years, PT)
Other GPs aimed to strike a balance between writing such detailed notes that a colleague might be deterred from reading them, and writing enough so that what had been done could be understood:
‘When we keep notes we don’t want to write everything down if it’s got to be read in the future, and we’ve got a limited amount of time. So, I’ll try and put my thoughts down so that if someone else sees it or I see the patient again then I can pick it up from there.’
(GP08, M, aged 50 years, FT)
Accounts from GPs who worked part-time or as locums suggested that they were especially mindful that a patient they had seen in consultation could be seen next by a different GP. It was, therefore, important that what they wrote in the patient’s notes could be understood by their colleagues to ensure continuity of care. Sufficient detail was needed to follow the previous GP’s line of thought and know what had been discussed with the patient:
‘And because I work part-time, I do 3 days and other people work part-time, it’s important that we’re documenting what we’ve done and what the plan is, because often they’ll phone and it will be another doctor that’s picking up that question. So, it’s really important that the plan is written down.’
(GP18, F, aged 44 years, PT)
Adequate documentation was also seen as important medico-legally, as GP06 explained:
‘It’s critical, obviously, what you write there and then. It could be held up in a court of law, couldn’t it, a year or two later, and you’ve got to be certain that what you put down is adequate.’
(GP06, M, aged 42 years, FT)
Interviewed GPs who were working as short-term locums felt an added responsibility to ensure that patients they saw did not fall through the net if they knew they would not see them again. They were also anxious not to create unnecessary extra work for their permanent colleagues. GP22 said he would be:
‘… playing it safer, particularly where I don’t know the practice well, and particularly where I don’t know the communication systems well.’
(GP22, M, aged 38 years, locum)
These locums said they were more inclined to refer at the first appointment if they thought it unlikely they would see the patient again, and tried to put robust follow-up plans in place for those not referred straight away:
‘I tend to either make it a specific decision and decide that they’re being referred, or clearly outline when I’d want to see them next and the conditions associated with it.’
(GP24, M, aged 36 years, locum)
Both full- and part-time GPs said they sometimes made reminders or, if they knew they would be away, asked a colleague to check that follow-up had happened for some patients:
‘My system is that I send myself a note to either think about this patient a little bit more deeply in terms of what’s gone on in the past, or to make sure they have come back at a certain time … if I see they’re coming back to see the nurse I can write a message underneath their name and say, “Please make sure this patient understands that they need to …”’
(GP03, F, aged 54 years, PT)
