Assessing acutely unwell children in primary care is fraught with challenges. While clinicians may use objective clinical tools to support their assessment, Clark et al’s recent study highlights their limitations in general practice.1 Their evaluation of scoring tools, including The National Paediatric Early Warning System (PEWS), found they performed poorly at predicting which children would require hospital admission within 48 hours of presenting to general practice. This builds on their previous work which showed the NICE ‘Traffic Light’ system failed to reliably distinguish serious illnesses from self-limiting conditions in children.2 Thankfully, the incidence of children subsequently admitted to hospital at 48 hours in Clark’s study was low (1.6%).1 However, GPs face the ongoing challenge of identifying children who can be safely managed in the community without missing those at risk of deterioration. Alongside this, we must balance our duty to use limited healthcare resources wisely and avoid inadvertently harming our patients with unwarranted prescriptions, investigations, or referrals. One way to address the uncertainty that today’s assessment may not reflect tomorrow’s healthcare needs is to implement effective safety netting.
Safety netting
It has been over 15 years since Susan Almond and colleagues published their seminal Delphi consensus study on what safety-netting advice for acutely ill children should include.3 Despite the passage of time, these principles remain as relevant today.
They recommended safety-netting advice should include:
What exactly to look out for.
How exactly to seek further help.
What to expect (specifically about illness time-course if known).
The existence of diagnostic uncertainty (if present).
No consensus was achieved on when or whether written safety-netting advice should be provided. Recently, Black urged us to reconsider, questioning whether it is ‘time to stop relying on verbal [safety-netting] interventions’.4 Black highlights the time constraints of a primary care consultation and the inherent fallibility of human memory — both for patients and clinicians. However, just providing an information leaflet without verbal advice may be insufficient. Neill et al’s systematic review found that parents retained more knowledge about managing acute childhood illness when both verbal and written information were provided, compared to written advice alone.5
New safety-netting research
The BJGP has published the first network meta-analysis of safety-netting interventions for acutely ill children supporting Black’s assertion. Burvenich et al found that written safety-netting advice was associated with reduced antibiotic and reconsultation rates compared to usual care.6 Other formats, such as video and online resources, were shown to enhance parental knowledge, while web-based modules appeared to improve parental satisfaction. They concluded that combining written and verbal safety-netting advice may be the most effective approach for reducing antibiotic use. This meta-analysis included randomised controlled trials, non-randomised intervention trials, and controlled before-after studies. However, these research settings differ from usual care, where parents/carers often express dissatisfaction with the level and consistency of written advice.7
Edwards et al conducted a retrospective study of 2400 adult out-of-hours consultation records from 2013 to 2020.8 The study found an increasing frequency of documented safety-netting advice in medical records (71.7% in 2013 versus 82.2% in 2020), yet again, the frequency of written safety-netting advice provided to patients was low (0.2%). On a more positive note, clinicians were observed to record more specific safety-netting advice over time and include a greater number of symptoms for patients to monitor. However, the second most common symptom patients were told to look out for was if their symptoms persisted, but only one in five cases recorded that they had provided a timeframe. They also found safety-netting advice was more prevalent in face-to-face rather than telephone encounters. This resonates with the 2023 RCGP health services research paper of the year, which evaluated safety incidents in remote primary care consultations. In this paper, Payne et al found inadequate safety netting as a contributing factor towards serious harm and death.9
Can artificial intelligence aid safety netting?
Generative artificial intelligence (AI) tools capable of summarising clinical encounters (AI scribes) and facilitating real-time safety-netting advice, along with its documentation, could mark a new era in digital health.10 These tools have the potential to enhance patient safety while protecting clinicians from medicolegal risks. Additionally, they may play a role in (re)writing medical records into formats that are more easily understandable for patients.11 This is of particular importance now all NHS patients in England, by default, have access to their full primary care medical records. Deliberate ethical and practical considerations should be given to the use of such tools for patients and carers from ethnic minority backgrounds for whom English is not their first language.
Conclusions and recommendations
Box 1 highlights common safety-netting pitfalls and mitigation strategies. It is recommended that clinicians, where possible, use written, specific safety netting as an adjunct to professional clinical judgement, in concordance with best practice.12,13 This is of particular importance in cases of diagnostic uncertainty and when assessing and treating acutely unwell children, whose conditions can change rapidly. Pre-set text message templates for common conditions can save time, but clinicians should ensure patients can access the resources provided (for example, ability to read or access hyperlinks requiring a smartphone).14 Additionally, while multi-problem GP consultations are now commonplace, research highlights GPs less frequently provide safety netting for issues raised after the first problem.15 Sharing this risk with patients may help manage expectations of what can safely be assessed in a single consultation. We also recommend delivering safety netting in the ‘treatment planning’ phase of the consultation, as observational research indicates GPs are more likely to provide specific advice if safety netting is incorporated as part of a management plan, rather than used to ‘close’ the consultation (for example, ‘any problems, let me know’ as you open the door).15 This would help overcome previous parental concerns that generic safety netting for children is often ‘too vague to be useful’.16 However, it is worth retaining some clinical autonomy and recognising that information needs for patients and carers will vary depending on pre-existing health literacy and stage of illness presentation amongst other contextual factors. Where possible, safety-netting information should be accessible in a variety of languages and formats. The ‘Healthier Together’ website is a useful resource with paediatric safety-netting sheets for parents and carers that are available in over 100 languages and available as an application (see Box 2 for details and further useful resources). Particular consideration should be given to telephone consultations where the risk for patient harm is potentially greater.
Common safety-netting pitfalls |
• Providing vague advice only, for example, ‘any problems, come back’ or ‘come back if it’s not better’ without specifying a timeframe. |
• Over emphasising certain symptoms, or using symptoms associated with the disease as red flags for example, telling a parent of a child with a vomiting illness to return if the vomiting persists (the red flag is signs of dehydration not vomiting). |
• Assessing multiple problems in one consultation but failing to safety net problems raised later. |
• Patients being unable to recall verbal safety-netting advice. |
• Assuming patients can access or understand online resources without confirming this. |
Mitigation strategies |
• Include specific safety netting as part of the management plan rather than using it to close the consultation. |
• Utilise pre-set text messages or leaflets for common conditions with specific safety-netting advice. Post-consultation text/online messaging can be particularly useful when supervising junior colleagues if safety netting has been overlooked. |
• Share with patients that research has identified safety concerns associated with addressing multiple problems in a single consultation to help manage their expectations. |
• Check if patients can access text/online advice or need an alternative format. |
Box 1. Common safety-netting pitfalls and mitigation strategies
Box 2. Useful resources for parents/carers
Future studies should focus on evaluating whether effective safety netting improves health outcomes deemed important by patients, carers, and healthcare professionals, linking this to datasets tracking healthcare utilisation to better understand the impact and cost-effectiveness of safety-netting interventions on patient care.
Notes
Funding
Mavin Kashyap was funded by an
NIHR Academic Clinical Fellowship in General Practice (ACF-2021-25-014). Peter Edwards was funded by an NIHR In-Practice Fellowship (NIHR302692). Damian Rowland declares no specific funding for this work. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
Provenance
Commissioned; not externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2025