Safety Netting

1. Safety Netting • Missed diagnosis in general practice is inevitable • A process where people at low risk, but not no risk, of having cancer are actively monitored in primary care to see if the risk of cancer changes. • No diagnostic test or clinical decision in general practice is 100% sensitive. • individuals present at different stages in the evolution of their illness • at an early stage red flag signs and symptoms may be absent • or present much later when disease is too advanced • Safety netting is a 'diagnostic strategy' or 'consultation technique' to ensure timely re-appraisal • Important for conditions such as suspected cancer • patients present infrequently • symptoms are common and non-specific

2. Why Safety Net? • Improves patient safety • Supports early diagnosis of cancer outcomes • Effective team work – helps colleagues follow the patient journey • Medico-legal protection and evidence of systems reduces risk • Quality Improvement • Appraisal • Revalidation • CQC

3. Why Safety Net? “The number of clinical negligence claims against health professionals continues to rise……one fifth of all claims brought against GP members involve cancer and by far the most frequent type of errors made by GPs in these cases related to concerns over diagnosis (81% of all errors made by GPs in cancer claims)”

4. Safety Netting • The term ‘safety-netting’ was introduced to general practice by Roger Neighbour • Questions to ask yourself • If I am right what do I expect to happen • How will I know if I am wrong • What would I do then? • Safety Netting means different things to different people • Little consensus as symptoms have varied trajectory on ‘when to worry’ • What we can agree however is that proactive safety netting is necessary for early diagnosis of cancer and consistent with good practice

5. Safety Netting Safety netting in consultation may include • Advising patients ‘when to worry’ • Advising patients when to return for a review • VERBAL and/or WRITTEN information • Fixing follow-up before the patient leaves the consultation • Read coding and clear documentation

6. Safety Netting Safety netting systems may include • Checking patient contact details as a continuum or opportunistically • Confirmation of a suspected cancer clinic appointment, attendance and follow-up • Confirmation of diagnostics appointment and attendance • Hotlines for elderly or vulnerable patients who may co-morbidities that affect access • Continuity of care / ‘usual doctor’ or ‘buddy’ systems • Use of the patient healthcare software to ELECTRONICALLY safety net

7. Reception Three failed attempts to contact patient with abnormal chest x-ray suspicious of lung cancer – telephone number on record not in use • Reception teams can check contact information and address proactively • GPs should confirm contact information for diagnostics and referrals • Clear plan to patient how to access results (two-way communication) • Patient information leaflets on why patient has been referred and document • Iterates the seriousness to the patient • Provide clear instructions to the patient how they access you • Face-to-face/ telephone • Direct message / email • Via a practice administrator or dedicated receptionist

8. Symptoms “ Come back and see me if the back pain persists for another 3-4 weeks” • This is a classic example of safety netting in consultation • No commitment from the patient or the GP • For minor concerns only • Always give the patient a timeline of when to be re-assessed • Patient information leaflets on symptoms and ‘when to worry’ • Provide clear instructions to the patient how they access you • Face-to-face/ telephone • Direct message / email • Via a practice administrator or dedicated receptionist

9. Diagnostics “Book an appointment a week after your MRI brain to discuss the results” • This is another common example of safety netting for direct access diagnostics • READ code Refer for MRI imaging • Little commitment from GP and puts it all on to the patient • Patient may not receive the appointment in a timely manner • Give the patient a timeline of when they should expect their appointment • May not be appropriate for patients with co-morbidities, cognitive impairment or mental health problems • Provide contact telephone numbers for patients to secure or chase their diagnostics appointment • Use of practice administrator as the point-of-contact • Pitfall: Unless coded it is not auditable and no method to track patient DNA’s or results not received

10. Referrals “ Contact the surgery if you do not get an appointment from the breast clinic in the next two weeks” READ code all suspected cancer referrals DO not use EMIS codes as they are non-transferrable E-referrals and emailed referrals (no more fax) Tracking system should be established where administrator confirms referral has been received and appointment allocated Proactive recall of patients who DNA Follow up codes or diary entries to PRO-ACTIVELY safety net and track patients in their journey

11. Follow up “ Take this note and ask reception to book a blood test and follow up appointment a week later” Patients are more likely to book follow up if given an appointment slip Better engagement Less likely to be lost to follow up Should document clearly in the notes Helps reception to book appointments appropriately at the right intervals Slips can be adapted to include details info for the reception team • Usual doctor follow up, blood test appointment, time frames Pitfall: Not easily auditable and no method to track patient DNA’s or results not received

12. IT software “ For annual PSA” or “ repeat FBC to monitor Hb and check iron status” Regular review of pathology requests • Use electronic means to order pathology and imaging • List reviews • Call patient who have not attended for their investigations Text reminder to patients regarding primary care appointments • Reduces DNA rates Messaging service via patient access to the electronic record to patients • Patient can send a message (24hour messaging system) • E-consultation using WebGP

13. IT software Use of Diaryentry or follow-upcodes Weekly search on patient healthcare record Generates a spreadsheet divided into usual doctor Sent to GP teams to proactively review • Suspected cancer referral outcomes • Blood test and imaging (diagnostics) outcomes • DNAs • Patient who have not re-attended for a review of their symptoms as advised • Cancer care reviews

14. Safety Netting Codes

15. Quality of documentation • Clear Problem Titles • Reviewed, evolved, grouped and combined when diagnosis is made • Makes it easier to view patient journey • Minimise clutter on screen • Code symptoms (for use of Qcancer) • Code weight, BP, smoking status • Code Family history • Code ‘Fast track suspected cancer referral’

16. Cancer specific codes • Cancer diagnosis: active indefinitely • Code fast track cancer referrals • Code cancer treatments • Single episode: Chemotherapy completed • Single episode: Radiotherapy started

17. Cancer Screening Codes

18. From symptoms to diagnoses:Why is it so difficult to pick up cancer? Patients symptomology Outcome

19. Opportunities to Safety Net • At the first consultation • Ongoing reviews • Direct access diagnostics • Communications with secondary care • Suspected cancer referrals • Follow-up • Locum protocols • Annual leave protocols

20. Top 10 Tips • Offer a timely review and action after investigations have been requested • Actively monitor symptoms in people at low risk (but not no risk) to see if their risk of cancer changes • Where appropriate reassure people who are concerned that they may have cancer that with their current symptoms their risk of having cancer is low. • Explain to people who are being offered safety netting which symptoms to look out for and when they should return for re-evaluation. It may be appropriate to provide written information. • Ensure that results of are reviewed and acted upon promptly and appropriately; the healthcare professional who ordered the investigation taking or explicitly delegating responsibility for this. Be aware of the possibility of false-negative results for chest X-rays • Consider a review for people with any symptom that is associated with an increased risk of cancer, but who do not meet the criteria for referral or other investigative action.

21. Top 10 Tips • The review may be planned within a time frame agreed with the person or be patient-initiated if new symptoms develop, the person continues to be concerned or their symptoms recur, persist or worsen. • Read code suspected cancer referrals and direct access diagnostics e.g. fast track suspected (breast) cancer referral, referral for ultrasound investigation • Track patient attendance and outcomes for blood tests/ imaging/ endoscopy/ suspected cancer outpatient appointments using the relevant software, e.g. ICE software, Tquest list management or other robust electronic safety netting system(s). • Pro-active recall using an electronic search to review patients who do not attend their appointment for diagnostics / two week wait clinic appointment within the time frame agreed For example in EMisWeb, a coded Diaryentry within the ‘follow up’ component of the consultation with a specified date; a regular search can be conducted to track patients in their suspected cancer/diagnostics journey

22. Resources REFERENCES NICE NG12, Suspected cancer: recognition and referral (2015) https://www.nice.org.uk/guidance/ng12 NICE CG27, Referral Guideline for Suspected Cancer (2005) http://webarchive.nationalarchives.gov.uk/20060715141954/http://nice.org.uk/nicemedia/pdf/cg027niceguideline.pdf RESOURCES Pan London Suspected Cancer Safety Netting Guide, Transforming Cancer Services Team, Healthy London Partnership https://www.myhealth.london.nhs.uk/system/files/Pan%20London%20Suspected%20Cancer%20Safety%20Netting%20Guide%202016.pdf CRUK Safety netting guide: http://www.cancerresearchuk.org/sites/default/files/16._safety_netting.pdf London Cancer & Macmillan Safety Netting Guide http://www.londoncancer.org/media/126626/150708_Guide-to-coding-and-safety-netting_report_Dr-A-Bhuiya_V3.pdf