Optimising GPs’ communication of advice to facilitate patients’ self-care and prompt follow-up when the diagnosis is uncertain: a realist review of ‘safety-netting’ in primary care (30 March 2022)

Summary

Many people see their GP with symptoms that could either get better without treatment, or be a sign of serious illness; their diagnosis is uncertain. Research has explored how GPs and patients can work together to develop follow-up plans (a process known as safety-netting). New recommendations could help GPs manage uncertain diagnoses.

To avoid unnecessary referrals, GPs may adopt a ‘watch and wait’ strategy when someone has an uncertain diagnosis. This strategy should come with a clear follow-up plan so that people understand the possible causes of their symptoms, how to look after themselves and what to do if symptoms persist. This is good safety-netting.

Without good safety-netting, watch and wait carries risks. For example, late cancer diagnoses have been linked to poor safety-netting. However, professional guidance on safety-netting is lacking. This is a knowledge and practice gap.

A study from Friedemann Smith explored the best ways to deliver safety-netting advice. It suggests that people are more likely to follow advice if they are involved in developing the follow-up plan. They need to understand:

• why they are receiving this advice
• what actions are required, and by whom.

The lack of time within primary care consultations is well known. This may need to be addressed for clinicians to have long enough to develop a safety-netting plan. Professionals may also need training to develop the appropriate communication skills.

Content

How to offer safety-netting advice

• Build safety-netting into the entire consultation; it should not be rushed at the end.
• Use simple terms and avoid jargon and abbreviations (but include appropriate technical terms); tailor advice and address potential sources of anxiety (for instance being young or a first-time parent).
• Consider grouping chunks of information to help the patient remember the advice.
• Give people the opportunity to share their expectations and concerns, and address these in the safety-netting plan.

What advice to give: the safety-netting plan

• Explain and discuss uncertainties and the follow-up plan.
• Offer an initial diagnosis, explain how long you expect symptoms to last (or how they might change), give practical tips for self-care and symptom management (which give people a sense of control) and instructions for when they should be concerned.
• Personalise someone’s risk based on their characteristics (such as age or medical history) and not on population data. The plan should also be personalised and address factors that might make an individual less likely to follow advice (for instance if they have had a previous missed diagnosis).
• Give the patient the opportunity to ask questions and to share in decision-making.
• Actively check the patient’s understanding.
• Acknowledge the patient’s ability to make judgements about their own health, and to change their mind about a plan.