How and when is safety-netting advice delivered in routine primary care consultations?

Problem

'Safety-netting' is widely endorsed by many professional organisations across multiple guidelines, and forms part of the RCGP curriculum for training new GPs, but little is known about how and when safety-netting advice is delivered in routine primary care consultations.

Approach

318 recorded consultations from the 'One in a Million' Primary Care Consultation Archive were screened for the presence or absence of safety-netting advice and subsequently analysed. The archive contains predominantly video-recorded (but also includes some audio only) unselected adult consultations with 23 different GPs across 12 diverse practices, in areas of high and low deprivation. The archive was collected between 2014-2015 across three CCG areas in the West of England.In this study, safety-netting advice was defined as "information shared with a patient designed to help them identify the need to seek medical help if their condition failed to improve, deteriorated, or if they had further concerns about their health." Consultations were analysed using a novel interaction coding tool developed to assess how and when safety-netting is delivered during healthcare encounters. The foundations of the tool were grounded in the available published literature, but repeated cycles of refinement were required to enable the tool to effectively capture all the key characteristics of safety-netting advice given for a wide variety of medical problems. Key features of the tool include: does the patient or the clinician initiate the safety-netting advice, in what stage of the consultation is the advice discussed, does the advice include any specific symptoms to look out for or a time frame for resolution of any current symptoms, what action is advised, how do patients respond to the advice, does the clinician check that the patient has understood the advice, and is any uncertainty around the diagnosis discussed during the consultation. The tool is primarily focussed on assessing contingency planning, but also records the incidence of non-contingent plans such as routine follow-up and investigations.

Findings

Safety-netting advice was observed in 205/318 (64%) consultations and for 254/536 (47%) medical problems raised during these consultations. Medical notes were available for 190/205 (93%) consultations that included safety-netting advice and there was evidence that safety-netting advice was at least partially documented in 91/190 (48%) consultations and for 99/236 (42%) medical problems. Full analysis of the intricate details of how and when safety-netting advice was delivered in these consultations using the coding tool will be presented at the conference.

Consequences

Safety-netting advice was delivered in almost two thirds of consultations and for half of medical problems raised during these consultations. Safety-netting was found to be poorly documented in the medical notes, which may leave GPs susceptible to medico-legal criticism.