Safety netting – to net or not?

If you are prone to falling, it is useful to have a safety net. You know, something behind or underneath you that will stop the harm that might occur otherwise.

Safety nets are used extensively within healthcare.

In medicine, you will find this more commonly in primary rather than secondary care, in that, in the former, a patient is typically at home ‘responsible’ for themselves and the interaction with the GP or community nurse is episodic – a phone call or a visit and then they move-on. Most of the minding or supervision is done by someone else – the person/patient, their family or carers.

For hospital inpatients this I different in that that care is usually continuous during the time that person is in a bed or a clinic, in effect, the responsibility shifts from the person to the nurse, therapist or doctor who is doing the doing.

The most common trope, or at least the one I encounter when reading clinical records is the sign-off, ‘If you have any more pain/nausea/dizziness/palpitations/etc call 111 or 999.’

That is the safety net.

It says, ‘I have seen you and at the time of our meeting, you seemed OK, you might be unwell but not bad enough for additional help or transfer to hospital for emergency care, you might however get worse and if you do, don’t ignore the symptoms, call for help.’

This is sensible advice as a worst case scenario would be a patient who experiences central crushing chest pain thinking, ‘I’ve just seen the doctor, she said it was my indigestion, I’ll take two aspirin and lie down.’ Or, ‘The doctor said the rash looked like a bruise, my headache, difficulty looking at the light and vomiting must be nothing to worry about.’

Sure, some readers will think, ‘Honestly, this isn’t nannyworld, people have some responsibility, they should use their common sense.’

It is however down to the language and communication, the confidence with which the doctor or nurse engages with the patient and how that is heard and understood.

You might be wondering, ‘So what?’

Well, for me, the ‘So what?’ is perhaps the over-use or over-reliance on the safety net.

I’ll explain by means of analogy, think a tightrope walker, winging their way between two high places.

The presence or absence of a safety net changes the narrative.

It changes the spectacle for sure, although likely and more importantly it changes the behaviour of the walker, after all, a fall without a net is the end, with the net is an embarrassing bounce.

I don’t want to suggest the carer in the nursing home who calls 111 when the resident has a further funny-do is an bounce, it does however let the initial assessor – doctor, nurse, paramedic a little off the hook. They are OK to be less confident in their original review and potentially even less thorough, and this might be communicated to the carer.

The walker without the net is surely a more careful walker.

Is the doctor who uses a net a less careful medic?

It is hard to say although certainly when I review clinical records, it seems the more junior and less experienced staff tend to rely more on the net than those who have been around longer.

You might question whether the presence of the safety net is an issue.

Well, you see, and this is particularly a Covid phenomenon, the numbers of clinical encounters between patient and clinician who have never met or spoken to one another has increased, whether this is new staff in a surgery who haven’t had the more traditional face-to-face contact or those visiting services (often nurses and paramedics) who have stepped-in to undertake home-visits in place of the more traditional GP house calls.

When you interact with someone who doesn’t really know you, and who perhaps has less access to details of your medical history, the tendency is towards what we call risk aversion – this is the behaviour where every possibility is considered something bad, every rash is meningitis, every bump a cancer, when, in reality, most rashes are eczema and bumps are just bumps.

Disentangling this is tricky and that is the reason we value those working in the NHS for their skill and discernment.

A referral through a cancer pathway or acute admission to hospital for a rash that has been present for 10 years is not usually in anyone’s best interests, yet it still happens and it is more likely to happen if the person seeing you has not seen you before, or has never seen you at all if the encounter is on the phone.

And, yes, we don’t want gung-ho high-risk folk who skirt around the peripheries of diligence and miss important diagnoses.

We want Goldilocks.

And this is the tension between risk aversion and safety netting.

The risk averse doctor or nurse is more likely to safety net, they are more likely to communicate their uncertainty to the patient and carer which leads to an interaction that is diminished of its value, after all, most patients just want some reassurance and, reassurance is not what is provided in the risk-averse, over safety netted encounter.

The solution?

Well, I suspect a major part of this is shifting back in part (not the whole way) to pre-Covid face-to-face encounters when possible, particularly if the doctor or nurse has never met the patient before (and even more if the patient has cognitive, visual or auditory impairment).

It is also returning to continuity of care.

The same clinician seeing the same patient on more than one occasion.

The creation, development and nurturing of relationships.

Unfortunately with the latter, the continuity has been bedevilled most recently by Covid but more generally by the most towards system-led healthcare with bigger and bigger health centres where staff work shifts and individual relationships are broken-down.

(If you are one of 5,000 patients or one of 50,000 you will know the difference).

If I know that Mary has a tendency to rashes or picking spots or whatever, the next time I see her I will automatically view her through a lens of rash/picking/spots. If she is new to me the encounter will be a tabula rasa. And yes, a new pair of eyes is sometimes required to overcome preconceptions, it is however, particularly in my world of older people who are never quite right a greater risk.

How to end?

To net or not?

A doctor who doesn’t net at all is one who lives precariously, and I would not suggest that this is done away with, I would however recommend a review of the language and how it is used, the way diagnoses or impressions are communicated, the way reassurance is provided and received.

‘It’s nothing to worry about,’ will allow a person to feel better, ‘I’m not sure, I think it is nothing, although it might be something, if it gets any worse, if it starts to grow or bleed or not improve, call me back.’ Less so. And, ‘I am sure you will be fine, if you are worried, call an ambulance.’ Not at all.