Friedemann Smith, Claire

Nicholson, Brian D

English

Oxford University Research Archive

Dear Editor,We read this Analysis article with great interest. Time plays a central role in the feasibility of core aspects of primary care and the article brought to mind two areas from our own work where time needed to treat (TNT) could be useful.Safety-netting, or advice to support self-care when appropriate and encourage help-seeking when necessary, is regarded as best practice but tends to be delivered poorly, in a rush, and at the end of the consultation (1). Dedicated time throughout the consultation is also required to put safety-netting recommendations into practice (2), for example, explaining clinical reasoning, checking patient understanding, and agreeing a follow-up plan. A favourable TNT for these recommendations could demonstrate that limited additional time is needed to incorporate them into the consultation. Equally, an unfavourable TNT could help to prioritise the most time-efficient components of safety-netting. Secondly, gut-feelings are described as mental ‘short-cuts’ to guide decision making in primary care. They rapidly combine clinical experience and knowledge of the patient to arrive at a sense of alarm or reassurance about the patient’s health that can be investigated further (3,4). In recent years, we have seen growing awareness that the use of gut-feelings is common in primary care and a gradual increase in the acceptance of GP ‘gut-feeling’, for example with its inclusion as a standalone referral criterion for cancer rapid diagnostic centres (5,6). Given the evidence that exists for the utility of gut-feelings, TNT could be used to strengthen the case for their inclusion in referral pathways more widely by demonstrating the time savings possible from this rapid way of thinking. With these examples, we support the authors’ proposal that the TNT could become a valuable metric in clinical scenarios with finite resources, such as primary care. We believe it could prove to be as useful as number needed to treat (NNT) is for treatment decisions (7).(1) Evans J, Ziebland S, MacArtney J, Bankhead CR, Rose PW, Nicholson BD. GPs’ understanding and practice of safety netting for potential cancer presentations: a qualitative study in primary care. BJGP 2018; 68 (672): e505-e511.(2) Friedemann Smith C, Lunn H, Wong G, Nicholson BD. 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. BMJ Quality & Safety 2022;31:541-554.(3) Friedemann Smith C, Drew S, Ziebland S, Nicholson BD. Understanding the role of GPs’ gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. BJGP 2020; 70 (698): e612-e621..(4) Friedemann Smith C, Møller Kristensen B, Sand Andersen R, Hobbs FDR, Ziebland S, Nicholson BD. GPs’ use of gut feelings when assessing cancer risk: a qualitative study in UK primary care. BJGP 2021; 71 (706): e356-e363. (5) Dolly, S.O., Jones, G., Allchorne, P. et al. The effectiveness of the Guy’s Rapid Diagnostic Clinic (RDC) in detecting cancer and serious conditions in vague symptom patients. Br J Cancer 2021; 124, 1079–1087.(6) Nicholson BD, Oke J, Friedemann Smith C, et al. The Suspected CANcer (SCAN) pathway: protocol for evaluating a new standard of care for patients with non-specific symptoms of cancer. BMJ Open 2018; 8:e018168.(7) Cook RJ, Sackett DL. The number needed to treat: a clinically useful measure of treatment effect. BMJ 1995; 310 :452

Guidelines: safety netting and gut feeling should be factored in to time needed to treat

https://ora.ox.ac.uk/objects/uuid:bbc9850a-ff64-45c4-bcba-faa52b48c9fa/files/rt148fj370

Guidelines: safety netting and gut feeling should be factored in to time needed to treat

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