COVID-19: toolkit for GPs and GP practices

High-risk patients and shielding arrangements

Location: England Wales Scotland
Audience: GPs Practice managers
Updated: Monday 6 July 2020
Topics: COVID 19

This guidance is for England only - scroll down for guidance for Wales.

We have produced guidance for practices about the list of shielded patients and those that have self identified using GOV.UK.

 

Timeline

  • The CMO sent a letter on 21 March asking practices to identify additional patients who may be known as being at highest clinical risk.
  • By 24 April, practices were sent a list of patients that had self-identified but had not been identified through a central process, to be reviewed to determine their appropriate COVID-19 risk category. 
  • Patients flagged as high risk were sent a letter advising to shield until 30 June.
  • On 4 June, NHSE/I published a letter about the support of people who have been shielding confirming Government’s updated guidance that they could now leave their home, and providing guidance on how to remove people from the list. There was also an updated letter to high risk patients.
  • A letter will also be sent to a small number of patients who have been removed from the list.
  • On 22 June, the Government announced that from Monday 6 July, the advisory guidance for clinically extremely vulnerable people who are currently shielding from coronavirus, will be eased in two stages (6 July and 1 August) and that these patients will be sent a letter advising them to continue with the care/treatment arrangements currently in place. The Chief Medical Officer and NHS Medical Director also published an updated letter to the NHS on shielding. 
  • The guidance for the clinically extremely vulnerable group remains advisory. More detailed advice will be provided by the Government in England as the changes in advice come into effect on 6 July and 1 August. The Government have said that unless they see a significant rise in COVID-19 cases they expect the shielding programme to be paused on 31 July.

The RCPCH have produced guidance on identifying children and young people at high-risk of infection.

 

What shielded patients can expect in social care

Being on the shielded list means patients in social care's details will be shared with other bodies and agencies.

If they do not currently have their prescriptions collected or delivered, they will be a priority for pharmacies to do this. The pharmacy may find a volunteer (who will have been ID checked) or deliver it if their own service is unable to.

They may continue to receive free food parcels until the end of July and be given priority for supermarket home delivery services. Health or social care providers involved in their care will be asked to take additional precautions to make sure that the individual is protected.

Read more on GOV.UK on shielding and protection extremely vulnerable persons from COVID-19.

 

About the shielding list

What is the validated list?

The method by which the list was validated has been published by NHS Digital. The list is dynamic - new people can be added and removed by practices and hospitals, for instance with changes in diseases/treatments (ie new diagnosis or therapy finishing).  

The list will be updated on a regular basis through national data extractions so that people recently added can be included in national messaging and receive the necessary support. The list will continue to be maintained after August, so that it can be used again in the future if necessary. 

Work is being done to develop a new predictive risk tool which takes into consideration a wider range of factors such as demographics alongside long-term health conditions, to better understand cumulative risk of serious illness for individuals if they catch COVID-19, which could lead to an updated list in the future. The research model for this tool has been published by the University of Oxford, and you can read more about in the letter to the NHS published on 22 June 2020. 

Accuracy of list

The list is based on hospital (administrative data) over the last 14 years and all GP data (flu extract) ever coded.

Hospital data are valid for payment purposes – and uses clinical classifications – and are by their nature broad. The route of coding can be (more historically) separate from the patient. It is old data – ie hospital episode statistics data is three months old. It also does not capture people who do not go to hospital or had significant procedures abroad or privately.

GP data uses terminologies which are more specific but is variably used by practices. Some codes relating to cancer or other conditions where patients are no longer receiving active treatment may still be retained in a patient’s active problem lists to support a holistic approach to their care by the practice. 

Other codes, such as sickle cell trait, may also have a code for disease on their records, which has been picked up by the national data.

Hospital procedures and interventions are coded in a variable manner. The 10 April release used GP flu data from 16 March – which did not include many cancer codes nor drug codes.

Codes and classifications have historically been used for purposes other than intended – the practice of using 'local codes' has reduced but is still widely recognised.

The CMO categories and the data production was done at speed and in a best endeavours approach. These are all known risks and have been accepted by the CMO and Government. It has led to additional work for practices as they have needed to spend time validating the information provided.

False positives

There is a risk that some patients have been identified as benefitting from shielding who do not fully meet the national criteria. However, they should be socially distancing.

If a patient is wrongly identified due to their record stating that they have one or more vulnerabilities when in fact they don’t, or the condition they had no longer has an impact on their health then a false positive for this patient will be extracted to the summary care record. This could impact decisions for the care of this patient in other parts of the system. The record will be automatically updated weekly through extracts from the GP systems.

False negatives

Despite the national data extractions, there may still be some people who have not yet been identified and notified that they should be taking steps to shield. Identifying such people will require local knowledge, including specifically about anything that has happened to them in the last three months. It is important for practices and hospitals to add such patients to the list when appropriate.

NHS Digital has identified patients who meet the high risk criteria for contracting coronavirus, due to their inclusion in one or more of the disease groups. You can view the list of conditions.

 

Shielding arrangements in Wales

Following a central interrogation of NHS Wales patient data (methodology defined here), beginning 24 March the chief medical officer for Wales sent out letters to 88,000 patients across Wales who are considered 'very high risk patients' and advising them to undertake shielding measures.

On 4 June, the chief medical officer for Wales announced that the shielding advice would continue for a further period until 16 August, with some restrictions on exercising and meeting people outside relaxed.

The capacity for GPs to add patients to the list continues with an updated template. Welsh Government also asked GPs to review a list of their patients over concerns they had not received any shielding advice.

It has been clarified that this request does not mean that practices have to review their entire list, rather a defined group identified via the primary care information portal. Practices were asked to contact these patients to check if they had received advice and amend contact details if incorrect.

See Welsh Government guidance for vulnerable people on shielding

If a patient does not understand why they have received the letter

The GP is encouraged to review the spreadsheet to check which category they fall under.

If the GP and the patient agree together that, they do not meet the criteria for extremely vulnerable patients and they wish to be removed from the list, keep a record of their wishes but the GP is advised not to do anything further at this time.

If a high risk patient has not received a letter

If a GP decides that some of their other patients should also receive shielding advice, the GP should issue a letter to that patient using Welsh Government’s template. In doing so, GPs input a specific ‘Read’ code on the patient’s record.

Using this code, the NHS Wales Informatics Service are able to detect patients who had been provided with a practice-issued shielding letter through a weekly ‘audit plus’ search. These patients are then added to the centralised national list.