COVID-19: toolkit for GPs and GP practices

Shielding and protecting clinically extremely vulnerable patients

Location: England Wales Scotland
Audience: GPs Practice managers
Updated: Tuesday 22 September 2020
Topics: COVID 19, GP practices

We have produced guidance for practices about arrangements for patients at high-risk of coronavirus.

This guidance is for England only.



  • The CMO sent a letter on 21 March asking practices to identify additional patients who may be known as being at highest clinical risk.
  • On 22 June, the Government announced that the advisory guidance for clinically extremely vulnerable people who were previously advised to shield, would be eased in two stages (6 July and 1 August) and that these patients would 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.
  • Prior to the UK Government’s announcement of a three-tier (medium, high, very high) lockdown approach for England on 12 October, the BMA has called for even stronger measures to reduce the spread of the COVID-19 infection and put forward a series of recommendations.
  • On 13 October, it was announced that the most clinically vulnerable will receive updated guidance depending on the level of risk in their local area.
  • This new guidance provides advice for the clinically extremely vulnerable to follow in addition to the new rules and guidance for everyone based on the level of risk in their local area. More restrictive ‘shielding’ measures will only be used in areas facing the highest risk. The Government would write to people to inform them directly should they be advised to shield.
  • Those where the local COVID alert level is very high are advised to work from home, in general stay at home as much as possible, and avoid all but essential travel. Read more about the three alert levels.
  • Whatever the current local COVID alert levels are, GP practices remain open. Whilst remote consultations should be the main way in which patient care is delivered, when it is clinically necessary to see vulnerable patients face to face they would normally be expected to attend the surgery.

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


About the list of high risk patients previously advised to shield

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 is continuing to be maintained, so that it can be used again if necessary in the future. 

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.