Identifying patients at highest risk from COVID-19: advice for GPs

by Dr Farah Jameel Guidance from the BMA GPs committee England on the list of at-risk patients and shielding arrangements.
Location: England
Published: Thursday 16 April 2020
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The CMO letter published on 21 March asked practices to identify additional patients who may be known to practices as being at highest clinical risk. On 3 April, NHSE/I advised practices to disregard this advice and instead refer to its update on the Government shielding policy and implications for general practice. This was then updated on 9 April with a CAS message from NHSE/I and NHS Digital describing the specific tasks practices should try to do to complete this process, by the end of 14 April.

These changes in advice from the Government and NHSEI, together with the very short timescale for practices to validate the list, in the second occasion over the Easter bank holiday, caused a number of problems. GPC England has therefore produced this guidance for practices on steps to take on the list of shielded patients and those that have self-identified using the Government website.

 

What is the validated list?

The method by which the list was validated has been published by NHS Digital. The list by definition 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 regularly through national data extractions, so people recently added can be included in national messaging and receive the necessary support.

 

Accuracy of list

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

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

GP data uses terminologies which are more specific; it is near to the patient but is variably used by practices and practitioners. 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. 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 extraction. Hospital procedures and interventions are coded in a variable manner. The April 10 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 across the system.

The CMO categories and the data production has been 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, though, as they have needed to spend time validating the information provided.

 

Reviewing individuals who have self-identified as vulnerable

A number of patients have been able to self-identify as clinically extremely vulnerable via the Cabinet Office website. The names of those who registered prior to 29 March but have not been identified through the central process will be communicated to each GP practice shortly. The list will be sent within your GP IT system on or around 24 April.

Once you receive the list, please review these individuals, determine their appropriate COVID-19 risk category and flag them as high, medium or low risk as appropriate. For any patients flagged as high risk, you will need to send them a copy of the patient letter giving advice on shielding.

NHS Digital will pull the details of these flags from GP IT systems weekly and individuals who you flag as high risk will receive the full Government shielding service. Individuals who you flag as medium or low risk will not receive a shielding service. The task will need to be completed by 5pm on 28 April.

Download NHS letter template for patients assessed as not being at high risk

 

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, it is almost certain that such people 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 SCR (Summary Care Record). This could in theory subsequently impact decisions for the care of this patient in other parts of the system.

The SCR 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 therefore important for practices and hospitals to add such patients to the list when appropriate.

NHS Digital has described the methodology used to identify patients who meet the high-risk criteria for contracting COVID-19, due to their inclusion in one or more of the disease groups. The list of conditions that defined this cohort was signed off by the chief medical officers of the four nations of the UK on 18 March.

 

BAME groups

There is emerging and concerning evidence from hospital admissions and mortality data that people from BAME (black, Asian and ethnic minority) backgrounds appear to be more adversely impacted by COVID-19. The underlying causes and reasons for this are not yet clear and further work is urgently being done to understand this.

 

What shielded patients can expect in social care

Being on the shielded list means patients’ 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. The pharmacy may find a volunteer (who will have been ID checked) to deliver if their own service is unable to. They may receive free food parcels 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 the individual is protected.

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

 

If you have any questions, please contact the NHS Digital Shielded Patients List Hub at [email protected].

More information can be found in the FAQs and guidance from NHSEI about caring for people at highest clinical risk during COVID-19