Patients who are most at risk of severe complications from COVID-19 have been asked to 'shield' themselves. This means that they should stay at home and avoid face-to-face contact with anyone from outside of their household. Members of their household are advised to stringently follow social distancing rules.
As of 1 June, shielded patients have been advised that they can spend time outdoors with members of their own household or if they live alone with one person from another household. The change has caused significant confusion because shielded patients were originally advised that they should remain at home until 30 June. GPs were also given no prior warning of the change in rules.
A new standard oeprating procedure for GP practices that was published on 29 May also set out the role they should play in supporting shielded patients going forwards (see below for more on this). There are currently 2.2m people shielding.
Which patients should be shielding?
The following patients were on the CMO's original list of high-risk patients:
- People with a solid organ transplant such as a kidney or liver transplant
- People with cancer who are undergoing active chemotherapy or radical radiotherapy for lung cancer
- People with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
- People having immunotherapy or other continuing antibody treatments for cancer
- People having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors.
- People who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs.
- People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe COPD. The criteria to identify severe asthma and severe COPD is here.
- People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as SCID, homozygous sickle cell).
- People on immunosuppression therapies sufficient to significantly increase risk of infection. The relevant therapies are listed here (Annex F).
- People who are pregnant with significant heart disease, congenital or acquired.
The following groups have since been added to the list:
- Patients who have had a splenectomy
- Patients with interstitial lung disease, some with bronchiectasis and those with pulmonary hypertension
- Renal dialysis patients
Adding other patients
GPs and consultants are also be able to add additional patients to the shielding group throughout the pandemic by using appropriate codes. Any patient identified by the practice should be sent a letter (template letters are here). Patients identified in secondary care should receive a letter from their hospital doctor, who should also inform the practice that they have added this patient to the list.
If GPs don't agree that a patient identified as 'high risk' by the hospital falls into this category they should discuss it with the trust. If different opinions still exist the patient should remain in the highest risk category.
Patients can also be removed from the list by being re-coded as low or medium risk. The original code will remain in the record, but any reports run will use the most-recently added code.
If patients not included on the register want to follow shielding advice that is there own choice. However the latest guidance says that those not on the register, but in the broader group of patients at risk (which is effectively the groups entitled to a free flu jab), should be advised to follow social distancing. These patients will not receive access to the government support offer.
What should practices do for shielded patients?
The latest standard operating procedure (dated 29 May) sets out the support practices should provide for shielded patients. This is broadly similar to what practices had been advised to do prior to this, with the main addition is that practices should ensure there shielded patients have a named, lead care co-ordinator, who could be based in primary or secondary care.
The SOP also says that all shielded patients should register with the government website, whether or not they need additional support.
According to the SOP practices should:
- Ensure the situation is clearly flagged in the patient’s records and visible to all teams involved in the patient’s care.
- Ensure a named, lead co-ordinator is in place, either in primary or secondary care.
- Review and update personalised care plans and undertake any essential followup.
- Support patient self-management.
- Support patients with urgent medical needs (patients may also need to contact their specialist consultant directly).
- If the patient needs face-to-face assessment, they should be seen on a home visit, ideally by a dedicated team, and not brought into general practice premises unless clinically indicated.
- Ensure that there has been at least one contact by the practice with all its registered patients on the shielded list, as a follow-up to the original letter and follow up as required. Make every contact count.
- Help patients secure their medicine supplies regularly by ensuring electronic repeat dispensing is used for all suitable patients, and ensure they know how to access information about how they can have their medicines delivered.
- People in shielded groups may be particularly affected by mental health issues. GPs should work with local mental health, learning disability or autism services to review patients receiving care from these services.
What help will patients get?
NHS Digital will pull details of the patient records that are flagged every week. This means that these people will be able to access the government's shielding support for food and medicines delivery – although support is initially focused on people who have no other means of getting food and medicine. The guidance says that there may be a lag in processing this information and, if so, patients requiring urgent help should contact their local authority.
Patients are also required to register for this support here: https://www.gov.uk/coronavirus-extremely-vulnerable If someone does not have access to the internet, refer them to the phone line in the letter.
The NHS is also providing further support to patients at risk via the Goodsam App and NHS Volunteer Responders. Any health professional or local authority can refer people who require assistance. Referrals can be made via the NHS Volunteer Responders portal here https://goodsamapp.org/NHSreferral or by calling 0808 196 3382. This support is available to anyone in need and not just the highest-risk group.
Shielded patients can also self refer to NHS Volunteers by calling 0808 196 3646 between 8am and 8pm.
- Guidance on vulnerable patients for GP practices - including letters for patients added to the list
- NHS Digital guidance on shielded patient lists
- Current search guidance for each system provider can be found in the annex to this letter to practices.