Shielding (COVID-19)

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Nov 2020
  • Shielding lists require to be maintained on an ongoing basis with additions and removals being identified.  Updates are sent to Public Health Scotland to maintain an accurate list in case shielding is reactivated. See below for maintaining shielding list.
  • Patients on the shielding list have been advised that they should follow the protection level guidance for the general population as a minimum. Scottish Government have provided extra advice for areas including work, school, shopping and contact with others found at https://www.mygov.scot/support-shielding/.  Patients are encouraged to consider the number of cases in the local area, their own health situation, advice from their GP, consultant or clinician, and the risk different activities carry.   An advice booklet is being developed which will be issued to patients in November. 
  • Patients are encouraged to sign up to a Scottish Government text messaging service for rapid updates and advised that Scottish Government would tell them immediately if they needed to shield again to stay safe.
  • New categories of patients have been added to the shielded list as per attached letter - 30th October.
  • Adults with Down Syndrome have been identified through hospital records. These individuals have been issued with a bespoke letter and an additional easy read version.  Down Syndrome identifications have been classified as Group 4 (rare diseases).
  • Patients with Chronic Kidney Disease Stage 5 (CKD5)  should be added to the shielding list. Many of these patients will already be on the central Shielding list if they are receiving renal dialysis, are awaiting a renal transplant or have had a transplant. Searches will initially be carried out by the Renal Units through their electronic records to identify additional patients and a search will subsequently be undertaken of GP records to identify people with CKD5 that are not captured by the initial search.
  • Dementia - The QCOVID data highlights that people with dementia are at high risk from COVID-19. This covers a broad spectrum of illness and includes some who may be at risk of further cognitive impairment or distress where there is impaired capacity and limited understanding. Public Health Scotland are not adding dementia to the shielding list as a group. However, clinicians can add patients to the list based on their clinical judgement and discussion with the individual and/or their carer.
  • QCovid BMJ Paper - The University of Oxford has been commissioned by the New and Emerging Respiratory Virus Threat Advisory Group (NERVTAG) to develop a new predictive risk model that takes into account a range of factors, (including health conditions, ethnicity, age and BMI) now known to increase risk of serious outcomes from Covid19.  The model  (now known as QCovid) uses an algorithm that is based on actual Covid19 hospitalisation and mortality data (as opposed to assumptions based on flu), and gives  a  more accurate assessment of risk. Two possible uses being considered are to identify those at highest clinical risk at a population level  and as a tool for clinicians. A peer reviewed article explaining the algorithm was published in the British Medical Journal on the 20 October attached
  •  Condition-specific advice for patients in the main shielding groups has also been produced and continues to be updated on the Scottish Government website.  The latest updates on shielding are available at: https://www.gov.scot/publications/covid-shielding/
Oct 2020
Latest updates on Shielding for patients at highest risk of COVID-19
Scottish Government letter (23/10/2020) sent to all vulnerable patients on the shielding list. Contents:
  1. Letter to inform patients that, from the 2nd Nov, there will be 5 protection levels in Scotland and that patients who had previously been asked to shield should follow the guidance for their local area’s protection level (see table below). Protection level by area will be available at www.gov.scot/coronavirus. People considered at higher risk from coronavirus should follow this guidance as a minimum and are being advised to make decisions for their own situation, ie the number of cases in their local area, their own health situation, advice from their GP, consultant or clinician, and the risk different activities carry. A practical protection plan for these people is to follow
  2. Table: Extra protection level advice for people at highest risk guidance from coronavirus.
  3. Letter with
         *   Information on how to obtain a free supply of vitamin D
         *   Reminder for the flu vaccine
         *   Reminder of the Scottish Governments SMS alert text messaging service
Further information about the Coronavirus (COVID-19): Scotland's strategic framework: https://www.gov.scot/publications/covid-19-scotlands-strategic-framework/
ACTIONS FOR GPS AND HOSPITAL CLINICIANS: MAINTAINING THE SHIELDING LIST
  • The CMO has stated that although the advice to shield may pause from 1 August,  GPs and hospital clinicians are asked to continue to identify patients who meet the criteria for shielding.  If the prevalence of COVID-19 increases in the future the advice to shield may be reactivated and Public Health Scotland will require to contact patients who may need support.   The Shielding List must therefore remain active and up-to-date.   
  • If patients who have previously been identified as requiring to shield no longer meet the criteria they should be put forward for removal
  • Please send any new patients or removals to the NHS Highland Shielding Team nhsh.nhshshielding@nhs.scot and the details will be passed to Public Health Scotland to update the national list.  Please provide CHI, name, address and risk category 1 - 7
  • A specific exercise is being undertaken to review the continuation of shielding for all children on the shielding list, the output of which requires to be submitted to the Scottish Government by 31/07/20
Decision to shield: addition and removal

The decision for a patient to shield is a clinical one – there are benefits and risks. Over 5000 NHS Highland patients were selected for shielding by searches of national datasets. A large number of additional patients have also been selected as being appropriate for shielding by GPs and Hospital Clinicians.

In General Practice, NSS have sent flags into VISION to alert you to the patients in your practice who have been written to (identified either using national data or from Hospital colleagues).

  • If a patient approaches the practice to ask if they are on the shielded list, please check Vision for the shielding code or your internal shielded list and inform the patient accordingly. Only redirect the patient to the local authority for services related to shielding.
  • If sadly, a shielded patient dies, please do let the local authority know by calling the appropriate number as listed below.
  • After reviewing your practice list, if you have no additional patients to be added to the shielded patient list, please send a null response to high-uhb.nhshshielding@nhs.net
Selecting a patient for shielding

If General Practices identify patients without a flag on their record who they believe should be shielded, or have newly diagnosed patients who require to be shielded please do the following:

  • Provide the patient with advice to shield and highlight further information available at NHS Inform. You may choose to provide a copy of the generic patient letter so that the patient receives the advice of the letter sooner; this is optional.
  • Add the code 9d44. with a flag/alert to their record
  • Send the patient’s CHI number and details to the NHS Highland Shielding Coordinating team, high-uhb.nhshshielding@nhs.net using the template attached. The Highland Coordinating team will submit the newly identified patients to NSS who will write to your patient and let Local Authorities know that the patient is eligible for social support.
  • Please advise the patient that there may be a delay of up to 7 days before the information exchange is complete.
  • The decision to shield is a clinical one. If you do not believe a patient meets criteria 1 – 7 for shielding, please do not advise them to contact the Local Authority to discuss shielding, however see “Other Support for Patients” as relevant
  • If a patient contacts the practice to ask if they have been put forward for shielding, please advise them of their status by checking if the Read Code has been applied to their record or if the GP Practice has identified them in a subsequent search. If on reflection the patient should be put forward for shielding follow steps as above.
Removing a patient for shielding
  • If you believe a patient has been incorrectly identified for shielding, please discuss this with the patient and, if in agreement that shielding is not appropriate or in their best overall interests, advise the patient that they will be removed.
  • Send their CHI number and category to the NHS Highland Shielding Team high-uhb.nhshshielding@nhs.net highlighting that the patient is no longer to shield and that this has been discussed with the patient. The Highland coordinating team will update NSS that the person is no longer to shield.
Other support for patients

If you do not assess a patient as meeting the clinical criteria for shielding there is still a wide range of help that the councils and their partners can help to provide for patients, if they have no other family or friend support.

In ARGYLL & BUTE this includes:
  • Assistance with grocery shopping and also provision of a weekly fresh food parcel
  • Help with the delivery of prescription medicines and foodstuffs
  • Animal welfare concerns such as veterinary arrangements or dog walking
  • Well being concerns including helping to overcome isolation through befriending or counselling.
  • Help to organise other forms of domestic assistance such as urgent repairs or community transport.
  • Patients can easily access this help by calling or helpline on 01546605524 or using a simple online form: https://argyllandbute.custhelp.com/app/VOL/Help_Request .
  • Please note that the Helpline is staffed from 9am to 5pm Monday to Friday, but there is an easy to use voiceform out of hours through which you can ask for help.
In NORTH HIGHLAND
  • Requests for assistance and offers of help come via the new Council help line: 0300 303 1362
  • Or through the dedicated line for anyone required to self-isolate (including the shielding group) because of their health condition: 01349 886669.
  • Lines are currently open 8am to 6pm Monday to Friday but call volumes are being monitored daily to assess whether extended opening hours are required, including over public holidays and weekends.
  • The new national helpline for vulnerable people (not the shielding group) is also routed for all Highland callers to the 01349 886669 number.
Shielding: FAQs for clinicians
What is shielding? What are the benefits? What are the risks?

Shielding is a measure to protect extremely vulnerable people from coming into contact with coronavirus, by minimising all interaction between them and others. The benefit is that, by following the extremely stringent process of avoiding contact with others, this will minimise the chance of catching COVID-19. However, this is a very challenging ask of people because of the negative physical, psychological and social consequences of isolating themselves for such a long period of time.

Who should be shielded?

Those people who are at the clinically highest risk of severe morbidity and mortality of COVID-19. It does not include all people eligible for the flu vaccine, only a very specific sub-set considered to be at highest risk of severe illness and hospitalisation from COVID-19. It does not include those who may be vulnerable, at risk, or needing support for other reasons. Groups of people at clinically highest risk are:

  1. Solid organ transplant recipients
  2. People with specific cancers
    • 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
  3. People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe COPD. This includes those long-term home Oxygen for chronic respiratory conditions.
  4. People with rare diseases, including all forms of Interstitial Lung Disease/Sarcoidosis, and inborn errors of metabolism that significantly increase the risk of infections (such as SCID, homozygous sickle cell)
  5. People on immunosuppression therapies sufficient to significantly increase risk of infection
  6. People who are pregnant with significant heart disease, congenital or acquired
Who agreed this list?

The 4 UK Chief Medical Officers, following expert advice.

What about other patients who are extremely clinically vulnerable/at highest risk of severe morbidity or mortality of COVID-19?

We have added a mechanism where patients who, in your clinical judgement, need to be shielded as they are clinically at ‘highest risk’ of severe morbidity or mortality from COVID-19, but are not included in the above six groups, can be included. In Scotland we call this Group 7.

How did you identify people in this highest risk group?

National held databases for dispensed prescriptions from general practice and hospital based episodes of care have been used to identify the majority of people that are in this highest risk group. However, we do not have national data for all of the groups. We have published the approach used to identify patients using national data on the Public Health Scotland website at: https://www.hps.scot.nhs.uk/web-resources-container/covid-19-search-criteria-for-highest-risk-patients-for-shielding/

There are limitations with some of our national data, which means that we may over-identify some (who you recognise may not need to shield) and under-identify others (who you recognise should follow shielding advice).

As a result, we are grateful to both colleagues in General Practice and Hospitals for assisting with the identification of other people who will not have been written to, using national data.

How long will patients be recommended to shield for?

When writing to patients we are advising to shield for at least 12 weeks. If this changes, we will write to those patients and update you as clinicians.

How will I know if my patients have been advised to shield by NHS Scotland?

NHS National Services Scotland are coordinating a database of patients who have been identified through 3 mechanisms: centrally using national data sets, from colleagues in General Practice, and from colleagues in Hospitals. All those identified to shield from these three routes should be known to NHS National Services Scotland.

In General Practice, NHS National Services Scotland will send flags into VISION and EMIS PCS to update General Practice colleagues of those patients in their practice who have been written to (identified either using national data or from Hospital colleagues). There may be several phases to this process. When colleagues in General Practice identify patients not already with a flag on their record, please add the code 9d44. with a flag/alert to their record and send the patient’s CHI number to your Health Board Coordinating team, along with the criteria risk group e.g. group 4. If they don’t fit into any of the existing risk groups but you feel they qualify due to other medical conditions, please identify as Group 7. The Health Board Coordinating team will then compile a list of CHI numbers of newly identified patients and send these to NHS National Services Scotland, who will write to your patient and let Local Authorities know that the patient is eligible for social support.

In Hospital Practice, NHS National Services Scotland will send updated lists of patients identified in their region to local Health Board coordinating teams. Local Health Board coordinating teams are asked to share with Hospital colleagues; local arrangements for doing this may differ.

I feel one of my patients should be shielded, but they have not yet received a letter?

Please let your health board coordinating team know the patient’s CHI number and the group for shielding e.g. group 2. Your local health board coordinating team will then update NHS National Services Scotland who will write out to your patient, update their GP record with a flag (unless you are a GP practice in which case we ask you to add the flag to your record), and activate social support for your patients should they require this during the shielding period.

What about newly diagnosed patients in the future? Will shielding advice apply to future patients?

You may become aware of patients under your care who have new diagnoses or therapies which would result in being in the highest risk group where shielding is advised. Please provide your patient with advice to shield and highlight further information being available at NHS Inform. Please also let your health board coordinating team know your patient’s CHI number and their group (e.g. group 2). NHS National Services Scotland will write to the patient with a letter which includes their CHI number, allowing the patient to register for social support if this is required; NSS will also send a flag to the GP IT system; this process will happen as fast as possible. Some clinicians may choose to provide a copy of the generic patient letter so that the patient receives the advice of the letter sooner; this is optional; we have provided clinicians with a copy of the generic Clinician-issued patient letter in an update on 8/9 April 2020.

My patient has been advised to shield but this may not be appropriate. What should I do?

Please discuss this with your patient. If it is agreed that shielding is not appropriate or in their best overall interests, please send their CHI number and group to your local health board coordinating team, highlighting that the patient is no longer to shield. Your health board coordinating team will update NHS National Services Scotland that the person is no longer to shield.

I have received notification from a hospital clinician/GP identifying one of my patients as at highest clinical risk. I do not agree with this. What do I do now?

Please discuss this with the other clinician. If it is agreed that the person should not be shielding, please discuss this with your patient who will have received a letter, and follow the advice in the last answer.

A patient has asked that they be shielded, however I do not consider that they are in the highest risk group. What should I do?

The decision to shield is a clinical one – there are benefits and risks. If, following a discussion with the patient, you agree that they should be shielded then please let your Health Board coordinating team know. If, following a discussion with the patient, you do not feel that the patient should be shielded, but they fall into the at risk group, then strict social distancing measures should be followed. Social support is provided only for those who require shielding.

Should I be advising that all those in a household should shield or only the person at highest risk?

The rest of the household are not required to adopt shielding measures for themselves; only those identified to shield. However the rest of the household should support the shielded person by stringently following social distancing measures.

Shielding updates to Vision and EMIS

From now on COVID-19 Shielding Scripts will be deployed to all

  • Vision practices overnight on Tuesdays and
  • EMIS practices overnight on Wednesdays

The updates should include updated patients sent a Shielding letter by Scottish government up to and including the Monday before the update.

Any queries related to the updates should be directed to the eHealth Facilitators Email nhshighland.ehealthfacilitators@nhs.net

Shielding archive

Shielding search methodology

The search methodology document has been updated: https://www.hps.scot.nhs.uk/web-resources-container/covid-19-search-criteria-for-highest-risk-patients-for-shielding/

CMO letters (to clinicians and patients)

CMO letter to patients 08/06/20: Extended shielding (NB NHS Highland intranet access required)

CMO letter 05/06/20 (secondary care)

CMO update letter 11/05/20 (primary care) is an update to general practice on shielding of the clinically highest risk patients. It updates GPs on:

  • People receiving renal dialysis treatment
  • People who have had their spleens removed
  • Identification of additional patients for shielding
  • People incorrectly identified for shielding
  • Coding
  • Audits in Vision
  • ESCRO Shielding reports
  • Updates to GP records systems.

CMO letter 07/05/20 (secondary care)

Change in recommendation for shielded patients and FAQs 11/06/20

FAQs 11/06/2020

Information for healthcare colleagues on the recent change in recommendations for shielded patients

Changes from 18/06/20 on patients who should be shielded

See guidance here

Changes to shielding 09/07/2020

Updated letter to patients can be found here

Updated letter to clinicians can be found here

Shielding update 24/07/2020

Annex A - CMO Letter to Patients - Update on Stopping Shielding

Annex B - Identification and Data Process Guidance

CMO Letter to Clinicians and Boards - Shielding Updates 24.07.20

Editorial Information

Last reviewed: 06 November 2020

Next review: 06 January 2021

Author(s): Medical Director, NHS Highland

Version: 1

Reviewer Name(s): Dr Boyd Peters and Rachel Hill

Document Id: COVID032