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:
- Solid organ transplant recipients
- 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
- 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.
- 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)
- People on immunosuppression therapies sufficient to significantly increase risk of infection
- 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.