Letter to NHS 7 July shielding guidance changes
- Shielding update
- Annex 1: Updated shielding advice and maintaining the shielded patient list – key points
- Annex 2: Local lockdown measures and differences in shielding guidance
- Annex 3: Adding or removing children and young people from the shielded patient list
Publications approval reference: 001559 / C0661
8 July 2020
We appreciate how much work has gone into shielding and protecting people who are clinically extremely vulnerable from COVID-19. Since writing to you on 22nd June to outline planned changes to the government’s guidance, we have received additional advice from the Royal College of Paediatrics and Child Health (RCPCH). This letter provides three key updates since that communication.
- Annex 1 sets out key points about the updated guidance the Government has now published which applies from 6 July 2020, as well as information on maintaining the shielded patient list (SPL).
- Annex 2 sets out key points about local lockdown measures and how they relate to shielding and protecting people who are considered clinically extremely vulnerable.
- Annex 3 provides details on what this guidance means in relation to children and young people and how we expect this guidance to be implemented. In summary, the updated guidance confirms that the majority of children currently considered clinically extremely vulnerable to COVID-19 will be able to be removed from the SPL following consultation with their specialist clinician or GP. All children and young people currently identified as clinically extremely vulnerable should now be reviewed and, where appropriate, removed from the SPL. Please ensure this information is cascaded to and implemented by clinicians in your organisation.
Thank you once again for all your continued efforts to protect and support individuals who may be at highest risk during this pandemic.
Professor Chris Whitty | Chief Medical Officer for England
Professor Stephen Powis | NHS Medical Director
Annex 1: Updated shielding advice and maintaining the shielded patient list – key points
- Everyone who has been identified as clinically extremely vulnerable, including children and young people, should continue to follow the latest government shielding advice until 31 July.
- From Monday 6 July this advice is that:
- You are still strongly advised to stay at home as much as possible and keep interactions outside to a minimum.
- You no longer need to socially distance from people you live with.
- If you want to, you can meet in a group of up to six people outdoors, including people from other households.
- You may also form a ‘support bubble’ with one other household if you want to, but one of the households in the ‘support bubble’ should be a single adult household (either an adult living alone or with children under 18 only). You can all spend time together outside and inside each other’s homes, including overnight.
- People who are shielding are still advised not to work outside their home. Statutory Sick Pay (SSP) is available for people who are unable to work from home or to be furloughed under the Coronavirus Job Retention Scheme.
- Children who are currently on the shielded patient list (SPL) are advised they should not return to school or nursery before the 31 July. If parents or carers are shielding it is advised that their child only attends education or childcare settings if social distancing can be adhered to. If this is not possible, their child should be supported to learn or work at home until 31 July.
- Those on the SPL and living in an area where a local lockdown is in place should follow shielding guidance set out locally for that area during any time of increased local community transmission.
- Government has written to everyone currently on the SPL to inform them that shielding advice continues to 31 July. Government has also written to everyone who has been removed from the SPL by clinicians up to now, to ensure they are aware they no longer need to follow shielding advice. People can only be removed from the SPL by a GP or hospital specialist. Clinicians have been asked to inform individuals when they are removed from the SPL and have been provided with a template letter for doing this.
- From 1 August, provided there are no significant increases in the number of COVID-19 cases, shielding advice will be paused. The Government will re-confirm this and publish the updated guidance when it comes into effect on or around the 1 August.
- The national government support service has also been extended to 31 July. Because people will no longer be advised to shield from that point, the national government support offer to people considered clinically extremely vulnerable will also then be paused. New registrations for support from the national shielding service will not be accepted after 17 July 2020.
- If people are receiving free food boxes, medicines or personal care through the national shielding service, this support will stop after 31 July (unless local arrangements are put in place in the case of local outbreaks/lockdowns). People will still be able to access other support from their local authority and NHS Volunteer Responders past this point and priority supermarket delivery slots will continue beyond the end of July for those already signed up for support.
- Specialists in paediatric medicine have reviewed the evidence on the level of risk posed to children and young people from COVID-19. This latest evidence indicates that the risk of serious illness for most children and young people is low. Only a small group of children who receive specialist care in hospitals are likely to still be considered clinically extremely vulnerable to coronavirus, and potentially advised to shield again in future. Health services will be in touch with children and their families over the summer, ahead of the new school term, to discuss what the new evidence means for them personally in the longer term. Families, carers and young people do not need to make immediate contact.
- Now that more evidence regarding the COVID-19 risk factors is available, the government has commissioned work to develop and evaluate a clinical risk prediction model to estimate short term risks of catching and experiencing adverse outcomes from COVID-19 in adults.
- While this risk tool is being developed, and even though shielding guidance is being paused from 1 August, the existing SPL should be maintained. Clinicians should continue to identify and record people who may be clinically extremely vulnerable to coronavirus and ensure the individual is made aware of this. This is in case shielding (or other) measures are reintroduced at any point in the future, and it is necessary to quickly identify people who are considered clinically extremely vulnerable.
- An updated template letter for notifying people who have been identified as clinically extremely vulnerable was distributed to practices and trusts on 3 July and is available on the NHS Digital website, along with details of the process for adding and removing people from the SPL. It is important that older versions of the letter referring people to the Government support offer are no longer sent, as registrations for this service will no longer be possible for people newly identified as clinically extremely vulnerable.
Annex 2: Local lockdown measures and differences in shielding guidance
On 30 June the government implemented a local lockdown in certain areas of Leicestershire. The lockdown measures mean that shielding guidance in those areas currently differs from the rest of the country. Similar local variation may be required in other areas in future during periods of increased local community transmission.
Where specific local measures are required, government will work with colleagues in the affected area, including NHS organisations, to discuss and agree the policy and communications plan and ensure those considered clinically extremely vulnerable receive appropriate advice as quickly as possible.
The government’s guidance for those considered clinically extremely vulnerable is led by the scientific evidence and clinical advice of the Chief Medical Officers. To avoid public confusion, local organisations should not issue guidance to people considered clinically extremely vulnerable that differs from the government advice in place at any given point in time, unless this is part of a response to a local outbreak agreed with government.
Annex 3: Adding or removing children and young people from the shielded patient list
Independent evidence is now available from the Royal College of Paediatrics and Child Health (RCPCH) regarding the impact COVID-19 infection has on children and young people with comorbidities. This shows the risk of serious illness for children and young people is generally low and only those with the most severe conditions should still be considered clinically extremely vulnerable.
Based on this evidence, RCPCH has published updated guidance on which paediatric patient groups they think should be defined as clinically extremely vulnerable. This evidence has now been reflected in the national shielding guidance updated on 6 July 2020.
Actions for the NHS
- All children and young people currently identified as clinically extremely vulnerable and included on the shielded patient list (SPL) should now be reviewed, with reference to the RCPCH guidance. Conversations should take place with the individual and their families, to discuss whether they are still considered clinically extremely vulnerable. These consultations should happen before the start of the new school term in September 2020.
- A small group of children who receive specialist care will still be considered clinically extremely vulnerable and may need to remain on the SPL following this consultation with their doctor. This is so they can be advised accordingly if the shielding policy, or any other intervention for those considered clinically extremely vulnerable, is reactivated in future. This group includes, for example, children and young people receiving cancer care or those at risk of severe infection due to an immunodeficiency.
- Most children and young people who were initially identified as being clinically extremely vulnerable, in particular those who are cared for just by their GP, are unlikely to need to remain on the SPL. This includes children with conditions such as asthma, diabetes, epilepsy and kidney disease. However, there could be rare exceptions to this, and removals should always be the result of a clinical assessment and discussion with the patient and their family. If unsure, GPs should refer to the RCPCH guidance.
- Where individuals are no longer considered clinically extremely vulnerable it should be explained that they will no longer be advised to shield in future and will be removed from the SPL. No one should be removed from the shielded patient list by their GP or specialist until a discussion has taken place.
- Young people who are transitioning to adult services should discuss their individual circumstances with their current and future specialist, or GP.
Instructions for specialists
RCPCH expects specialist centres to be in regular contact with many of the children and young people who have previously been identified as clinically extremely vulnerable, and to have these conversations as soon as possible as part of ongoing care. Specialists should proactively initiate these conversations where necessary, and take decisions in partnership with families, balancing the clinical and social impact of a child being identified as clinically extremely vulnerable, and potentially advised to shield.
Once this conversation has happened, and if it is agreed that an individual is no longer considered clinically extremely vulnerable, specialists should follow the usual process for removing patients from the SPL, outlined below.
NHS Digital provides lists of patients on the NHS shielded patient list to acute trusts on a weekly basis. This is made available to nominated individuals in the trust, normally in the data department. If you are unsure who is able to access the list in your Trust, please contact email@example.com
NHS trusts should prioritise the provision of advice and guidance to GPs supporting children and young people who are not receiving specialist care (see below). RCPCH will also ask its members to provide support to primary care colleagues, to ensure all children and young people receive the right advice.
Instructions for GPs
If approached for advice by children or young people who are under specialist care, GPs should direct them to their specialist to discuss how the RCPCH guidance applies to them.
There will be a small number of children and young people who have previously been identified as clinically extremely vulnerable and who are not under the care of a specialist. Practices will need to identify and advise these individuals.
Practices should search for children in their IT systems using the high risk of complications from COVID-19 code. Guidance is published here: https://digital.nhs.uk/coronavirus/shielded-patient-list/guidance-for-general-practice
Where these individuals are not receiving care from a specialist team, GPs should proactively contact them to advise whether or not they are still considered clinically extremely vulnerable according to the new RCPCH guidance. If unsure, GPs should request advice from a specialist on whether the patient should be considered clinically extremely vulnerable, using an ‘advice and guidance’ approach where appropriate.
Where no longer considered clinically extremely vulnerable by RCPCH criteria, GPs should follow the usual process for removing patients from the SPL, outlined below.
Maintaining the shielded patient list
Even though shielding guidance is due to be paused from 1 August, it is important that clinicians continue to add children and young people who they consider to be clinically extremely vulnerable to the SPL. This is so they can be advised accordingly if the shielding policy, or any other intervention for those considered clinically extremely vulnerable, is reactivated in future.
As new patients are born or diagnosed with conditions that may make them clinically extremely vulnerable to coronavirus, specialists should consider each patient in light of the guidance and decide whether or not to add them to the SPL after discussion with the patient and family.
Likewise, specialists should continue to review children and young people who remain on the SPL and remove them in future if their conditions or circumstances change so they are no longer considered clinically extremely vulnerable.
Details of how to add and remove people from the SPL are summarised below, and available in full on NHS Digital’s website.
The national NHS Digital algorithm will also be amended to reflect the new guidance, so that in future only children and young people meeting the revised criteria are added through the national process. Further details on this will be provided as soon as possible. In the meantime, a small number of children and young people may be added to the SPL under the existing criteria. These individuals should be reviewed by a specialist as part of the same process for everyone already on the SPL and removed as appropriate. As now, clinician decisions to add or remove individuals will always override the algorithm once applied.
Further guidance on applying the updated evidence, and on having conversations with children and families, is available on the RCPCH website.
Guidance on supporting children and young people’s mental health and wellbeing during the coronavirus outbreak is available here.
RCPCH and RCGP will be hosting a joint webinar, 1pm – 2pm, on 9 July on COVID-19 and children. This will include an update on the shielding guidance for children and young people.
Adding and removing people from the shielded patient list
To process an addition:
- GPs should add the ‘High risk category for developing complication from coronavirus disease’ flag to the individual’s GP record. Guidance on how to do this can be found on the NHS Digital website.
- Acute hospitals should submit the individual’s details to NHS Digital via their Trust’s SEFT system. Guidance on how to do this can be found on the NHS Digital website. They should also inform the patient’s GP.
Any clinician adding a patient to the list should also speak to the patient and send them the updated letter.
To process a removal:
- GPs should adjust the flag in the patient record, marking the person as ‘moderate’ or ‘low’ category for developing complication from coronavirus disease. Guidance on the definitions of the risk categories can be found on the NHS Digital website.
- Acute hospitals should submit a request for the patient to be removed from the list. Guidance on how to do this can be found on the NHS Digital website.
A removal should only be processed once there has been a discussion with the patient and, where the individual is receiving treatment from a specialist hospital team, or teams, agreement reached between their GP and specialist.
Template letters for adding and removing patients from the SPL are available on NHS Digital’s website.
Please contact firstname.lastname@example.org if you have any questions about the process to add or remove patients from the SPL.