Update on guidance for clinically extremely vulnerable individuals and actions for acute trusts


Classification: Official
Publication approval reference: C0830


  • NHS trust medical directors
  • NHS trust chief nursing officers
  • NHS trust chief operating officers
  • NHS trust COVID-19 data leads
  • Regional clinical directors

Dear Colleagues,

Update on guidance for clinically extremely vulnerable individuals and actions for acute trusts

We are very grateful for the considerable work you have undertaken over the last seven months to identify, notify and care for people who are clinically extremely vulnerable to COVID-19.

As you will be aware, on 31 October the Government announced new national restrictions to help control the spread of the virus, that will apply from 5 November. The reason we are writing is that the government, advised by the Chief Medical Officer:

  • Will be updating the advice and support available for people who are clinically extremely vulnerable alongside the new national restrictions.
  • Has identified two additional groups of people who should now be considered as clinically extremely vulnerable to COVID-19:
    • adults with stage 5 chronic kidney disease
    • adults with Down’s syndrome
  • Has highlighted the urgency of clinicians completing the process of reviewing – and, where appropriate, removing – children and young people on the Shielded Patient List.

These changes mean that we urgently need to ensure that the list of people considered to be clinically extremely vulnerable (known as the Shielded Patient List [SPL]) is as complete and accurate as possible, so that individual patients are given the most appropriate advice.

This letter sets out information for all trusts, and requests the following specific urgent actions be taken by acute trusts:

  1. Familiarise yourself with the revised guidance when it is published here. Publication is expected imminently and will be communicated to all patients on the SPL by letter. This letter will provide evidence for Statutory Sick Pay purposes if required.
  2. Identify, contact and add adults with stage 5 chronic kidney disease to the SPL (see Annex 1)
  3. Immediately review all children and young people remaining on the SPL who are on your trust’s list, and – where appropriate – remove them from the SPL and communicate this change to the individual; and prepare for calls from parents seeking urgent reviews and from GPs (see Annex 2).
  4. Ensure you continue to maintain the SPL by adding a high risk flag for patients you identify as being clinically extremely vulnerable, and notifying the patient of their status and the advice they should follow. Information on maintaining the SPL can be found on the NHS Digital website.

We recognise this is an additional task on top of the enormous effort already underway to restore services, but your professional expertise is critical to ensure patients receive the correct advice so that they can manage their risk appropriately.

Individuals who have been told that they are clinically extremely vulnerable to COVID-19 will be urged to continue to seek NHS treatment. As you will be aware, they may be particularly anxious about attending health settings, and please take this into account when planning and delivering services. I know that you will have in place measures to provide environments where the risk of infection is managed for all patients.

Thank you for continuing to focus on providing care to our patients at greatest risk.

Yours sincerely,

Professor Stephen Powis | National Medical Director
NHS England and NHS Improvement

Annex 1: Additions to the Shielded Patient List

  • A COVID-19 predictive risk model and decision support tool is being developed, based on clinical outcomes (hospitalisation and mortality) observed during the first wave of the pandemic.
  • The model takes into account age, sex, pre-existing conditions, ethnicity and BMI to predict weighted and cumulative risk of serious illness at an individual level. This work – commissioned by the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) – is being led by Oxford University. The protocol was published in June, and the research results from the model has now been peer reviewed and published.
  • The UK CMOs have reviewed the emerging data from the new model, to see whether this suggested any conditions should be added to the clinically extremely vulnerable criteria.
  • Based on this evidence, the UK CMOs have identified two groups of people where the relative risk and/or absolute risk appears to be significantly higher compared to their age-sex matched peer group. They have therefore decided that people meeting the following criteria should be added to the SPL:
    • adults with stage 5 chronic kidney disease (not on dialysis or with a renal transplant – these patients are already on the SPL).
    • adults with Down’s syndrome
  • We have written to GP practices to ask that they identify and add adults with Down’s syndrome. This letter will soon be available on our website. Trusts are not required to take action to identify these patients at this time.
  • Evidence relating to the risk associated with other conditions has been, and continues to be, reviewed by UK CMOs. Some of these conditions, such as dementia, require very careful consideration to ensure all relevant risks and harms can be balanced in practice to impact positively on people’s lives. For this reason, additional categories are not automatically added to the criteria for identifying individuals who are clinically extremely vulnerable, but may be updated in future.

Patients with stage 5 chronic kidney disease

This action refers to adults with chronic kidney disease stage 5 (CKD 5) not on dialysis or with a renal transplant, as those patients should already have been included on the SPL.

Clinicians will be aware that renal dialysis as a group was not listed in the Government guidance. However, under an earlier process, renal units have identified individuals receiving dialysis as clinically extremely vulnerable and notified these patients on an individual basis.

Actions for acute trusts

Acute trusts are now required to support renal units to:

  1. Identify adults (18+) with CKD 5 (or G5 A1-3) not on renal replacement therapy (dialysis and renal transplantation), defined as:
    1. chronic kidney disease (CKD) defined as a reduction in kidney function or structural damage (or both) present for more than three months (NICE CG 182)
    2. CKD stage 5 (or G5 A1-3) defined as a GFR less than 15 ml/min
    3. It excludes individuals who transiently drop below 15 ml/min (eg acute kidney injury, acute on chronic kidney disease).
    4. This process needs to be ongoing, with patients added and removed from the list in accordance with the definition above.
    5. Further guidance can be found here.
  2. Send a list of these patients to your trust’s named data COVID-19 lead(s), asking them to add them to the SPL. When sending a list of these patients to your trust’s named data COVID-19 lead(s), please ensure that you have included each patient’s NHS number, date of birth, postcode and consultant, with a request to add these patients to the SPL.
  3. Ensure that these patients are sent the letter informing them that they have been identified as clinically extremely vulnerable. This letter template will shortly be available on the NHS Digital website.
  4. Follow up with your trust’s data lead to confirm that your patients have been added to the SPL.
  5. This process needs to be ongoing, with patients added and removed from the list in accordance with the definition above. Wherever you no longer think a patient should be considered clinically extremely vulnerable, please have a conversation with them about their personal situation and, if they agree, they should be removed from the list. Please follow the process described above to request removals.

Your trust’s data team should be able to provide details of COVID-19 lead(s) for your trust. Failing this, contact information can be provided to NHS trust staff by emailing SPLquery@nhs.net.

If you are your trust’s COVID-19 lead, you should:

  • submit data received from renal units to the Strategic Data Collection Service (SDCS). The submission window for the SDCS will be open daily between 8am and 5pm. Only one submission per trust will be accepted each day, so please liaise with the other COVID-19 data leads in your trust to ensure you are only submitting one return per day.
  • For more details about the process of adding/removing and maintaining the SPL, please visit the NHS Digital website here.

Annex 2: Review and removal of children and young people currently identified as clinically extremely vulnerable

  • Evidence published by the Royal College of Paediatrics and Child Health (RCPCH) in June suggests that only a small proportion of children and young people should still be considered at highest risk of poor outcomes from COVID-19 and remain on the SPL.
  • On 8 July 2020, the Chief Medical Officer for England and NHS Medical Director asked clinicians to review all children and young people who were on the SPL. It was asked that this task was completed by the beginning of September. We know that many trusts have been working to review their young patients over the past few months and to remove patients from the SPL where appropriate. We are grateful for the time and attention you have given to this task. The reviews from one major children’s hospital found only a tiny minority of children and young people needed to be on the SPL.
  • However, despite these efforts, significantly more children and young people remain on the SPL than would be expected.
  • Given the detrimental impact to children’s wellbeing of unnecessary additional social restrictions, I am sure you will appreciate that it is critical to ensure that children and young people are not inappropriately left on the SPL.
  • We are therefore asking that with immediate affect you review any children and young people on your trust list who have not already been reviewed, and contact parents to advise on their child’s clinical vulnerability if this has not already occurred.
  • Specialists should also expect contact from parents and guardians asking for reviews. We understand the Government will write to all parents or carers of children and young people remaining on the SPL in the coming days. That letter will ask parents or carers to contact their child’s usual hospital doctor (or GP if they are not currently receiving specialist care) if they have not already heard the outcome of a review.
  • We are also asking you to support GPs who are reviewing children and young people who they added to the SPL or who have been contacted directly for advice by a young person, parent or guardian. GPs have been advised to seek specialist advice when required, using an ‘advice and guidance’ approach. We would be grateful for your help in prioritising and quickly responding to any requests for support to ensure the best decision is made rapidly for these young patients. If trusts have a single point of contact for GPs to obtain paediatric advice this may be the best means to coordinate such contact.

Actions for trusts

  • If the task to review and remove children and young people from the SPL has not been completed in your trust, please immediately review and if appropriate, remove your young patients from the SPL and inform parents of their child’s status if this conversation has not already occurred. Likewise, please urgently respond to any request from a parent.
  • Please note: there is a known data lag meaning that any children recently reviewed and removed by trusts may still be awaiting final system update. This request applies to those children and their families who have not yet had a clinical consultation and a removal instigated.
  • Instructions on how to remove children and young people from the SPL are available on NHS Digital’s website.

They can be summarised as the following three actions:

  1. Identify anyone under the age of 18 currently on the SPL.
  2. Contact the family to confirm whether they are still considered clinically extremely vulnerable, as per the RCPCH guidance, with a follow-up conversation where necessary. Write to the patient confirming your decision, using the template letter which will be available on NHS Digital’s website.
  3. If the patient should be removed, inform your shielding lead. These are likely located in the data department of your Trust. If you do not know who to contact, email SPLquery@nhs.net who will be able to help.

The data lead will request the patient is removed from the SPL using an electronic form. Note that the patient is deducted from the list weekly. They will not receive a national letter.

NHS Digital will provide further data to support trusts in completing this task as if becomes available.

Please note: we are still awaiting final government guidance in relation to children and young people considered clinically extremely vulnerable. We will keep the process outlined above under review. It is possible this will need to be updated further in light of that guidance.