Letter to GPs about the new COVID-19 Population Risk Assessment

Contents

 

Classification: Official

Publications approval reference: C1099

15 February 2021

Dear colleagues

Information on an additional cohort of patients identified at increased risk from COVID-19, and the implications for their vaccination, support and advice

We are very grateful for your ongoing work to identify and support people who are clinically extremely vulnerable to COVID-19.

We are continually learning more about COVID-19 and the factors that lead to severe outcomes including hospitalisation and death.

We are writing today to make you aware of a new, data-driven risk assessment, called the COVID-19 Population Risk Assessment. This has been developed to help identify people who may be at high risk from COVID-19. It has been used at a national level to help identify an additional group of patients with specific multiple risk factors which, combined, may put them at similar risk to those who are clinically extremely vulnerable to severe outcomes.

As a precautionary measure, this group will now be added to the Shielded Patient List (SPL), on the advice of the Chief Medical Officer. This is to enable them to be prioritised for vaccination, if not already vaccinated, and to provide them with additional advice and support. In practice, this means they will now be offered vaccines at the top of cohort 6.

What does this mean for patients?

Additional patients identified by this risk assessment will be added to the SPL by NHS Digital, starting with those aged 19-69. They will be contacted directly to inform them from this week. You do not need to inform patients yourself.

Patients will be informed that this measure will allow them more rapid access to vaccination if they have not already been vaccinated. They will also be advised to follow Government guidance for those who are high risk, which currently includes shielding, as a precaution. Government communications will recognise that whilst people may feel that the advice is not so relevant as infection rates decline, it is still important that they are aware of their risk status.

What does this mean for GP practices?

To act as quickly as possible and reduce GP workload, NHS Digital will add these patients directly to the SPL and you should be able to see this in their record in the coming week to ten days.

As part of the current SPL process, you can add or remove a patient at any time. As now, you can continue to review individual patients on an ongoing basis, according to your clinical judgement and patient request.

We ask that you familiarise yourself with the changes explained in this letter and that Primary Care Network Local Vaccination Services should prioritise this group for vaccination, as set out in section 3 of the annex below.

What information is included in this letter?

The annex below provides detail on:

  1. How these patients have been identified
  2. How these patients will be informed
  3. How these patients should be prioritised for vaccination
  4. The advice these patients should follow to keep themselves safe and the support available
  5. How these patients will be added to the Shielded Patient List
  6. The opportunity for practices to review and amend the additions, and;
  7. Questions that patients may ask

We hope this approach will help you and the NHS to support more people to stay safe. Please note that a similar letter is also being issued to NHS trusts this week.

Thank you again for everything you are doing in supporting this important phase of the COVID-19 response.

Dr Jenny Harries OBE | Deputy Chief Medical Officer for England

Dr Nikki Kanani MBE | Medical Director of Primary Care | NHS England and NHS Improvement

Professor Jonathan Benger | Interim Chief Medical Officer | NHS Digital

Annex

1. How these patients have been identified

Background

Evidence about COVID-19 and the factors that lead people to become seriously ill is constantly improving.

The CEV group was initially identified by establishing a list of clinical conditions believed to put an individual at high risk from COVID-19. Last year, the Chief Medical Officer (CMO) for England commissioned an expert sub-group of the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) to develop a predictive risk model to enable a data-driven and individualised approach to clinical risk. The model is known as QCovid®. It has been developed by a group of researchers led by the University of Oxford, and combines data on a number of factors to estimate the risk of catching and then being hospitalised by or dying from coronavirus. The research has been published in the BMJ and the code will be published under open source protocols.

The model has now been validated using an independent dataset by the Office for National Statistics and shown to perform in the excellent range (as judged by Harrell’s C statistic).

NHS Digital and the Department of Health and Social Care have therefore worked to develop, test, and apply the model in the COVID-19 Population Risk Assessment.

How has the model been used to identify people at risk?

NHS Digital has used the model at a national level to calculate risk assessments for a cohort of individuals in England likely to be at high risk based on centrally-held patient data. The CMO has agreed that people whose risk assessment result is higher than an agreed threshold for mortality will be added to the SPL on a precautionary basis. Given the slightly different assessment basis, the Government will describe this high risk group as similar to the clinically extremely vulnerable group.

If certain information is missing from a patient’s record, then default values have been used as a substitute to calculate risk scores. A precautionary approach has been taken to these default values, so that patients who are potentially at high risk of severe outcomes can access vaccinations, support, and advice, including to shield. Patients always have a choice as to whether to be vaccinated, access support and follow the advice, particularly if they feel their risk assessment does not reflect their current clinical context, or personal risk appetite.

More information on the risk thresholds, default values, and how the COVID-19 Population Risk Assessment has been developed and used to identify those at high risk, can be found on the NHS Digital website.

2. How these patients will be informed

Patients will be added to the SPL in two groups. We expect patients aged 19-69 who are being added to the SPL will start to receive notification of this from this week, with letters continuing to land into the following week. You do not need to inform patients directly.

The remaining individuals aged 70+ are expected to be added to the SPL as soon as possible after that. These individuals aged 70+ should already have been offered a priority vaccination as part of Joint Committee on Vaccination and Immunisation (JCVI) Priority Groups 1-4.

The letter will inform patients that they have been identified by the Department of Health and Social Care and NHS Digital as being of similar risk to CEV. It will note that this follows an analysis of the combined risk factors in their centrally-held record by the COVID-19 Population Risk Assessment. It will explain that patients will be offered priority COVID-19 vaccination, and will give details of the support available and the additional shielding advice to those who are CEV. It will note that adding people to the SPL is the easiest way to ensure earlier vaccination and emphasise that following shielding advice is voluntary. People may feel that at this stage of the pandemic the shielding advice is not relevant to them, but it is important that we make them aware of their risk status and the support available.

We will share a copy of this letter, including further updates, via the Primary Care Bulletin when available on the gov.uk website.

Patients for whom the NHS holds an email address will also receive this communication via email. Please continue to encourage patients to register an email address and phone number with their practice to help with the speed and accuracy of communications to this group. Please note that although GP IT providers receive information at the same time as patients receive emails, it can take up to 5 working days for flags to show on GP systems (see section 5 below).

The remaining patients aged 70+ will be contacted in the same way with further advice as soon as possible – most likely to commence from the start of March. We will confirm this via the Primary Care bulletin closer to the time.

3. How these patients should be prioritised for vaccination

Those individuals aged 19-69 added to the SPL should be recognised as having an equivalent risk to those previously identified as CEV.

In practical terms, this means that those under 65 should be prioritised ahead of others in cohort 6, once the new high risk flags are visible on your system.

Individuals aged 65-69 will already be called to vaccination centres as part of cohort 5, but may now be more inclined to use local vaccination services. We ask that Primary Care Network local vaccination services support such requests.

4. The advice these patients should follow to keep themselves safe and the support available

There is guidance and support available for individuals at high risk here to help them take extra precautions. The Government advice and support to shield is being extended nationally until 31 March.

We recognise that people may find their new identification as CEV worrying, even with the offer of vaccination. They may therefore contact their GP about this.

Even if CEV individuals have had both doses of the vaccine, they are still recommended to follow this shielding advice until vaccine effectiveness has been formally assessed. Individuals on the SPL will receive updated advice by letter before 31 March.

5. How these patients will be added to the Shielded Patient List

NHS Digital will add all individuals to the SPL in England who:

  • Meet the risk assessment threshold agreed by the CMO;
  • Have not previously been added to or removed from the SPL; and
  • Have not previously been assigned a high, moderate or low risk flag by their GP practice

Additions are being made as quickly as possible, but due to the large numbers involved, they will take place in two stages.

  • Individuals aged 19-69 should be added to the SPL and given a high risk flag in practice systems from this week.
  • The remaining individuals aged 70+ are expected to be added to the SPL as soon as possible after that.

6. The opportunity for practices to review and amend the additions

To act as quickly as possible and reduce GP workload, NHS Digital will add these patients directly to the SPL. However, as part of the current SPL process you can add or remove a patient at any time. As now, you can continue to review individual patients on an ongoing basis, according to your clinical judgement and patient request.

If you do wish to add or remove people from this list, please follow the established process detailed here. Please remember to contact any patients you remove from the SPL. A specific template letter for doing so has been made available on the SPL pages of the NHS Digital website. Individuals who have already been invited for vaccination should still proceed with their vaccination appointment.

These individuals will be flagged as being on the SPL using the standard ‘high risk for developing complications for coronavirus’ SNOMED code. Further information on how to identify these patients can be found here.

The QCovid® model that has been used to identify patients at high risk nationally has also been turned into a tool that clinicians can use locally. The COVID-19 Clinical Risk Assessment Tool enables you to enter patient information and check their risk assessment results. You may wish to use this when reviewing patients added to the SPL as a result of the COVID-19 Population Risk Assessment, or as part of general consultations with patients. Information about how to access the tool and guidance on its use is available on the NHS Digital website.

A list and more information about patients at your practice whose risk results did not meet the CMO agreed threshold, and who therefore have not been added to the SPL through this process, will also be made available through an NHS Digital web portal within the next 4 weeks, should you wish to review this. More information about the list, the web portal and how to review this information is available on the NHS Digital website.

7. Questions that patients may ask

The following elements of the guidance above may be particularly useful in answering questions from patients:

Q. What do I say to newly added patients if they receive their letter before I can see a high risk flag against them in the GP IT system?

A. We want to make sure patients are alerted that they are at risk as soon as possible. This means that GP IT providers receive information at the same time as patients receive emails and letters go to print. It can sometimes take up to 5 working days for flags to show in GP IT systems.

If a patient has received a letter, they should follow the advice included within it unless they hear otherwise subsequently.

Q. What do I say if patients ask why they are only now being identified as high risk and advised to shield?

A. Evidence about COVID-19 and the factors that lead people to become seriously ill is constantly improving.

These individuals have been identified by a new risk assessment model, commissioned by the Chief Medical Officer for England, to predict a person’s risk of becoming seriously unwell from COVID-19.

This model has been developed using data which was gathered during the first wave of the pandemic. It has been through the most rigorous standards of review and testing and this is the earliest time that it has been available to identify patients at a national level in this way. We are acting as rapidly as possible to implement this, in order to help inform the immediate prioritisation of COVID vaccination and make sure patients are provided with the right advice and support.

Q. Do patients have to follow shielding advice if they don’t want to?

A. Patients at high risk of severe outcomes from COVID-19 infection are strongly encouraged to follow shielding guidance. However, this is advice, and not the law. Patients can choose whether or not they want to follow it.

Q. Are there likely to be patients who have been added in error by the tool?

A. If certain information is missing from a patient’s record, then default values have been used as a substitute to calculate risk assessment results. A precautionary approach has been taken, to allow patients identified as at high risk to access vaccination, support and advice including to shield. Clinicians can use the COVID-19 Clinical Risk Assessment Tool to review a patient’s risk assessment results (more information is available on the NHS Digital website), and can add or remove patients from the SPL as per the usual process.

8. Links to additional information