Shielding update letter to NHS
- Shielding update
- Updated advice to those shielding
- Clinical evidence for the new guidance
- New clinical evidence on children
- Maintaining the Shielded Patient List
- Risk stratification
- Frequently Asked Questions
From the Chief Medical Officer & NHS Medical Director
Thank you for your ongoing assistance with the identification and support to patients who have been identified as clinically extremely vulnerable (CEV) and who were advised to shield at home to protect themselves from Coronavirus (COVID-19). This has been a challenging programme but an essential one to protect those most at risk of COVID-19.
This document provides you with an update on the latest Government advice for this group, the epidemiological basis on which this advice has been developed and plans for a more individualised approach to risk stratification in the future.
Please accept our sincere thanks for your expertise, help, patience and support to those shielding.
Professor Chris Whitty | Chief Medical Officer for England
Professor Stephen Powis | NHS Medical Director
Updated advice to those shielding
Those who have been identified as clinically extremely vulnerable are thought to be at high risk of developing serious illness following COVID-19 infection. On 23 March, the Government advised all those considered to be clinically extremely vulnerable to shield at home and avoid all face-to-face contact, in order to protect them from COVID-19. Initial advice recommended shielding for a period of 12 weeks, which was expected to cover the initial peak of the epidemic which happened in April. The advice was then updated to apply up to 30th June. This guidance has always been, and will remain, advisory.
The latest evidence indicates that the prevalence of COVID-19 in the community has continued to decline. As a result, the Government has reviewed its guidance on shielding.
We know that the advice to those shielding has been challenging to follow and that it will take time for those affected to adjust and return to normal daily life. That is why the Government advice to those who are considered clinically extremely vulnerable will be relaxed in two stages:
- From 6 July, the clinically extremely vulnerable may, if they wish:
- meet in a group of up to 6 people outdoors, including people from different households, while maintaining strict social distancing;
- no longer observe social distancing with other members of their household; and
- in line with the wider guidance for single adult households (either an adult living alone or with dependent children under 18) in the general population, form a ‘support bubble’ with one other household. All those in a support bubble will be able to spend time together inside each other’s homes, including overnight, without needing to socially distance.
This is a small advisory change that brings those affected a step nearer others in their communities. However, all the other current shielding advice will remain unchanged at this time.
From 1 August, provided there are no significant increases in incidents, the guidance will be further relaxed. Specifically:
- People can go to work, if they cannot work from home, as long as the business is COVID-safe;
- children who are clinically extremely vulnerable can return to their education settings if they are eligible and in line with their peers. Where possible children should practise frequent hand washing and social distancing;
- people can go outside to buy food, to places of worship and for exercise but should maintain strict social distancing; and
- people should remain cautious as they are still at risk of severe illness if they catch Coronavirus, so the advice is to stay at home where possible and, if they do go out, follow strict social distancing.
The current advice can be found on GOV.UK.
Government support for this group, including food box provision and free medicines deliveries, will continue until the end of July to allow for a graduated return to normal life. Patients can continue to access other support from local government and the NHS Volunteer Responders past this point and seven supermarkets have given access to priority supermarket delivery slots that will continue beyond the end of July for those already signed up for support.
Over the next few days the Government will be writing to all patients who are currently on the Shielded Patient List to inform them of these updates. The Government will also be writing to all those who have been removed from the list by clinicians up to now, to ensure they are aware they no longer need to shield. For this latter group this will be a permanent change and their names will not be retained on the Shielded Patient List.
Clinical evidence for the new guidance
The Government’s shielding guidance is always led by the latest scientific evidence. The clinically extremely vulnerable were advised to shield to prevent fatalities from COVID-19 during the initial peak of the epidemic wave in England. The initial period of approximately 12 weeks was set to cover the unmodified modelled peak until low disease rates were re-established.
The current epidemiological survey shows that prevalence of disease in the community has continued to drop over the last few weeks. On average, four weeks ago, one person in 500 was infected with COVID-19. Last week it was less than 1 in 1700.
Whilst it is not possible to completely remove the risk of infection from any individual in any setting, the Government has concluded it is proportionate to recommend to those considered clinically extremely vulnerable that easing their self-protection is an appropriate measure, subject to the current epidemiology being maintained.
New clinical evidence on children
Recent experience and knowledge of the impact COVID-19 infection has on children and young people with comorbidities suggests not all those on the Shielded Patient List need to be shielding. RCPCH recently published updated guidance on which paediatric patient groups they think should be advised to shield. They have identified three groups:
- children and young people who are cared for just in primary care are very unlikely to need to continue to shield;
- a small group of children who are clinically extremely vulnerable due to their pre- existing condition will need to continue to shield; and
- a further larger group of children exists who due to their underlying condition may need to shield and the decision to continue to shield would normally result from a discussion between the clinician, the child and their family.
RCPCH expect that all patients who need to continue to shield will be seen in a specialist centre before September 2020 (but not all those with specialist appointments will need to shield). Decisions on shielding will generally be led by a specialist, balancing the clinical and social impact of shielding. Patients should only be removed from the Shielded Patient List by their GP or specialist following consultation with the child and their family, and other clinicians where appropriate.
Further guidance on having conversations with children and families can be found on the RCPCH website.
The Government works closely with the RCPCH and welcomes their valuable scientific input. We recommend that clinicians follow up with children (and their parents) on the Shielded Patient List to discuss what RCPCH guidance means for them.
Maintaining the Shielded Patient List
Whilst the prevalence of COVID-19 in the community is currently low, it may increase in the future, at which point the Government may tighten shielding measures for the protection of those who are considered clinically extremely vulnerable. We are therefore asking that clinicians continue to maintain the Shielded Patient List in line with the instructions in the NHS letter of 4 June.
Wherever a patient is newly identified as clinically extremely vulnerable, please have a conversation with them about their risk of being severely ill if they catch COVID-19 and add them to the Shielded Patient List by marking their healthcare record or adding them to your Trust’s SEFT system. Please note, the last date for registering for government support is 17 July, letters that reference the Government support offer should therefore be stopped from 6 July, to allow for processing time.
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, remove them in a similar way.
The process for adding and removing categories of patients will continue if new evidence comes to light. This will go through the UK clinical review panel, with a recommendation to the UK Chief Medical Officers and any resulting changes will likely be implemented locally. Details on the process for additions and removals can be found on the NHS Digital website.
In March, based on the earliest available clinical evidence, we worked with senior clinicians to identify a group of clinical conditions that were considered likely to increase an individual’s risk of severe illness following infection with COVID-19.
To improve our understanding, NERVTAG (the New and Emerging Respiratory Virus Threats Advisory Group) have been commissioned by the office of the Chief Medical Officer to review national and international emerging evidence on COVID-19.
From this work, a team of leading academics have been working with senior clinicians to develop a predictive risk model that reflects a wider range of factors such as demographics alongside long-term health conditions, to better understand cumulative risk of serious illness for individuals if they catch COVID-19.
The research protocol for this model has been published by The University of Oxford on 22 June 2020.
Options for applying this model across a variety of health and care settings, including developing a tool to support conversations between patients and clinicians on individual risk, are being considered. More information will be provided over the summer as this work progresses.
We recognise that the significant new pressures the NHS is under and the changing pace of guidance and requests that we make of you in support of your patients, are significant. The current guidance is available here and some frequently asked questions are annexed to this letter to support you in conversations with your patients.
Frequently Asked Questions
1. Is it really safe to stop shielding?
We have been clear that each step towards relaxing the shielding guidance should be taken carefully. People classed as clinically extremely vulnerable are still at risk of severe illness if they catch Coronavirus and should continue to take precautions, but the risk of catching Coronavirus is now sufficiently low, the Government believe that the time is now right to further relax the advice. The latest epidemiological data from the ONS COVID-19 Infection Survey shows that the chances of encountering Coronavirus in the community has continued to decline. Four weeks ago, on average only one person in 500 had the virus. Last week it was less than one in 1700. In addition, a test and trace system is now in place, including within schools, and there are robust measures in place to manage potential areas of higher risk.
2. Can I keep shielding if I want to?
The guidance for those classed as clinically extremely vulnerable continues to be advisory, and we have no plans to enforce it, so you can continue shielding if you want to. However, centrally provided food boxes and the Medicines Delivery Service will only be available while the advice is to shield, which is currently until the end of July.
Beyond July, NHS Volunteer Responders can continue to help with collecting food shopping and medicines deliveries. Simply call NHS Volunteer Responders on 0808 196 3646 (8 am to 8pm) to access this support.
3. Can I go to all my hospital appointments now?
The NHS is preparing to gradually increase some important face-to-face services, but only where this can be done safely. Hospitals and other health facilities have been asked to put extra planning and protection in place for people who are at highest risk from Covid-19.
These measures should be discussed with you in advance.
Where possible, appointments will be offered using remote services such as a video or phone consultation. If you do need to attend hospital for planned (non-emergency) care, you will be asked to take some steps to ensure you can get the care you need in an environment that keeps you safe, as well as staff and other patients.
- Admissions (including day surgery): if you are being admitted to hospital, you and any members of your household will be asked to isolate at home for 14 days prior. Where possible, you may be asked to complete a test within 72 hours before going to hospital. If you are unable to isolate effectively or be tested before coming to hospital, your admission may be rescheduled. This will be determined by your care team using clinical judgement and in consultation with you. Admissions teams will give you all the information you need when booking you.
- Outpatient appointments: you should only attend your outpatient appointment if you have no symptoms of Coronavirus. While at the hospital/health facility, it is important that you comply with normal social distancing requirements.
4. Can I return to work?
Until the end of July, if you have been able to work at home, you should continue to do so. At this time, we do not advise clinically extremely vulnerable individuals to attend their place of
work (workplace/’onsite’) if this requires them to leave their home. This guidance remains advisory.
From 1 August the Government is planning to further relax advice to those shielding, bringing it in line with the advice to the clinically vulnerable group. This means that if they are unable to work from home but can work on site, they should do so, provided the business is COVID-safe.
5. What if I don’t want to return to work?
You should look to come to an agreement with your employer and understand their specific policies around health and safety and workplace attendance, especially in relation to COVID- 19.
If you have concerns about your health and safety at work, you can raise them with any union safety representatives, or ultimately with the organisation responsibility for enforcement in your workplace, either the Health and Safety Executive or your local authority.
You can get advice on your specific situation and your employment rights by visiting the Acas website or calling the Acas helpline, 0300 123 1100.
6. I still need help with my food shopping?
Those in receipt of centrally provided food boxes, who continue to need help, will receive this support while they are advised to shield, until the end of July. This will give those shielding the time to adapt to advice that visiting shops, including supermarkets, is likely to be as safe as when they stopped these usual daily activities, provided they follow social distancing advice.
Beyond July, NHS Volunteer Responders can continue to help with collecting food shopping. Simply call NHS Volunteer Responders on 0808 196 3646 (8 am to 8pm) to access this support.
The Government also continues to support the use of priority delivery slots to help the clinically most vulnerable where possible. Priority delivery slots are at the discretion of supermarkets, but we can confirm that seven supermarkets have given access to priority supermarket delivery slots that will continue beyond the end of July for those already signed up for support.
7. Can my children go back to school?
From 1 August the Government is planning to further relax advice to those shielding, bringing it in line with the advice to the clinically vulnerable group. This means that children can return to school/nursey. Where possible children should maintain social distancing and try and practise good, frequent hand washing. The latest advice can be found on GOV.UK.
8. When might you bring shielding back?
The latest scientific evidence shows that the chances of encountering Coronavirus in the community has continued to decline. The Government regularly monitors this position and if the rates of infection in the community rise, then it may be necessary to advise that more restrictive measures should be taken.
9. What is the guidance for the clinically vulnerable?
Public safety throughout this period is the Government’s top priority – this includes keeping safe society’s most vulnerable. We advise those who are clinically vulnerable to follow the Staying Alert and Safe social distancing guidance available on the gov.uk website. The advice is to stay at home as much as possible and, if you do go out, take particular care to minimise contact with others outside your household or support bubble. By this we mean always staying 2m apart from others outside your household or support bubble, avoiding crowds, and keeping your hands and face as clean as possible.
10. Is the letter I’ve received real, telling me that I don’t need to shield anymore?
The letter you have received is from Government, signed by Matt Hancock and Robert Jenrick. This letter will have arrived between 24 and 26 June. You can find a copy of the letter online at gov.uk.
11. Where can I find accessible or alternative formats of my shielding letter?
Translated, BSL and easy read versions of the letter can soon be found at gov.uk. If a patient is blind or partially sighted they can access audio or braille formats by calling the RNIB helpline at 0303 123 9999.