Update on guidance for clinically extremely vulnerable individuals and actions for GPs



Classification: Official

Publication approval reference: 001559 / C0830


  • GP Practices
  • CCG accountable officers and Heads of primary care commissioning
  • ICS/STP leaders
  • Regional directors of primary care

2 November 2020

Dear Colleagues,

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 (SPL).

We know this is an extremely challenging time for practices. However, given the vulnerable nature of those on this list, we are asking your practice to take the following specific actions:

  1. Familiarise yourself with the updated guidance for clinically extremely vulnerable people when it is published here. Publication is expected imminently and will be communicated to all patients on the SPL by letters, which we expect will begin arriving from the middle of this week. These letters will provide evidence for Statutory Sick Pay purposes if required. We will seek to provide primary care with any additional information following that publication here.
  2. Immediately review any children and young people remaining on the SPL who your practice added and, where appropriate, remove them from the SPL. You should also plan to urgently respond to calls from parents and guardians of children on the SPL seeking a review – parents and guardians will be advised by Government to contact their child’s specialist or their GP, if they are still unsure whether their child should remain on the SPL (Annex 1).
    1. We want to highlight that the vast majority of children and young people who have been reviewed to date using the Royal College of Paediatrics and Child Health (RCPCH) guidance have been found to be no longer considered clinically extremely vulnerable. Given the detrimental impact to children’s wellbeing of following unnecessary additional restrictions, it is important we complete this exercise as soon as possible.
  3. Urgently identify, contact and flag adults with Down’s syndrome. You may also want to take the opportunity to ensure they receive a flu vaccine and to schedule an annual health check if these are needed (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.

I know all of us want to ensure that those who are clinically extremely vulnerable continue to fully access appropriate NHS care. We have previously published best practice guidance on providing NHS care for those who shielded during the initial wave of COVID (see Annex B in 4 June letter).

Thank you for all your continued work to identity and support our patients at greatest risk in a week when I know that there are multiple requests on your time.

Yours sincerely,

Dr Nikita Kanani | Medical Director for Primary Care | NHS England and NHS Improvement

Annex 1: Review of all children and young people identified as clinically extremely vulnerable

  • Evidence published by the 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.
  • Trusts have been working to review their lists over the past few months and we know that many practices have reviewed their patients. They have found that the vast majority of children and young people should not be considered clinically extremely vulnerable. For example, one specialist children’s hospital has reviewed all those under their care who were on the SPL and concluded that only a tiny minority of them should remain on it.
  • Despite these efforts, significantly more children and young people remain on the SPL than would be expected.
  • It is essential that young patients are safely removed from the SPL so that they can follow the appropriate advice and do not restrict themselves unnecessarily.
  • We know that many general practices have fully or partially reviewed their lists. However, we are asking you all to do a final urgent review of every child or young person that you added as a practice who remains on the SPL.
  • Practices should also expect contact from parents and guardians and be prepared to respond urgently. We understand that the Government will write to all carers of children and young people on the SPL in the coming days. Given the critical importance of ensuring that children and young people are not following unnecessary restrictions, that letter will ask parents or carers to contact their child’s usual hospital doctor or GP if they have not already heard the outcome of a review.
  • Our expectation is that the majority of children and young people no longer need to be on the Shielded Patient List.

Actions for practices

  1. We are now asking that practices urgently review children and young people on their lists and prepare for reviews requested by young people or parents.
  2. Where an individual is no longer considered clinically extremely vulnerable by RCPCH criteria, please inform the patient/their parent or guardian, and follow the usual process for removing patients from the SPL.
  3. If unsure, please request advice from a specialist on whether the patient should be considered clinically extremely vulnerable, using an ‘advice and guidance’ approach where appropriate. Specialists have been asked to prioritise supporting GPs with these decisions. If there is a single point of contact for paediatric advice in your area this is likely to be the best route for specialist advice in the first instance.
  4. Parents and guardians of children and young people still on the SPL are expected to receive letters confirming the latest government guidance from 5 November. These letters will confirm that all children on the SPL should have been reviewed by their clinician, and will ask parents and carers to contact their child’s usual specialist or their GP (if they are not currently receiving specialist care) if they have not yet heard the outcome. If you are contacted by a young person, or the parent of a child who has not yet been reviewed, please ensure this review is now completed urgently, regardless of whether you originally added them to the SPL, seeking specialist advice if required.
  5. Please note that a proportion of children and young people were initially added to the SPL by the national process, and so may not have been removed through the process of practices and trusts reviewing those they added locally.
  6. You can search for all children (under the age of 18) registered with your practice remaining on the SPL, using the high risk of complications from COVID-19 code. Guidance is published here. The freetext of the SNOMED CT code will usually record which organisation added the patient.
  7. 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.

Annex 2: Changes to the Shielded Patient List – additional cohorts

  • 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 this model have 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 Shielded Patient List:
    • adults with stage 5 chronic kidney disease (not on dialysis or with a renal transplant – these patients should already be on the SPL)
    • adults with Down’s syndrome.
  • 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.

Adults with Down’s syndrome

  • The COVID-19 risk model indicates that there is a significantly higher relative risk from COVID-19 in adults with Down’s syndrome. This risk increases with age; if the person has underlying health conditions; and also appears to further increase if the person lives in residential care.
  • All adults with Down’s syndrome should be identified and reviewed by practices for inclusion on the SPL.
  • The decision to include these patients on the SPL is so that they get the advice and support they need to help keep themselves as safe as possible, but we are aware that it could cause increased anxiety.
  • The Oxford modelling commissioned by DCMO does not include children, as there is not sufficient data from the first wave of the pandemic; but the RCPCH guidance applies to all children and young people. Therefore, the CMO office has advised that children and young people with Down’s syndrome should not be automatically included on the SPL.

Actions for practices

  1. Identify qualifying patients on your lists: Please run a search on your system for adults (18 and over) with Down’s syndrome. Details of how to do this and the relevant codes to use will be on the NHS Digital website. Please note, in contrast to previous additions to the SPL, at this stage there will not be a central process to identify these patients.
  2. Contact the patients: Once you have identified the appropriate patients, we would ask that you arrange to have a conversation with them and/or their carer to explain what this means for them. This review could be part of wider QOF, health checks or care planning for this cohort and an opportunity to deliver the flu jab.
  3. Provide the patient letters: A specific new ‘patient additions’ letter for this cohort has been created for this purpose, which should be available shortly and will also be available in Easy Read. We recommend that both the Easy Read and the full patient letter are provided. If possible, a colour edition of the Easy Read version should be provided.
    The letters will be available for download from the NHS Digital website. They will also shortly be available in your system template libraries. The Government Guidance will also be available in Easy Read.
    Patients and their families/carers can also be referred to the Down’s syndrome Association website and helpline – 0333 12 12 300 – for further accessible resources and other types of information and support.
  4. Flag the patient record: Please then mark the patient’s healthcare record with the ‘high-risk from developing complications from coronavirus’ flag to add them to the SPL. Details of how to do this are on the NHS Digital website.

People with stage 5 chronic kidney disease

  • Acute trusts and renal units have been asked to identify and contact qualifying patients with stage 5 chronic kidney disease (not on dialysis or with a renal transplant – these patients should already be on the SPL). The letter requesting this action will be available here.
  • At this time there is no action required from practices regarding identification of these patients. However, we recognise that practices may be approached by patients hearing of the inclusion of stage 5 chronic kidney disease. These patients should be advised that they will be contacted by their renal unit.
  • If, after discussion, the practice wishes to add the patient themselves, this can be done by applying the high risk marker to their record. Please ensure that you also send them the appropriate patient letter and notify their renal unit of their inclusion. These letters will shortly be available in your system template libraries and on the NHS Digital website.