This case study describes how more than 12,000 people were added to the shielding list during the COVID-19 pandemic using population health management techniques in Norfolk and Waveney.

Initially, 30,000 people were identified on the national list but the Norfolk COVID Protect scheme used primary, secondary, ambulance and social care data to identify 12,000 more susceptible to serious illness and hospitalisation.

Text messages and letters for this group led to 23,000 people being actively engaged and regularly contacted by a virtual care team which prioritised and escalated their individual clinical and non-clinical needs.