Coronavirus (COVID-19): Shielded patients list

The shielded patients list (SPL) is made up of a clinical algorithm, a publication, and our dissemination of the data.

High risk of developing complications from coronavirus (COVID-19) infection.

The algorithm looks to identify:

1. Solid organ transplant recipients.
2. People with specific cancers:

• people with cancer who are undergoing active chemotherapy
• people with lung cancer who are undergoing radical radiotherapy
• people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
• people having immunotherapy or other continuing antibody treatments for cancer
• people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
• people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs

3. People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary (COPD).
4. People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as Severe combined immunodeficiency (SCID), homozygous sickle cell).
5. People on immunosuppression therapies sufficient to significantly increase risk of infection.
6. Women who are pregnant with significant heart disease, congenital or acquired.

Some specialty organisations have developed decision-support tools to help identify patients. Please note that this is guidance, and ultimately the decision to add a person to the highest clinical risk registry will be on a case by case basis. 

• Association of British Neurologists
• British Society of Gastroenterology
• The renal association
• British Society for Rheumatology
• British Association of Dermatologists
• British Thoracic Society

Moderate risk of developing complications from coronavirus (COVID-19) infection

Patients are at moderate risk of developing complications from coronavirus (COVID-19) where:

• they meet the criteria that make them eligible for the annual flu vaccination (except those aged 65 to 69 year old inclusive who have no other qualifying conditions)
• and they do not meet the CMO criteria for the high risk group for COVID-19

This includes the following patient groups:

• aged 70 or older (regardless of medical conditions)
• under 70 with an underlying health condition listed below (for adults this is usually anyone instructed to get a flu jab as an adult each year on medical grounds):
  • chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis
  • chronic heart disease, such as heart failure
  • chronic kidney disease
  • chronic liver disease, such as hepatitis
  • chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy
  • diabetes
  • those with a weakened immune system caused by a medical condition or medications such as steroid tablets or chemotherapy
  • being seriously overweight (a BMI of 40 or above)
  • those who are pregnant.

Low risk of developing complications from coronavirus (COVID-19) infection

Patients are low risk if they are not in the moderate or high risk groups. 

We have published the algorithm and detailed methodology for the shielded patients list.

The methodology is currently under review following the acceptance and publication of Royal College of Paediatrics and Child Health (RCPCH) guidance.

We are aware of the following issues. If you wish us to investigate cases where the algorithm may have an issue please contact splquery@nhs.net.

Deductions from the SPL arising from the CMO rule set

In mid-August we became aware of circa 23,000 patients records which have been removed from the NHS Shielded Patient List as they no longer meet the requirements of the national methodology, but were not removed at the request of a clinician. During September we will write to the patients to inform them that they have been removed from the list. A small number of patients have been reinstated on the list by GPs following their removal. 

Hospital Deductions of Patients

A small number of request by hospital Trusts to remove patients from the NHS SPL were not correctly processed. These have been passed to general practice during August for review using a technical method known as an intra-systems task to ensure that the latest clinical information is used in the decision making. Once GPs have reviewed, the patients will be removed from the NHS SPL by them adding a low or moderate risk code.

Missing Risk Status in GP Records

In mid-August we became aware of circa 65,000 patient records in general practice where the patient was on the NHS Shielded Patient List but there was not a similar entry on their GP record, for example if added by the national algorithm. The patients had been advised they were high risk and other organisations, including the Government service, were aware. The issue will be resolved by adding the information to the GP record, with the work scheduled to complete by Friday 25 September latest.

Stable HIV

Patients with stable HIV and no other conditions have not been specifically been allocated to the shielded patient list.

We are aware that despite this they are being identified as high risk. This is likely because the code of “immunosuppressed” is used on their record and this is being used to add an entry.

Sickle cell trait

The code for sickle cell disease has been used on the patient’s record rather than sickle cell trait. This has meant patients have been over identified.

Peripheral Vascular disease (PVD)

We have received reports that PVD is being picked up. PVD is not on any of the inclusion criteria. This cannot be explained without further specific investigation.

Splenectomy

Splenectomy was included in the indications for identifying people who may be clinically extremely vulnerable to COVID19 as a precautionary measure in England, based on the available evidence and expert advice taken at the time.  Given emerging evidence and the improving epidemiology, the Government’s Shielding policy is currently under review.  

While this is underway the Government advice, available on GOV.UK, is that all people who have been added to the shielded patient list continue to follow the shielding measures. Anybody who is unsure about whether they should follow this guidance should contact their GP or hospital specialist to discuss their individual circumstances.  Further guidance will be issued by the Government when the shielding policy review is completed. Further information is available.

Antineoplastic Chemotherapy (GP Extract)

In the GP flu cluster Antineoplastic Chemotherapy is included in the immunosuppresion category which means it is not limited by time, i.e. it includes patients who have ever had Antineoplastic Chemotherapy . We intend to limit this by time (24 months in a later release)

Corneal Implant (HES)

Following specialist input, corneal implant where patients are on systemic immunosuppression drugs will remain part of the national algorithm.

Incorrect category selected by Trust

A small number of additions made by Trusts are for the category “Women who are pregnant with significant heart disease, congenital or acquired” where this is not possible (e.g. aged over 70). We have contacted the Trusts to make them aware of the issue. GPs should delete the code or mark it in error and add a new high-risk code.

Risk of exposure to communicable disease Flag

At the start of the NHS Shielded Patient List, GP IT systems used the “Risk of exposure to communicable disease (situation))” flag whilst the correct SNOMED CT codes were being added. Patients who have been flagged with a communicable disease during this period (e.g. scarlet fever) will also have been added to the NHS Shielded Patient List.

Deceased patients

Some shielding patients who have sadly died may receive a letter about the changes to shielding policy guidance. This is because there are a few days delay between the list being generated and the letter being printed, which means that letters may be sent using slightly out of date information. We apologise if this has caused distress to any loved ones.

Overlapping communications about shielding

Some patients may receive two letters about shielding – one to advise them about the new guidance and another to advise them that because their condition has changed or their doctor has evaluated them as not needing to be on the shielded patient list, they have been removed from the list. This is because we regularly update the list to ensure that people are added or removed from the list by doctors as their clinical circumstances change or evidence changes. We will continue to keep the Shielded Patient List up to date throughout the lifetime of the pandemic, so even though the guidance has changed, patients may still receive a letter to say they have been added to, or removed from, the list.

An updated NHS SPL will be generated weekly by NHS Digital, incorporating additional patient data provided by acute Trusts and GP practices.  Each list will be based on the latest version of the SPL clinical algorithm at that time.

Questions about the SPL publication process should be directed to: SPLQuery@nhs.net

Full details can be found on our timings for information flows between systems page. 

The shielded patient list is only sent to recipients under data sharing terms of release, and is subject to information governance controls.

We openly publish recipients of the list on our website.