Vulnerable patients: The role of general practice, NHS letter, 23 March
NHS letter on the role of general practice with regards to vulnerable patients
Please note: This letter has now been superseded by new guidance, which alters the processes described below. NHS England's updated information on categorising and contacting shielded patients can now be found here.
23 March 2020
This guidance has been developed for clinicians working in general practice. It is not intended to replace clinical judgement for individual patient cases but to give some overarching guidance to ensure we can protect our vulnerable patients in a timely fashion, provide the necessary advice and clinical care, protect the primary care workforce and reduce the pressure on hospital services. It is to be read alongside the NHSE/I letter Caring for People at Highest Risk During Covid-19 Incident letter dated 21 Mar 20.
There are some central actions being taken by NHS England (NHSE/I) to support patients who are at most risk during the COVID19 pandemic.
1. NHSE/I has worked with the providers of GP IT systems to add functionality that identifies patients who are potentially at risk from COVID-19 and produces alerts within patient records. You will notice this function appearing on your systems by 23.3.20.
2. The following table highlights how this will be done. The majority of this process will happen centrally but there will be some actions for general practices.
A. At Risk
• Aged 70 or older (regardless of medical conditions)
• Aged under 70 with an underlying health condition (i.e. anyone advised to get a flu jab as an adult each year on medical grounds)
Have already received advice on social distancing measures on the 16th March (UK government announcement).
This cohort of at-risk patients will, where practically possible, need to be reviewed by general practices and those felt to be at very high risk who are not already in Category B will need to be added to Category C.
B. At Very High Risk (Groups 1-3)
• People with a solid organ transplant such as a kidney or liver transplant
• People with specific cancers People with cancer who are undergoing active chemotherapy or radical radiotherapy for lung cancer
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.
• People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe COPD. See below.
• People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as SCID, homozygous sickle cell)
• People on immunosuppression therapies sufficient to significantly increase risk of infection
• People who are pregnant with significant congenital heart disease
• All patients on the following medications: Azathioprine, Mycophenolate (both types), Cyclosporin, Sirolimus, Tacrolimus.
Central Contact from NHS Business Services and hospital trusts with advice on shielding.
General practices are asked, where possible, to review this cohort of patients for accuracy and, where any of these
patients have dementia, a learning disability or autism, if required that you provide appropriate
additional support to them to ensure they continue receiving access to care. These patients will be highlighted in GP IT systems as “Covid-19 high risk”.
Stay at home at all times and avoid any face-to-face contact for at least twelve weeks.
C. At Very High Risk (Group 4)
Identified through a systematic search and review of records of patients in Category A within General Practice (see guidance below)
To be identified and contacted by general practices
Stay at home at all times and avoid any face-to-face contact for at least twelve weeks
Patients in the category B will receive a letter from NHS Business Services or from their hospital specialist department advising that they take action (shield). General practices are not asked to proactively contact these patients but it is quite possible that the patients themselves may contact their GP surgery for further advice after they receive the NHS Business Services letter.
General practices are asked to review this cohort of patients for accuracy and where any of these patients have significant dementia, a learning disability or autism, further support may be required; this may include proactively contacting the patient or as appropriate carer. These patients will be highlighted in GP IT systems as “Covid-19 high risk”.
Additional patients with long term conditions considered to be at high risk
Category C (Group 4) in the table above refers to patients which General Practice will be asked to add to the Very High Risk Group. General practice is asked, where practically possible, to carry out a review, which will rely on a combination of patient knowledge and local system interrogation, to identify this group. The methodology for this review will vary locally according to demographic but examples of patients to look for might include:
• Patients with diabetes with HbA1c greater than 75, recent diabetic ketoacidosis or poor medication adherence [PLEASE NOTE - THIS IS NO LONGER THE CASE. PATIENTS WITH DIABETES SHOULD SELF ISOLATE, BUT ARE NOT CONSIDERED TO BE ‘VERY HIGH RISK’];
• Patients with Chronic Obstructive Pulmonary Disease (COPD) who have required hospitalisation in the last 12 months or patients who have required 2 or more courses of steroids and/or antibiotics in the last 12 months;
• Patients with asthma with a history of hospitalisation in the last 12 months or ever been admitted to intensive care;
• Patients with significant heart failure which has required hospitalisation for their heart failure within the last 12 months;
• Patients with multiple long-term conditions;
• Patients who have had a splenectomy;
• Patients taking continuous oral corticosteroids of the equivalent of 20 mg of prednisolone or more for over 4 weeks;
• Patients taking immunosuppressive or immunomodulating medication such as ciclosporine, cyclophosphamide, azathioprine, leflunomide, methotrexate, mycophenolate. It is expected that patients taking these medications will be under a shared-care protocol with hospital specialist colleagues and a risk stratification approach should be taken. Advice can be sought from the relevant specialist. Guidance is available from the British Society of Rheumatology https://www.rheumatology.org.uk/news-policy/details/Covid19-Coronavirus-update-members
• Other patients that the general practitioner considers would be at high risk such as patients with severe dementia, cognitive impairment.
These patients will not have received a letter asking them to self-distance or shield from NHS Business Services. Having identified these patients, we would ask general practices to contact these patients individually asking them to shield utilising the NHS England template letter accompanying this document.
We recognise that there is enormous pressure on the whole NHS at present. We sense that this will require significant resource but it is important to be prioritised in order to minimise additional pressure on our system as the situation progresses. Our recommendation is that this process is, where practical, completed over a 7-day period as much as possible.
Key recommended actions from General Practice
It is anticipated that some patients in these categories, as well as having clinical conditions, may also be psychologically vulnerable, isolated and potentially frightened. Your support for these patients will be needed.
Acute requests for care
We would ask you to respond to requests for healthcare as required. All patients who display symptoms of COVID-19, have been asked to contact the NHS 111 (NHS 24 in Scotland) online coronavirus service, or call NHS 111 (NHS 24 in Scotland) if they do not have access to the internet. However, if patients have an urgent medical question relating to their pre-existing condition then they will contact you, or their specialist consultant, directly. It is recommended that consultations within general practice should be by telephone or video consultation in the first instance; this particularly applies to requests for home visits which should be triaged according to need.
Review on-going care arrangements
Practices are asked to review the list of patients in the categories above and contact patients as appropriate when there are specific concerns. These may include those living alone or those at high risk of hospital admission. The mechanism for contacting patients should be agreed locally as it will differ according to local systems however utilising social prescribing partners could be helpful.
Particular actions or advice could include:
• Confirm understanding of advice on shielding and on hygiene including regular hand washing in accordance with national guidelines.
• Advice on the importance of routine immunisations such as seasonal flu, pneumococcus, shingles, as appropriate.
• Advice on when and how to access medical care, if their condition deteriorates.
• Consider whether care plans and prescriptions are in place for end of life decisions. This should include information sharing to GP Out of Hours services and other agencies.
• Confirm details of carer and next of kin as appropriate.
• Confirm that the patient has sufficient medication. It is recommended that this is prescribed electronically, if possible.
• Consider an assessment of social care needs and referring the patient to social prescribing partners. This may be especially important for those who live alone to ensure that they have access to medication, day to day supplies and emotional support.
• General practitioners may also be asked to provide a Fit Note (Med3). Patients can now get an isolation note online. For example, https://111.nhs.uk/isolation-note
Over the next few months and weeks, it is possible that individuals may suffer significant stress, anxiety and related psychological difficulties. Please be mindful of the support available through community mental health teams, social services, the voluntary sector, online resources and other agencies and as appropriate report any safeguarding concerns according to local protocols.
What is Social Distancing?
What is Shielding?