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Independents' Day

Many more patients should shield in second Covid spike, says DHSC adviser

Exclusive Patients with diabetes, hypertension and cardiovascular disease should be added to the list of clinically extremely vulnerable patients who should shield during a second Covid-19 spike, experts have said.

They acknowledged this would lead to 'large numbers' of patients being added to the list - which is managed by GPs - while some GPs warned it could see an increase by 'ten-fold' that would be 'unworkable' to practices.

The suggestions come as these co-morbidities have been found to be especially prevalent in those who have become severely ill with Covid-19.

Professor Kamlesh Khunti, professor of primary care diabetes and vascular medicine at the University of Leicester and an adviser to the Government on the risk factors to BAME people, said respiratory risk factors such as asthma are much less significant than initially thought.

He said: ‘We were prepared for people being disproportionately affected if they had respiratory diseases as we do with influenza, but this virus has shown us that the three highest risk factors associated with severe disease and mortality are diabetes, hypertension and established CVD.’

Professor Khunti, who was also a member of the steering committee for the NHS Diabetes Prevention Programme, added that while severe COPD should ‘definitely’ remain on the list of conditions requiring shielding, diabetes and hypertension should also be added.

The latest study into Covid co-morbidities, in which Professor Khunti participated, found that these conditions - alongside COPD - siginfiicantly increased the severity of disease.

The paper said: 'This systematic review and meta-analysis has identified that the presence of co-morbidities such as diabetes, hypertension, CVD, and COPD in individuals with Covid-19 is associated with an approximate two-fold increased risk of developing severe symptoms and mortality.'

Professor Khunti acknowledged that ‘large numbers would be affected’ if these conditions were added to the shielding list, as population prevalence of hypertension is ‘anything from 15% onwards’ while diabetes stands at ‘about 8%’ in the adult population. 

But he said adding the conditions would also help protect those from Black, Asian and minority ethnic (BAME) backgrounds, who are at increased risk from hypertension, diabetes and CVD as well as Covid-19.

The news comes as the shielding programme in England is due to be paused from next month (1 August), while GPs and specialists will be asked to rewrite the Covid-19 shielding patient list ahead of a second spike. The new list will be based on a new risk prediction tool being developed by the University of Oxford and NHS Digital.

Dr John Ashcroft, a GPSI in cardiology in Derbyshire, said that the new algorithm should ‘absolutely’ include cardiovascular risk factors such as CVD and hypertension.

He said: ‘At the moment, the shielding system is very crude in comparison to what we use for cardiovascular risk assessments.'

Dr Ashcroft added that the lack of age-related risk factors on the official list is a ‘profound weakness’.

He said: ‘This is a respiratory virus that seems to cause predominantly a vascular disease and it’s vascular risk factors that are primarily a risk factor for coming to harm. [But] of course, the most important risk factor for CVD is age - it just trumps everything.’

Meanwhile, the numbers of additional shielding patients this would result in would then depend ‘where do you decide to draw your line of risk’, he added.

But Dr Mike Smith, St Albans GP partner, RCGP senior educator and former GP federation lead, warned that asking diabetes and hypertensive patients to shield could increase the list ‘ten-fold’.

He said: ‘What you’d see is the shielding list increase probably ten-fold at least. 

‘I had a practice in [Camden] prior to working here where we only had 3,000 patients and we had 350 patients with diabetes and 720 with hypertension.’

While some patients had both conditions, the practice’s shielding list would still see a ‘big leap’, he added.

He told Pulse that this would have ‘profound’ workload implications for practices and most GPs ‘just wouldn’t have the time’ to manage the list.

He said: ‘It is just unworkable [and] poorly thought through. What we should be doing is concentrating on other measures to try to limit disease spread and try to help people better their outlook through maintaining a healthy life.’

Dr Smith, who previously set up a primary care diabetes integrated practice unit, added that the move could also disrupt delivery of care as his practice has a high proportion of staff with treated hypertension. 

Meanwhile, he warned that the high levels of people estimated to have undiagnosed diabetes and hypertension would be ‘added complication’.

A DHSC spokesperson reiterated that the evidence on which medical conditions result in a greater risk from coronavirus is being kept ‘under review’.

In the latest GP webinar, clinical adviser to the chief medical officer Dr Nisha Mehta said that the implementation of the new risk calculator is 'still being finalised' with NHS Digital and the DHSC but that the 'vision' is to have it embedded in GP systems 'probably by September'.

PHE's delayed report into the risk factors associated with coronavirus recommended the improved management of conditions such as hypertension and diabetes.

In May, official data showed that over a quarter of the patients who died with Covid-19 in England had diabetes, however, the Government launched a specific support service for diabetes patients and stopped short of adding them to the shielding list.

Meanwhile, Professor Khunti told a parliamentary group earlier this month that the NHS Health Check programme should target people from ethnic minorities from age 25 to diagnose long-term conditions such as CVD and diabetes earlier, which are more prevalent in this cohort.

Earlier this week, the RCGP was forced to apologise after GP colleagues criticised its branding of Covid-19 as a 'lifestyle' disease.

Readers' comments (12)

  • At the danger of being politically incorrect surely these conditions are a proxy for obesity; and to a lesser extent age as they become more common with age. To make the process simple, God forbid, one could just give marks for age, gender and BMI. and there Bob's your uncle. End of this undignified political squabbling.

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  • I take it the professor is absolutely certain that there will be a second spike. And a third? A fourth? If he had replaced his certainty with “IF there is a second spike…”, he would have been cleared of charges that "government advisers” run a C19 project fear.

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  • there may not be a second spike as such as lockdown has created a different scenario. no rampaging across the population in one go as per normal and then mopping up the uninfected in 2nd and 3rd waves. we now have mutiple mini spikes across the country that will continue for the next few years either till everyone is exposed or we have a vaccine. as lockdowns start to affect peoples ability to earn cash and travel there will be less compliance with social distancing - there are already covid parties in the usa amongst the younger populations. the longer it goes on the less people with stick with the restrictions, regardless of the risk of harm to others, this is human nature. so at what point do we decide, if there is no vaccine coming, do we accept the inevitable and let the virus do its worst. 2 years, 3 years, 5 years ?? when exactly. with no conversations and no time frames coming from our leaders - people will do what they like and they clearly are at the moment. so i would suggest we ct with lockdown measures till march next year - post flu season - and then decide, if no vaccine coming in the next 2 years, end all restrictions in 2022. Give people a working time frame if you want compliance.

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  • This will also decimate the NHS workforce- theses are common conditions, and health care staff are not immune. Surely it will not be a blanket application- hopefully there will be a distinction made between a well controlled person with diabetes /hypertension, and one who has poor control? Are we aware of the mechanism in which people with hypertension are more susceptible to Covid-19?

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  • More shielding confusion to waste our time?

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  • Sadly we just don't know enough about the disease. Its emerging that ones genetic makeup decides if you are going to get the severe form of the disease and being older,hypertensive diabetic or obese just makes this worse if you have the wrong genetic make up.
    Shielding everyone with the above is just a big ask

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  • Yes the "Vulnerable" should shield and we now know a little more about who this group now is. Hopefully this will then also mean that everyone else can get on with their lives, accepting the risk of getting a "Cold".

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  • PS. Agree with Jeremy.

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  • This is one fantastic political (not scientific) experiment.

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  • It occurs to me that no-one appears to have seen the most reliable and evidence- based assessment tool. Go to www.alama.org.uk and access the Covid-19 assessment tool tab (no sign-in required).

    This system factors age into the equation and is rigorously evidence-based. It has been developed with workplace assessments in mind, but the underlying information is of relevance. Important to note that it is part of a clinical assessment, not a "ready reckoner". It appears that the way this article is reported suggests that an "all with condition a" approach should be advocated; this must be an over-simplification.

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