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How delays have hampered GPs’ efforts to assess patients at high risk from Covid-19

GP practices in England knew at the end of March they would have to urgently review around 1.5 million patients told to shield by the Government during the coronavirus pandemic.

NHS England stressed these patients were at ‘the highest risk of severe illness that would require hospitalisation from coronavirus’. They would have to stay six feet away from others in their household, and the extent of their outdoors experience for the next three months would be to open a window.

GPs were told NHS England would give them a list of the patients sent a shielding letter, and that they must contact any who had been missed, as well as remove those included by accident.

We had to go through 3,300 patient records over Easter – meaning Saturday and Sunday 

Dr Sally Dowler

All UK countries had problems – in Wales, 13,000 letters were sent to the wrong address, and GPs in Scotland and Northern Ireland reported spending time on the lists. But the biggest headaches were for GPs in England.

A Pulse survey has revealed that significant coding errors in the way NHS England identified patients requiring shielding saw practices having to remove 30 patients on average, causing a lot of anxiety among patients who had been wrongly identified as being highly vulnerable.

At the same time, they had to add an average of 53 patients, who had been unaware of the extreme measures they should have been taking. The process took up more than 24 hours of a practice’s time on average.

The problems were so stark that NHS England had to issue an apology.

Only patients who meet strict criteria set by England’s chief medical officer are supposed to shield (ie, quarantine for 12 weeks). These include transplant patients, those with certain cancers, severe respiratory conditions and rare diseases, pregnant women with significant heart disease and people on immunosuppression therapies.

But Pulse understands there were problems at all stages. When patients were being identified, charities were pressuring authorities to include more patients with their special interest on the lists.

Some charities then published their own clinical definitions, which were contradictory to subsequent official guidance. Later, consultants were being cautious with their own patients, also using definitions outside of those circulated by the NHS.

Some 20-30% don’t meet the criteria but in many cases we feel reluctant to remove and downgrade them

Dr Kevin Hollier

And there were missed deadlines throughout by NHS England. Initially, managers should have contacted patients by 29 March. GPs assumed by that point they would be told which of their patients were listed. But at the start of April, NHS England admitted the letters had been delayed. 

Distressed patients were calling GP practices to ask why they had not been told to shield. NHS England finally completed its part of the process in the week leading up to Easter – but chose to tell practices the day before Good Friday that they would need to assess 1.5 million patients by the end of bank holiday Monday.

This was later extended by a day, but this was scant help. Patients were also allowed to self-identify through the Government’s website as shielded – a list GPs were expected to assess from the start of April. But due to delays in sending out the names, NHS England eventually pushed that deadline back to 28 April.

The shifting deadlines and ‘poor’ information increased the burden on practices at a time of intense pressure. The Pulse survey of 588 GPs in England, carried out between 17 and 21 April, showed an average practice spent 26 hours in a week reviewing whether patients should be shielding. On average, they found errors with 83 patients.

GPs spoke of the frustration of having to complete a mammoth task in so little time.

I really do recognise you’ve been waiting to do something then all of a sudden there was a deadline

Dr Nikita Kanani

Essex-based Dr Sally Dowler says: ‘We had to go through 3,300 patient records over Easter – meaning Saturday and Sunday as we were working on Friday and Monday. That’s about 500 patient records each and it took hours.’

Practices could have searched their own patient data more effectively had they been allowed to, Dr Dowler adds.

Worcestershire GP Dr Kevin Hollier describes the shielded patient list sent to practices as ‘poor… some 20-30% don’t meet the criteria but in many cases we feel reluctant to remove and downgrade them. Many are still vulnerable.’

A number of GPs said coding issues meant high numbers of patients with sickle-cell trait and former cancer patients were wrongly identified as needing to shield.

NHS Digital has confirmed a number of errors affecting the shielded patient list, including the sickle cell coding problem, and has also issued an apology for sending almost 11,000 shielding letters to dead people.

Meanwhile NHS England acknowledged there had been problems. In a webinar on 16 April, director of primary care Dr Nikita Kanani told GPs: ‘I really do recognise you’ve been waiting to do something then all of a sudden there was a deadline. It’s been really frustrating and I’m sorry about that.’