The latest standard operating procedure (SOP) highlights the role that GP practices should play in supporting vulnerable patients. Full guidance for GP practices on this aspect of their role during the pandemic, including template letters for vulnerable patients, is available here.
Which patients are affected?
Patients in the very high risk group should have received a letter at the end of March advising them that they should 'shield' themselves. These include the following groups:
- People with a solid organ transplant such as a kidney or liver transplant
- 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. The criteria to identify severe asthma and severe COPD is here.
- 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. The relevant therapies are listed here (Annex F).
- People who are pregnant with significant heart disease, congenital or acquired.
These patients are being advised to stay at home at all times and avoid face-to-face contact for at least 12 weeks. Full guidance for patients is here.
Practices should have received details of these patients and advice on how to run a system search for this report from they system suppliers - if they have not, they should contact their supplier straight away. Practices are expected to review this list of patients in for accuracy and, where patients have significant dementia, a learning disability or autism, offer further support as required.
Practices were initially asked to identify any other very high risk patients and add them to this group and guidance was initially produced by NHS England, the BMA and the RCGP suggesting which patients this might be. However, a letter dated 3 April asked practices to disregard this advice.
An FAQ for clinicians published on the same date outlined two further phases of identifying additional patients that fall into the very high risk group. These will be ongoing throughout the pandemic:
- using primary care data extracted centrally that meet the CMO's criteria (above). These will be flagged automatically in the clinical system and practices will be informed by the system supplier when this is done. The same report that practices ran to identify the first cohort of patients will be adapted to pick up any codes that are added.
- hospital consultants and GPs can also add or remove patients from the register. GPs can do this by adding appropriate codes to the patient records – system suppliers should advise practices which codes to use. Any patient identified must also be sent a letter (template letters are here). Hospital consultants will have to submit a form to NHS Digital with details of their patients and practices should be alerted to these
Patients who self identify
Patients have also been asked to self-identify via the government website and practices will be sent a list of their patients to check and consider if they should be added to the list. If they should, practices will need to flag their record and send the patient a letter.
The guidance adds: 'You may wish to contact the people who self-referred and who you consider to not be the highest clinical risk group to confirm that they do not need to shield.'
If patients want to follow shielding advice that is there own choice. However the latest guidance says that those not included on the shielding list, but in the broader group of patients at risk (which is effectively the list of people who are entitled to a free flu jab), should follow social distancing.
Removing patients from the list
If GPs think there are patients on the register who should not be included in this group, they should code them low/medium risk vulnerability – system suppliers should have advised the practice of which code to use. This will remove them from the central registry. The CMO and NHS England says they may have been added to the list due to incorrect coding.
However, if these patients were added to the list centrailly they may well have received a letter advising them to 'shield'. Latest guidance says that practices will need to contact these patients to discuss their circumstances.
What should practices do for vulnerable patients?
According to the latest SOP (dated 5 April), practices should:
- Ensure the situation is clearly flagged in the patient's record.
- Review patients' care plans, adapting them where needed or appropriate, including undertaking any essential follow-up. This should be done remotely where possible.
- Help patients receive their medicine supplies regularly by helping them to arrange electronic repeat dispensing and enlisting the support of local resource (this could be co-ordinated through your social prescribing link worker or equivalent) and voluntary sector partners to collect and deliver.
- Speak to patients (remotely where possible) who have an urgent medical question relating to their health and/or pre-existing condition (they may also need to contact their specialist consultant directly).
- Liaise with local community health services to review patients receiving mental health or learning disability support who may need additional help or support.
The latest SOP advises that these patients should be dealt with remotely wherever possible. However, if they need to be seen face-to-face they should have a home visit.
The SOP recommends that local areas set up separate home visiting services for these patients for when they do need a face-to-face appointment. They shouldn't attend the surgery. Strict infection control processes should be employed when visiting these patients.
How patients can access support
All people in the highest clinically vulnerable group should register at https://www.gov.uk/coronavirus-extremely-vulnerable. If someone does not have access to the internet, refer them to the phone line in the letter. This means that they will gain access to food and medicine deliveries, although support is initially being focused on people who have no other means of getting food and medicine.
The NHS is also providing further support to those at highest clinical risk via the Goodsam App and NHS Volunteer Responders. Any health professional or local authority can refer people who require assistance. Referrals can be made via the NHS Volunteer Responders portal here https://goodsamapp.org/NHSreferrals
Local government is also working with the voluntary sector to set up local support systems for vulnerable and at-risk groups, which includes support for those feeling isolated.
There is not a government dedicated food and medicine delivery service to those outside the shielding group. However, people who have significant care needs not already addressed and or that family/carers can't provide should seek help from their local authority.
- Guidance on vulnerable patients for GP practices - including letters for patients
- FAQ for clinicians
- Latest standard operating procedure (dated 5 April)
- Government advice for patients who are shielding
- FAQs for patients