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Should we shield? Caring for the most vulnerable during the pandemic

RCP Deputy Registrar Dr Sonia Panchal shares her thoughts on shielding patients most at risk from COVID-19.

Where we were

Shielding was back in the spotlight earlier this month when the government amended the policy in England and Wales, which has kept more than two million of the most clinically vulnerable people inside their homes since March.

Suddenly, having been told to avoid any face to face contact for 12 weeks (until 30 June), these people were allowed to go outside once a day, either alone or with members of their household, whilst adhering to social distancing rules. However, that was not, and neither should it be, the end of shielding. A few days after the UK government’s announcement, the Chief Medical Officer for Wales announced a further extension to the shielding policy. We wait to hear from the other countries of the UK and the Prime Minister has promised that we will hear soon what the Department of Health and Social Care’s thinking is for England as lockdown measures are relaxed.

Shielding was initially conceived for use in the mitigation phase (phase 4) of the UK’s pandemic response, then as a way of ‘flattening the curve’ when it quickly became apparent that the NHS would not cope with the expected number of COVID-19 cases, based on what we were seeing in other countries. Shielding would help lessen the risk to those, including the immuno-suppressed, most at risk of contracting COVID-19 and most likely to suffer the worst outcomes. It is not compulsory and comes with attendant risks for mental and physical health.

The vulnerable were categorised into groups, identified through coding and central databases and contacted directly via NHS digital with advice to shield. Of the order of 908,000 patients, many under the care of physicians, initially received letters and text messages advising them to shield. Further granular data from general practice data sets increased the shielded population to 1.3 million in total.

Immunocompromised patients made up a large number of the group yet were difficult to identify centrally because their drugs were prescribed in secondary care or due to limitations of datasets. The RCP worked with specialty societies – the British Association of Dermatologists, British Society for Rheumatology, Renal Association, British Society of Gastroenterology, Association of British Neurologists and British Thoracic Society  to develop risk stratification tools to help categorise these immunocompromised patients into high, moderate and low risk based on disease activity, immunosuppressive medications and comorbidities. High risk patients were advised to shield, superseding government recommendations. While the four countries of the UK took slightly different approaches, these were accepted across the UK. Other specialities also identified other high-risk patients who were added to the central shielding database.

The implementation of the shielding policy proved challenging with limited evidence and data to support risk assessment for GPs and secondary care clinicians. This, coupled with poor communication and inconsistent messaging from DHSC, NHS digital and NHSE/I, led to duplication of workload, difficult conversations when de-shielding or shielding patients not initially advised to and confusion for patients.

As increasing age is an independent risk factor for the virus, all over 70s were advised to shield to protect them against the virus and complications, leading to reduced physical activity. This in turn can lead to further health related complications and therefore further risk assessment need be applied.

Through these challenges, we now have 2.2 million of the population shielding. Many are healthcare professionals – including 3% of our members according to a recent survey – so, despite the effort to design methods to protect the NHS, inadvertently this also has a negative impact on NHS services.

Where we are now

As we near the end of the initial 12 week period of shielding and our understanding of what makes people vulnerable to the effects of COVID-19 improves, we need to be more flexible in our decisions as to whether a patient should shield or not. With the relaxation of lockdown, we need to refine our definition of shielding and what that means to an individual based on risk profile, taking into account other parameters shown to impact susceptibility to COVID-19 including age, gender, BAME and comorbidities as well as take into consideration the negative impacts of social isolation and patient wishes.

Many questions are being asked of patients and healthcare professionals. The curve has flattened so the pressure on the NHS has reduced, but what does it mean for clinical risk? What does it mean if I want to go back to work? What happens next? Is my risk the same, increased or reduced? Does it change as lockdown relaxes further? What we know is that shielding for individuals has mental, psychological, physical and economic impact and therefore clear risk assessment is required to enable shared decision-making between healthcare professionals and the patients.

Where we would like to be

As physicians, we are used to managing risk and uncertainty with our patients. Is COVID-19 any different, apart from its speed and scale? We know, for example that using a drug to treat one condition, does not have the same impact, risk or benefit for another condition, so adhering to guidelines solely focusing on a single  disease or medication is unlikely to be as accurate as we need to be now. A consistent approach would be welcomed by all, providing  the ability to individualise care and discussion on a case by case basis, taking into account risk factors for susceptibility to COVID-19.

We are now aware that age has the biggest effect, with old age making individuals most vulnerable. Medical conditions, sex, BMI and ethnicity play a smaller but significant role. Many risk assessment tools have been created, to assess how vulnerable someone is to COVID-19. One example based on age as a main risk factor is an evidence-based approach using ‘COVID-age’. This tool provides an individual with a COVID-age based on weighting risk factors to determine their vulnerability. What that means in terms of clinical risk and shielding is yet to be determined. There is also the opportunity to leverage the records of the NHS to use a big data approach to develop algorithms to help individualise risk which should be the start point of the conversation with our patients. Such risk profiling will also enable a more sophisticated and equitable approach to population vaccination and medicines to treat COVID-19 as they become available, along with a nuanced approach to risk mitigation if and when a second surge occurs. We now know that children are at much lower risk than originally thought.

The government plans to publish updated advice  later this month to signal the approach to the next phase of the shielding process. From our recent experiences, it is clear that one size does not fit all and we need to continue to gather further evidence and insights  to help support  national and speciality level planning. However, with limited current data available and continued uncertainties, should we not exercise our usual approach to healthcare and provide individualised care plans appropriate to each patient in a shared decision-making process? We need clear, consistent and aligned messaging from the government to help ensure we provide consistent communication to our patients to help assess their risk benefit profile.