Each patient on my morning phone list has a note explaining what they are calling about. Usually they’re a broad mix of medical and social issues, but for the last week or two they have been dominated by descriptions such as “calling about shielding letter”, “wants to know if she is vulnerable” and “needs shielding letter for work”.
Shielding is a public health measure that aims to protect the most vulnerable, who would be at the highest risk of complications from COVID-19. This group are strongly advised not to leave the house at all until the end of June at the time of writing, and even social distance from the people they live with.
It’s quite a big deal to ask people to stay at home at all times, and has possible consequences for their physical and mental health. We need to be careful that only those who are at the highest risk are asked to shield.
Unfortunately, there has been much confusion about who should shield, with a recent apology from NHS England about how the process has been handled. There was also an admission from charity Asthma UK that there had been confusion about who should be shielding.
What is the relevance of this for pharmacists? It is likely that some patients may ask you if they need to shield. Sometimes you won’t be able to answer this question, as you will not have a full enough knowledge of their history. However, there are some patients who you can reassure don’t need to shield.
I have taken what seems like hundreds of phone calls from patients with asthma wanting to know if they should shield and the answer is almost always "no", as it is only a tiny fraction who meet the shielding criteria.
According to NHS England, “severe asthmatics” who need to shield are both:
- Taking a long-acting beta agonist or leukotriene receptor antagonists
- Received four or more prescriptions for prednisolone between July and December 2019.
This will largely be those on regular oral prednisolone, or those who are so unstable that they have regular exacerbations needing oral steroids. This will not apply to many patients.
There are a few other indications of severity, for example those taking biologic drugs such as omalizumab, according to the British Thoracic Society.
If an asthmatic patient asks you whether they should shield and they are on inhalers only, with no regular steroids, are not under secondary care and have never been in intensive care due to their asthma, then you can safely reassure them that they aren’t in the shielding group.
Similarly, for patients with chronic obstructive pulmonary disease (COPD), it is only those who recently received three medicines – a long-acting beta agonist, a long-acting muscarinic antagonists and an inhaled corticosteroid – or roflumilast who need to shield, not everyone with COPD.
Other patients who should shield include:
- Organ transplant recipients
- Patients with specific cancers, such as those with lung cancer undoing radical radiotherapy
- Patients who are immunocompromised
- Pregnant women with significant heart disease
- Patients who are on dialysis.
This list is not exhaustive, and some patients with other conditions will be told to shield by their consultants. If a patient has received a shielding letter from their consultant and isn’t sure whether it is correct, you could tell them to ring their consultant’s secretary, or clinical nurse specialist, rather than their GP.
For other patients on the list above it would be sensible to refer the patient to their GP to check as there are nuances, for example not all of those on drugs such as methotrexate need to shield. There are various guidelines available for checking about drugs that cause immunosuppression, such as those on the British Society for Rheumatology website.
There are clearly many vulnerable patients who aren’t on this list. They fall into a group at moderate risk of severe illness from COVID-19 that essentially includes anyone who is 70 or over or would normally be offered an NHS flu vaccination but does not fall into the shielding group.
This moderate risk group should carry out stringent social distancing, staying at home as much as possible, but do not need to shield. If you want to know more about shielding there is a short Royal College of General Practitioners module on the subject, which is regularly updated.
Toni Hazell is a GP based in London
Listen to Ms Hazell discusss this topic in a podcast: