Dear fellow or member,

Working with the Chief Medical Officer and the Academy of Medical Royal Colleges (AoMRC), we are writing to explain plans for identifying patients in secondary care who are at the highest risk of severe morbidity and mortality from coronavirus (COVID-19). These patients will be asked to consider undertaking highly restrictive social isolation measures for a period of 12 weeks.

On Monday 16 March the UK government announced a package of measures, advising those who are or may be at increased risk of severe illness of COVID-19 to be particularly stringent in following social distancing measures.

There is a subset of this group that is at significant risk of increased morbidity or mortality from COVID-19. This group has therefore been recommended to undertake shielding measures for their own protection. Expert consensus has suggested that this group should not exceed 1.5 million nationally and across specialties.

In order to be effective, these people would have to undergo strict social isolation with no contact from the outside world beyond that absolutely necessary, for a period of at least 12 weeks, a move which will significantly impact quality of life, increase social isolation, and would not be without its own attendant physical and mental health risks.

Working with the Chief Medical Officer and the AoMRC, we have identified and contacted the vast majority of this group, which has involved difficult clinical judgements about inclusion. There are a limited number of people we can shield effectively or for whom this highly socially isolating measure would be proportionate on health grounds, and many patients who fulfil the criteria may prefer not to be placed under such strict isolation for what will be a prolonged period.

A full breakdown of the groups that are being identified and contacted is set out in Appendix 1.

Further patients to be identified and contacted by all relevant medical specialties

Many of you will already be considering high risk groups as part of your planning to the response. Trusts will shortly receive a list of patients who have been contacted by NHS England using national databases (Group 1 patients) and for whom there is an open episode of secondary care. Colleagues in dermatology, gastroenterology, hepatology, neurology, respiratory, renal and rheumatology will identify a further cohort of immunosuppressed patients.

There may be other patients who you consider to be at the highest risk of death or severe morbidity, but not identified within the existing groups and for whom complete social isolation at home for 12 weeks is a proportionate response to that risk. If you do identify additional patients we ask you to:

• Contact them directly with a copy of the letter attached. Please bear in mind the overall target of identifying 1.5m people across all medical specialties.
• Let the patient’s GP know you have included them in the vulnerable group.

Please note, the group identified for highly restrictive social isolation for their own protection is a subset of those already identified to the public. This wider group, who broadly speaking meet the criteria of adults eligible for an annual flu vaccine (17.96 million individuals), will not be proactively contacted but have instead been asked to take steps to reduce their social interactions in order to reduce the transmission of coronavirus.

Communication with patients

Using the group identification approach, there is a risk that some patients may be identified and contacted by more than one route and therefore receive the same letter twice. We have accepted this risk as preferable to the risk of missing at-risk patients.

Some patients may wish to discuss the letter with you, and if this is the case we suggest the following principles guide your discussion with them:

• The recommendation for shielding the very high-risk group is just that, and we ask that your discussion with patients reflect this.
• Some patients may decide, on weighing up the risks that they would prefer not to follow the restrictive, stringent measures. We ask that you help your patients to work through this if they wish to.
• We also suggest that anybody with a terminal diagnosis who is thought to be in their last six months of life should be excluded from this group (unless they wish to be included), to allow them to maintain contact with their loved ones during the last phase of their illness.

We would greatly appreciate it if you could you please now work with colleagues in your departments to identify the highest risk patients in your caseload and contact them with the letter attached, as well as letting the GP know of your action.

Yours sincerely,

Professor Derek Alderson
President, Royal College of Surgeons of England

Appendix 1: Groups of high risk patients

Group 1

To be identified and contacted by NHS England

A key group of vulnerable individuals has been identified by expert consensus, who can be identified and contacted directly by NHS England using national datasets. This group will receive letters from 23 March:

1. Solid organ transplant recipients

2. People with specific cancers

• 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.

3. People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe COPD

4. People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as SCID, homozygous sickle cell disease)

5. People on immunosuppression therapies sufficient to significantly increase risk of infection

6. People who are pregnant with significant heart disease, congenital or acquired

Group 2

To be identified and contacted by specific medical subspecialties

We have taken a two-pronged approach to identification of the majority of medical patients on immunosuppression therapies sufficient to significantly increase the risk of infection (Group 1, Category 5). All patients on the following medications have been centrally identified and will be contacted via the NHS England letter:

• Azathioprine
• Mycophenolate (both types)
• Cyclosporin
• Sirolimus
• Tacrolimus

Central datasets are not sophisticated enough to identify all patients on immunosuppression medication, as they cannot reliably identify patients taking biologic drugs. For this reason, the Royal College of Physicians and associated medical societies will contact six specialties with very specific guidance about identification of patients on immunosuppression therapies who are at among the very highest risk. These specialists will be asked to identify such patients from their caseload and contact the patients with a version of the standard inclusion letter which Group 1 will receive directly from NHS England. They will also be asked to contact the patient’s GP to let them know of the inclusion of the affected patients in the vulnerable group.

Group 3

To be identified and contacted by all other relevant medical specialties

As detailed in the letter above. We have issued a template letter (download, .docx) to help with this.

Group 4

To be identified and contacted by primary care

There will be vulnerable patients who are well known to primary care, particularly the frail elderly with multi-morbidity, who may not be known to secondary care. GPs will be asked to identify such patients from their own lists and to include them in the vulnerable group for shielding.