Those who have been self-shielding or on the NHS shielding list fear their support will vanish, leaving them at heightened risk for a second peak

The threat to those most clinically vulnerable was communicated from the beginning of the covid-19 pandemic. As the virus spread, clinicians and patients with underlying health conditions harboured increasing anxieties around the risks, but no validated risk assessment existed. On 16th March, the UK Government advised those deemed to be at increased risk to follow stringent social distancing measures, and a subset, believed to have the highest risk of mortality and severe morbidity, were identified and sent an NHS letter to “shield” for at least 12 weeks. 

The initial shielding instruction was very clear: “Stay in your house, do not attend any gatherings, strictly avoid contact with those displaying symptoms.” [1] While it has been recently updated, the messages remain clear and concise. [2] Being on the shielding list brought relief of anxiety and allowed these people to access additional support. It was widely welcomed as a measure to avoid the NHS being overwhelmed. Doors closed, the shield went up and just a few days later the country went into lockdown. 

But then the clear messaging ended. A significant proportion of those in the larger group have been unable to understand what the exact guidance has been for them. A poll by the charity Independent Age found 43% of those over 65 believed the instruction to those over 70, with no underlying health condition was to shield, with only 30% identifying the correct advice for this group. [3] Problems with the distribution of shielding letters led to further confusion and anxiety around who fell into which group. [4] As the pandemic peaked, anxiety levels rose in the population and people welcomed the protective advice to those advised to shield. 

As lockdown eases towards the “new normal”, many younger people seem to have rapidly abandoned social distancing. [5] Those who have been self-shielding or on the NHS shielding list fear their support will vanish, leaving them at heightened risk for a second peak. [6]   

Government guidance has told those who have shielded to maintain social distancing, but day to day life has changed dramatically. Unlike other members of the general public, those who are shielding may be less familiar with the new one-way systems or etiquette that are embedding into normality. Their anxiety is not just around leaving their home, but also how to maintain the 2-metre social distancing that decreases risk. If shielding no longer applies, support may diminish, just as the general public relax infection control measures, further heightening their concerns of contracting covid-19 in the community. [6,7] 

Those returning to frontline healthcare have particular worries, as ONS data shows the risk of acquiring covid-19 in hospital is between four and six times that in the community. [8] Without herd immunity or a vaccine there is no easy answer. Clinicians urgently need enough high-protection personal protective equipment, preferably recyclable, to allow vulnerable staff to lower their shields while helping them hold it high enough to feel safe.

Those at higher risk need people to be kind, understanding, and allow them extra space, in public and in their workspaces. Those shielding are in all age groups, not only older people. Many have invisible vulnerabilities. You cannot tell them apart from the professional athlete they are stood beside—they could even be that professional athlete. So how can we help those we can’t easily identify?

People generally want to be considerate of others. But they need prompts. Employers can support working from home more. Colleagues can recognise the psychological impact of prolonged isolation and provide companionship in safe ways. Some have welcomed the suggestion of an easily recognised lapel badge in the shape of a shield that simply says “safer at 2m”, which could be worn, or a facemask to use when out with the same easily identified symbol on it. These suggestions may help society to function at negligible cost.

Helen Iliff, Anaesthetics Core Trainee; Department of Anaesthesia and Critical Care, Prince Charles Hospital, Cwm Taf Morgannwg UHB and Bevan exemplar, Wales. Twitter: @iliff_helen

Ilora Finlay, Baroness Finlay of Llandaff, House of Lords, Westminster SW1A 0PW and Bevan Commissioner Wales.

Competing interests: None declared. 

References:

1. Guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19. Public Health England. 18 May 2020. https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19 (accessed 20/05/2020)
2. Guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19. Public Health England. 05 June 2020. https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19 (accessed 17/06/2020)
3. Independent Age calls for clarity in government’s COVID-19 messaging to over-70s ahead of lockdown easing. 29 May 2020  https://www.independentage.org/news-media/press-releases/independent-age-calls-for-clarity-governments-covid-19-messaging-to-over (accessed 21/06/2020)
4. Dunhill L. “Abysmal” communication blamed for variations in self-isolation list. Health Service Journal. 12 June 2020. https://www.hsj.co.uk/coronavirus/abysmal-communication-blamed-for-variations-in-self-isolation-list/7027814.article?adredir=1  (accessed 21/06/2020)
5. Coronavirus and the social impacts on Great Britain: 19 June 2020. Office for National Statistics. 19 June 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/bulletins/coronavirusandthesocialimpactsongreatbritain/19june2020 (accessed 21/06/2020)
6. Coronavirus and shielding of clinically extremely vulnerable people in England: 28 May to 3 June 2020. Office for National Statistics. 15 June 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronavirusandshieldingofclinicallyextremelyvulnerablepeopleinengland/28mayto3june2020 (accessed 21/06/2020)
7. Coronavirus and anxiety, Great Britain: 3 April 2020 to 10 May 2020. Office for National Statistics. 15 June 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/coronavirusandanxietygreatbritain/3april2020to10may2020 (accessed: 21/06/2020)
8. Chappell D, Mythen M, Cook TM. COVID 19|Black and minority ethnic (BAME) death rates – update from the UK. TopMedTalk. 14 June 2020. https://www.topmedtalk.com/covid-19-black-and-minority-ethnic-bame-death-rates-update-from-the-uk/ (accessed 21/06/2020)