Last week we saw a lot of publicity about the expansion in numbers of individuals whom the NHS has advised to shield. From the 2.2 million contacted last March the list grew by a further 1.7million last week. This large increase came about because many more people had been identified as having a high risk of hospitalisation if they were to catch Covid.
This has important immediate implications for these people and their necessity to look after themselves, but even more importantly it has medium and long-term implications for the way in which the NHS provides care for people at high risk of ill health.
The aim of this post is to explore the longer-term potential for this work to improve health care outputs and outcomes.
But first I want to celebrate this epidemiological work itself.
In March 2020, for the original 2.2 million seen as extremely vulnerable, the letter advising them to shield came out of the blue. It was a list very speedily drawn up from the knowledge the NHS had at hand and aimed – probably quite successfully – at giving strong advice about protective behaviour. Most of the people I know that received letters understood and complied. Others – who didn’t receive them – were puzzled as to why they hadn’t and many shielded anyway – especially during the first lockdown.
Back in March 2020 we didn’t really know much about the virus. We didn’t know about differential infection or mortality rates. Since it was a virus it seemed that having a poor immune system could be dangerous – a good reason for being on the list.
Every month we learned more about risk factors. Early on, since the virus had an appalling impact on your breathing, it became clear that respiratory prior conditions would have an impact on mortality. Within a few weeks it appeared that obesity was an issue, and then in the summer black and minority ethnic people showed significantly higher morbidity and mortality.
Part of me wanted this increasing knowledge to lead to running updates to the extremely vulnerable list but that didn’t happen – and with hindsight it was right that it didn’t. Changing the list every month would have degraded its impact. Updating it after 11 months was the right thing to do.
Last week we saw the results of 11 months’ work from Oxford University to combine all the knowledge we had into a single algorithm indicating the levels of risk of being hospitalised by the virus. It was this knowledge that led to the significant addition of 1.7 million individuals.
Like the development of the vaccine this has been carried out at breakneck speed. A previous algorithm on the risk of cardiovascular disease took 10 years to develop.
This Covid tool (QCovid) was commissioned by Chris Whitty from a team at Oxford University and took into account a multiplicity of health conditions and circumstances that increase people’s likelihood of death from Covid.
This was based on health record data from more than 8 million people during the first wave of the epidemic. All of us know that this data is there, but, along with so many other things, it is the national crisis has taught us that the NHS needs to use it.
My main point today is that once this data has been used, the concept of using data to inform individuals about health risks it cannot be unthought. This project demonstrates that we know how to use data to develop a clear risk analysis – and then – and this is the crucial part –how to act upon it.
Recent years have seen the NHS talk a great deal about population health management (aka PHM). (My main intervention in this debate has been to change the phrase to managing the health of the population. What is important here is the active management of health – not the data on its own.)
It’s great to have the data. But it only matters if you actually do some health care management with it.
So what happened last week? As a result of this algorithm, all of these newly identified people received a letter from their GP suggesting they should shield until at least 31 March.
We are acting on the data. Not just by working out – with a clever bit of maths – that many black people in Newham are at higher risk than those in Surrey – but by then enabling their GPs to actually tell individual patients that because of their higher risk they need to do something.
So your GP is strongly suggesting that if you get such a letter you should radically change your behaviour. And it is quite likely that most of those 1.7 million individuals now being told they are at high risk will in fact change their behaviour.
Let’s consider what this means for the future.
This is all based on the premise that if your GP proactively contacts you about your health care risks, you might change your behaviour. It depends upon you trusting the warning letter the GP has sent you.
Every GP now knows which of the patients on their list are at higher risk of serious illness from Covid. And they don’t retain that knowledge in the surgery, they proactively inform their patients.
Set this alongside our experience of the vaccination programme – where GPs have been texting and ringing their patients asking them to get appointments for the vaccine. Up until now that has been about age but now it will also be about long-term conditions. This process now demonstrates a close understanding of personal issues and health risks by practices and acting on that knowledge, intervening to invite individuals for a medical input – the vaccination.
In the past primary care mainly waited until we referred ourselves to ‘see the doctor’. It was up to us to be active and for them to sit and wait.
Now in two crucial areas they have demonstrated that they can proactively contact us about health risks.
The chair of the BMA council Dr Chaand Nagpaul said the BMA has “long highlighted the fact that people from ethnic minority backgrounds, especially with underlying conditions are at high risk of death from Covid 19 and that those from poorer areas are also twice as likely to die from this terrible disease”.
Given the way in which primary care has now shown its capacity to inform patients about health care risks, and the BMA’s emphasis on better health care outputs and health outcomes for black and minority ethnic patients – we can expect, post Covid a much more proactive primary care.
Next time I will suggest how the BMA can work with GP colleagues to encourage proactive primary care that will in turn improve race health equality.
 Vaccines, and now algorithms. Scientists – when freed – can work at incredible speed to reach results that can save lives. I hope that this is one of a set of freedoms that lockdown will teach us forever