Managing individual and population risk from covid-19BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2098 (Published 01 June 2020) Cite this as: BMJ 2020;369:m2098
All rapid responses
Bradley and colleagues shine an important light on the potential consequences of a failure to manage risk effectively during the COVID-19 pandemic.  Our experience suggests that they are right to worry about the risk of reputational harm to the National Health Service (NHS) and damage to trust between patients and professionals.
In the UK, digital tools have played a prominent role in identifying ‘clinically vulnerable’ patients at high risk of severe COVID-19.  The algorithms underpinning these tools have cast a wide net so that vulnerable patients aren’t overlooked. However, given the stark social and psychological consequences of shielding, this must be balanced against the need for accuracy. Digital tools producing shielding lists must also be responsive to professional feedback and improve clinical workflow.
On clinical review, at one West London general practice, 66% of patients on a shielding list received from NHS Digital in early May did not require shielding. These patients had already received letters or text messages informing them of the need to shield. While it would have taken just 6 hours to review the accuracy of the list, telephone discussions with patients wrongly told to shield took around 23 hours of clinician time. General practitioners (GPs) may be concerned about the medicolegal consequences of removing patients from shielding lists, and this could lead to unnecessary retention of patients whose individual risk is scarcely greater than the population average. As a patient, could you trust NHS services again if you had wrongly been told that you needed to shield?
A rapid, centralized and data-driven approach to identifying and notifying clinically vulnerable patients of the need to shield may have saved lives at the start of the outbreak. However, as the crisis evolves, we must not bypass GPs and specialists. Local digital tools, such as the Whole Systems Integrated Care COVID-19 ‘shielding radar’,  add to NHS Digital lists by providing clinicians with useful contextual information, such as a patient’s purported reason for shielding and deficits in care planning. With shielding guidelines likely to change over time, a simple change in process could enhance clinician workflow and prevent confusion and anxiety in patients wrongly told to shield: notify clinicians first!
1. Bradley SH, Kirby E, Wheatstone P. Managing individual and population risk from covid-19. BMJ 2020; 369 doi: 10.1136/bmj.m2098
2. NHS Digital. COVID-19 – high risk shielded patient list identification methodology. Available at https://digital.nhs.uk/coronavirus/shielded-patient-list/methodology
[Accessed 16 June 2020]
3. North West London Collaboration of Clinical Commissioning Groups. WSIC Response to COVID-19. Available at: https://www.healthiernorthwestlondon.nhs.uk/news-resources/information-s... [Accessed 16 June 2020]
Competing interests: CC’s work is supported by a grant from the Imperial Health Charity. MW is the co-founder of Connecting Care for Children, and integrated child health model in North West London. NT declares no competing interests.
The WHO designates 2020 as the “Year of Nurses” to coincide with the 200th anniversary of Florence Nightingale's birth. (The Nurse has contributed enormously to the health of the world.) Graffiti artist Banksy appreciated the work being carried out in the United Kingdom by health professionals to combat the COVID-19 pandemic by dedicating a new mural to them, at Southampton General Hospital (England), showing a child holding a superhero nurse toy. All of them, I do not think they want to be remembered as heroines, but they are recognized as Super Nurse Nurses. All of them would fall unconscious with the health management of Donald Trump or the headlines of the New York Times announcing the loss of 100,000 Americans at the hands of COVID-19, more typical of the era of nurses who carried out their work during World War II (1939 -1945).
On May 12, worldwide is celebrated the International Day of Nursing, on this date the birth of Florence Nightingale (Italy) is celebrated, who dedicated her entire life to caring for the sick. She was the pioneer of the current training of the nursing professional, founding in 1860 the first School of Nursing in London. We also owe to it the precedent and the foundations on which the organization and the current healthcare system are based in England and in many other countries. During the Crimean War (1884), she organized, under the harshest conditions, the nursing service on the front, which made her a popular heroine and she received the Order of Merit from King Edward VII for the first time given to a woman. Florence Nightingale, an example of struggle and vocation, died on August 14, 1910, laid the foundations for the professionalization of the Nurse with the foundation of the School of Nursing at Saint Thomas Hospital in London (1860). Although it was believed that as this 2020 is the International Year of the Nurse and Midwife, a series of activities and programs would be held with the aim of making visible the great work and work of these professionals.
Without a doubt this year this celebration will be at least different, and why not, more special than ever. It has had to be a pandemic and a strong health crisis that has revalued their work and their great contribution in our society and in the health system. They are not superheroes, they are real people with real needs, who have decided, based on their professional training, to care for those who are suffering and who need them, the sick. Nurses are putting not only their health and their own lives at risk, but also that of their relatives and close people. And despite the risk, nurses in our country and around the world are still in their jobs, they have not relaxed for a single moment. Not only do they continue to respond to the current social demand, but they have increased their efforts and dedication to do so. In these moments of uncertainty, tension, pain, suffering and death ... and despite the risk, they continue to work. Without them little could be done in hospitals, or in the health system in general, their work is essential. Hopefully one day they can take a few moments to receive the social and professional recognition they so deserve.
Currently, in many countries, nurses are still forced to emigrate, reinvent themselves in order to qualify for a decent job and fair professional recognition, a situation that is even more incomprehensible today. Nowadays and in most of the world, nurses continue working to obtain the recognition they deserve at a social level and also before other professional groups. In the current context, there are still abysmal differences between her recent consideration of heroines and the low public recognition that the work of so many nurses has. Unfortunately none of this is new. It is necessary that nurses are systematically included in decision-making on health issues in an exercise of responsibility and that decent working and salary conditions are guaranteed to correct the real and current situation that many nurses still live. In this pandemic they have been able to demonstrate that they are necessary and essential, without using their voice, they have done it by demonstrating it with their dedication, their work, their sacrifice and above all for their professionalism. They have not stopped working to complain, they have understood that this was the stage of sacrifice, effort and responsibility ... and that the stage of demand should be postponed and wait. We should not wait for a health crisis to take care of and recognize the work of our nurses, but we should always take care of them so that they can face and overcome themselves in this and in the following and future crises.
Competing interests: No competing interests