Intended for healthcare professionals

Letters Respectful disagreement

Respectful disagreement: the covid-19 shielding list

BMJ 2021; 372 doi: (Published 09 February 2021) Cite this as: BMJ 2021;372:n382
  1. Anthony N Williams, consultant occupational physician
  1. Working Fit, PO Box 389, Temple Ewell CT16 9BF, UK
  1. tonywilliams{at}

Salisbury acknowledges the challenges GPs have had regarding “respectful disagreement” with covid-19 policy and guidance.1 An important example is shielding. GPs are expected to assist government in identifying those who should shield, in line with guidelines produced in mid-March 2020. Neither “vulnerability” nor “extreme vulnerability” were ever defined on the basis of evidence of a specific threshold of risk. Emerging evidence does not support many conditions listed as warranting shielding.23

Thus, the largest group on the current shielding list is patients taking immune suppressant drugs. Evidence shows a relative risk of around 1.2 for these patients, compared with a relative risk of 1.8 for being male.4 On the other hand, evidence has consistently shown age to be the major factor.56 There is no evidence that the extremely vulnerable list is materially any different from the vulnerable list: at age 55, the relative risk for solid organ cancer in the past year is 5.2, organ transplant 6.4, and type 1 diabetes 8.7.7 The data clearly show that the most vulnerable are the old, with multiple comorbidities, particularly diabetes, heart disease, and respiratory disease.89 Evidence shows that most patients on the extremely vulnerable list do not become extremely vulnerable until they are in their 70s and 80s. This suggests that around one and a half million patients are shielding unnecessarily.

The government has consistently stressed the importance of shielding, using the same list from March 2020 with minor adjustments. Shielding is a draconian process, with substantial impact on mental health, income, and on the economy generally. Clinicians can only reasonably advise patients if the guidance is evidence based. The current approach is fundamentally flawed and should be replaced by evidence based criteria such as QCovid10 for public health policy and covid age11 for occupational health.


  • Competing interests: ANW is chairman of the Association of Local Authority Medical Advisers (ALAMA) and project director of the ALAMA covid age project.

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