‘This disease is still killing people – we are now around where we were just before lockdown and we are seeing significant outbreaks in countries such as Germany where lockdown has been released.’
Ask Justin Varney, director of public health for Birmingham, why an adequate test-and-trace system is important, particularly with no vaccine available, and the answers are as clear as politicians often wish theirs are; this virus has not gone away, another wave of infection varying from manageable to catastrophic is likely and with another wave could come a further entrenchment of inequalities in society.
Until early June there was no comprehensive, functioning test-and-trace system running across the UK. In the early days of the pandemic, local public health teams – decimated by austerity – had attempted to keep pace with numbers but soon ran out of capacity.
And even in those areas of the country where local relationships and access to university facilities meant continuation was possible, a lack of lab capacity, far more available in Germany for example, hindered progress and national strategy was lacking.
Perhaps most damningly of all, successive Governments have been accused of having made a choice not to have the capacity to deal with this sort of pandemic.
Speaking to The Doctor, the former health secretary and now chair of the Commons health and social care select committee Jeremy Hunt says: ‘The main mistake was that we focused our preparation on pandemic flu rather than a SARS-like virus, all our thinking was geared to the way flu-type viruses behave – that there was no need to increase PPE [personal protective equipment] stocks or testing capacity.
‘I think that was where the mistake was during the period I was health secretary. I think in terms of test and trace the evidence from all over the world shows the more localised the approach, the more successful – in Germany the corona detectives and the role of local government in Korea, it’s highly localised.
‘We chose not to have that capacity because our mindset was a flu pandemic where the virus spreads so quickly that after a certain level of transmission you don’t try to isolate people any more and you accept that. It was contain, delay and mitigate and that is not the approach Korea, Singapore or Germany took.’
But these decisions were not the only problems contributing to a failure to test and trace to suppress infection and manage this pandemic. The 2012 Health and Social Care Act split public health from the NHS and left it in local authorities vulnerable to massive spending cuts and decimating capacity and expertise for exactly this sort of situation.
Public health medicine consultant and BMA public health committee member Penelope Toff says: ‘Over several years there has been decreased local and public health laboratory capacity and increased fragmentation in the public health system, so that although at the beginning of this pandemic there was contact tracing going on, by the middle of March the numbers of cases were just too high for that to be a feasible approach at the scale required.
‘What we heard from the Government was, “that’s the phase we were in and now we’ve moved on to the next one” but the reality is that most of the countries which have dealt very much better with COVID-19, continued to do contact tracing at the necessary scale to make it successful, along with other measures like self-isolation and social distancing.’
In a turn of events that would be welcome if the circumstances were not so tragic, the Government has pumped around £300m into local public health teams to do their part in test and trace and crisis planning. In Birmingham that equates to around £8m – which comes after several years of cuts totalling £5m in Dr Varney’s team.
Most of the countries which have dealt better with COVID-19, continued to do contact tracingDr Toff
But money alone isn’t enough. As Professor Jim McManus, vice president of the Association of Directors of Public Health, wrote recently: ‘While the additional funding of £300m for local councils is welcome, delivering these plans will require much more than money – a fully operational NHS test-and-trace service, high-quality and timely data flows, the right levels of capacity in all parts of local government and the health and care system, and strong national impetus to promote the public health messages that we all know save lives.’
The Government has publicly made test and trace a priority – as Professor McManus has stated it should be. In England the idea is that if you develop coronavirus symptoms and test positive for the disease you will be contacted and asked to log on to a website where personal details, places you have visited and names of those you have been in contact with should be submitted. Close contacts will then be contacted and told to stay at home for 14 days, even if they don’t have symptoms. The Government has suggested the scheme will be ‘world beating’.
Yet even now with test and trace at the top of the Government’s strategy – easing lockdown and paying for adverts on people’s television sets about the importance of the project – this is a process beset with problems. The first two weeks of statistics made available suggest at least a third of people are not providing their contacts to contact tracers and the ‘NHS’ test-and-trace system in England only reached around 10 per cent of the people the Office for National Statistics calculated were infected.
Not only that but much of the process has been contracted out to private firm Serco in a multimillion-pound deal – and professionals on the ground are reporting a lack of transparency and delays in receiving test results.
BMA deputy council chair David Wrigley says: ‘It just makes doctors sigh with disbelief that you can struggle to deliver successfully on previous contracts but then be handed further deals at such an important time. It beggars belief that this is continuing when you could utilise NHS staff, NHS services and NHS laboratories to do this work.’
Dr Toff adds: ‘We don’t need to reinvent the wheel – we don’t need to use the private sector for public health capacity simply because there hasn’t been sufficient investment in what we have in the public sector. The expertise and knowledge of how to control outbreaks and stop them spreading and becoming epidemics is there in local authority public health with support from PHE health protection units but it has not been adequately used and resourced. Furthermore, the expertise of those on the ground with this experience was not input into government plans from the beginning.’
Rupert Soames, chief executive of Serco, told the press his firm’s work in setting up the test-and-trace system was ‘extraordinary’ amid suggestions the contract should be cancelled.
Private sector reliance
The Government in England’s approach to dealing with the pandemic has relied on the private sector in many areas – a contract of undisclosed value was secured by Deloitte, one of the ‘big four’ consultancy firms, to set up and manage a network of 50 off-site testing centres.
The firm is responsible for managing logistics across these sites as well as booking tests, sending samples to laboratories and communicating test results. Deloitte nominated companies such as Serco, Sodexo, Mitie, G4S and Boots to staff and manage the day-to-day running of the testing sites and those unable to access the testing sites are advised to request home-testing kits that are produced and processed by diagnostics company Randox and dispatched by Amazon.
A network of ‘lighthouse’ laboratories was established by the Government to process the test samples. And Deloitte was handed further responsibility for coordinating these labs, located in Milton Keynes, Glasgow, Belfast and Cheshire.
A fifth lab is managed by Cambridge University and the pharmaceutical companies GlaxoSmithKline and AstraZeneca. These labs were designed to cope with testing on a mass scale, processing 75,000 tests of the Government’s 100,000 target.
There has been decreased capacity and increased fragmentation in the public health systemDr Toff
Meanwhile, 44 NHS labs were, according to a former senior figure at the World Health Organisation, Anthony Costello, left ‘underused’, clinical staff in the NHS were concerned that the development of a parallel system encouraged competition in supplies and reagents required – effectively reducing the capacity of existing NHS labs – and it was also reported that in the early stages of the pandemic, leading scientific centres such as the Francis Crick Institute and Oxford University offered their expertise and resources (such as PCR machines and trained personnel) to help increase testing capacity, but these offers were ignored.
Mr Hunt told The Doctor he had no problem with the ‘ideology’ of contracting private firms but felt a more localised approach and utilising available expertise might have been more helpful.
He says: ‘I think you would have some of these coordination issues regardless, but local authorities know their areas extremely well and can coordinate the testing and the tracing part of the programme much more easily if things are more highly localised. I have always wondered whether we should have involved local authorities earlier, with a more strategic process.’
The expertise and knowledge of how to control outbreaks and stop them becoming epidemics is thereDr Toff
And doctors and public health leaders have told The Doctor they face difficulties in delays of test results, a significant lack of data availability and regular communication failures between Serco, Public Health England nationally and local teams.
There are concerns about a lack of transparency, too. At a hearing of the health and social care committee in June Baroness Dido Harding, chair of NHS Improvement and NHS England and the Government’s test and trace tsar – smiling – repeatedly told the committee figures for how the process was going were not yet available or validated. The Doctor asked Mr Hunt what Baroness Harding’s approach said of the Government’s in general.
Mr Hunt says: ‘I do think if there was more transparency from the outset we would have had a more effective national response. The best example of that is the secrecy around SAGE – we didn’t know who the members of SAGE were or what advice was being given at the start of the crisis. And it is clear some of the advice was wrong.
‘In January SAGE was giving two options of either extreme lockdown or herd immunity with shielding for the vulnerable – they didn’t model track and trace and I think we may see that as a major oversight. But none of us knew it wasn’t being modelled because it was all kept secret. This should have been run in public like the way the Bank of England is and how the monetary committee vote, for example. If we had that transparency around SAGE, scientists up and down the country would have been able to scrutinise what they were saying.’
The problems run even deeper. The Government has planned for a contact-tracing app that can enable digital contact tracing on a much larger scale to be the centrepiece of its project. It was first announced on 5 May but has since been deemed flawed, and a new version does not appear likely to arrive for some months.
This is concerning for two reasons. In addition to reducing burden on those individuals employed to carry out ‘face-to-face’ contact tracing, digital contact tracing is a crucial tool for stemming any potential spread though interactions in pubs, restaurants, shops and on public transport where contact details are not readily available.
Moreover, digital contact tracing is better able to distinguish the type of interaction that takes place between two individuals, measuring proximity and length of interaction, thereby reducing the margin of error inherent in asking somebody to remember who they have seen and the nature of each interaction.
Some small pockets around the country have had success though – largely by acting quickly and with relative independence from national policy makers and their central command and control strategy.
If there was more transparency from the outset we would have had a more effective national responseJeremy hunt
The Shetland Isles to the far north-east of the Scottish mainland were one of the worst hit areas in the early days of the pandemic – and quick-thinking local experts acted swiftly to enforce a local lockdown and introduce a speedy test-and-trace system, with people drafted in from various NHS departments to phone around and tell people to self-isolate if required. Cases dropped very quickly and the virus has been quiet since.
Dylan Murphy is lead GP at the Lerwick Health Centre in Shetland. He says: ‘We had an early cluster of cases before social distancing was a thing – and before there was any testing. There was quite a lot of work at that point and we rapidly set up teams to respond.
‘We were quite reactive – I remember the schools up here, for instance, shut a week before they did anywhere else and similarly in primary care we were having discussions saying we’ve looked ahead of the curve and need to make decisions. We would be more proactive saying you shouldn’t be going out in public with these symptoms.’
Nipped in the bud
A rural part of Wales, Ceredigion, also had success with its own reactive measures. An initial flurry of cases in this coastal county led to the local authority taking action – setting up a ‘homemade’ and in-house test, track and trace system.
Speaking to Wales Online, the man responsible for the system, the local authority’s corporate director Barry Rees, feared slow reactions and slow test results would mean an increase in the spreading of the virus. He said: ‘We short-circuited that loop and didn’t wait for their test results to come back before taking action.
We were able to send a note down to our contact-tracing team to gather more information. If they’re showing symptoms then there’s almost the presumption of a positive test and that guides the advice we give to them.’
More recently, in Scotland, a system called NHS test and Protect is now in place. Between 28 May and 7 June 2020, 741 contacts were traced from 681 positive tests for the virus – an average of 1.5 contacts per case. Northern Ireland was the first part of the UK to bring in contact tracing. Contact tracing started in Wales on 1 June and is called ‘test, trace, protect’.
It seems that with the will and the local expertise, test and trace can be achieved in small pockets where local efforts are led by local experts – and there may be lessons from the Government to learn from this.
Frankly, the lessons for the Government look likely to be forming quite a long list: a lack of preparation for this sort of pandemic; an unwillingness to quickly strengthen public health teams decimated by cuts; a continued reliance on private companies; and little action on the fragmentation of services are all issues which are slowing progress. Add on top of that poor messaging and communication and it is little wonder the UK’s statistics around this pandemic look among the world’s worst.
Empower local areas
Regardless of the failures, test and trace continues to be of vital importance – for public health and in returning to a more normal society. So what should be done?
For Dr Toff the issues are clear: data and resources must be made freely available to those working on the ground, the turnaround of test results needs to be quicker and public messaging about the continuing risks made much more prominent in government messaging.
And for Dr Toff and public health professionals around the country, the empowering of local areas is key too. Few know their local populations as well as public health specialists embedded in those communities – it’s challenging to understand why prioritising a centralised approach was thought to be a sensible idea.
For Dr Varney there are a number of other crucial areas, too. COVID ‘pre-hab’, or the education of people who could be susceptible to the virus and helping them to make the best decisions to keep themselves safe is crucial. And, perhaps most of all, public health teams now in local governments need the support, backing and confidence to do their jobs.
He says: ‘The public health grant that funds me and my team is due to run out at the end of March 2021 so there is no certainty to our future at all – the Government needs to make a clear statement that the money we have been given for this process is part of the baseline of the grant for the next three years so we have security for the future in this COVID world.’
And – as crucially as anything – urgent action on the inequalities this disease highlights is needed, with test and trace in place to protect as much as possible.
He says: ‘We need a very honest discussion about the inequalities within society and substantial efforts on the living wage and tackling racism and discrimination. It can be done – but we have to stop talking about inequalities like they are an interesting topic and consider them to be a crisis such as climate change that we have to turn around.’
At the time of The Doctor going to press local outbreak plans were being finalised across the country with directors of public health drawing up their responses to further waves of infection. In Birmingham, Dr Varney’s team is ready to surge from 22 to 70 people and a massive project of community engagement is already unfolding. Doctors and experts across the country will be hoping their efforts mean any further wave comes under the manageable category, rather than the catastrophic.