The journey: NHS Test and Trace

INSIGHT –

As at 04 November 2020, over 1 million people in England have tested positive for SARS-CoV-2, with more than 37,000 confirmed deaths. While there is currently no approved vaccine, testing for Covid-19 to identify possible close contacts of those who test positive, and asking those close contacts to isolate, remains a critical task to help prevent further spread.

NHS Test and Trace is England’s Covid-19 contact tracing programme. It was launched on 28 May and is a central part of the government’s Covid-19 recovery strategy. The Prime Minister has pledged to deliver a ‘world-beating system’. Despite this, since it was introduced, the programme has been repeatedly criticised for consistently failing to meet expectations.

The Test and Trace programme is a £10bn national cross-government programme chaired by Baroness Dido Harding. The programme has four objectives:

  1. Increase the availability and speed of testing
  2. Identify possible close contacts of those who test positive, and asking those close contacts to isolate
  3. Rapidly identify and contain outbreaks
  4. Enable government to learn about infection rates and respond appropriately

To deliver these objectives, NHS Test and Trace originally intended to deliver widespread Covid testing alongside contact tracing based on online notifications, telephone-based contact tracers, a smartphone app, and partnerships with local authority public health teams. Difficulties have arisen at each stage of the programme’s development and it continues to see performance issues.

In the early stages of the pandemic around 1,500 tests per day were being processed. Capacity for further testing was largely limited, partly by the Public Health England (PHE) laboratory infrastructure that was designed to give quality assurance and specialist microbiology testing rather than testing en masse. Further complications arose when the virus was classified as a category 3 pathogen, meaning laboratories had to implement very stringent safety measures at pace. This limited testing to containment level 3 laboratories, most of which are operated by PHE. In early March, procedures were developed to allow testing to be carried out in containment level 2 laboratories.

On 12th March, testing of community cases ceased due to limitations in the testing capacity. Following this, testing capacity was initially increased through NHS England laboratory services but the number of tests that could be processed remained limited, in part due to a shortage of the testing materials and reagents needed. In early April, the government outlined its five-pillar strategy for increasing testing across the country, including an ambition to conduct 100,000 tests per day by the end of April.

  • Pillar 1: Increase NHS swab testing for those with a medical need and the most critical key workers, using NHS and Public Health England laboratory facilities
  • Pillar 2: Mass swab testing for critical key workers in the NHS, social care and other sectors using new facilities often based on commercial partnerships with the private sector
  • Pillar 3: Mass antibody testing to determine immunity
  • Pillar 4: Surveillance testing to learn more about the disease and to help develop new tests and treatments
  • Pillar 5: Develop a national effort for diagnostics to build large scale and long-term mass-testing capacity

The increase in testing capacity included setting up three new lighthouse laboratories in Milton Keynes, Alderley Park and Glasgow, and forming partnerships with pharmaceutical and diagnostic companies to allow for testing of frontline NHS staff. By 15th April, there was enough capacity for the government to expand testing to all symptomatic care home residents and staff – this included family members of staff with symptoms and all patients being discharged from hospital into care homes.

On 28th April, the expansion of armed forces-led mobile testing units saw the start of a roll-out programme of testing for:

  • Residents and staff in care homes for people with dementia or aged older than 65 years, with or without symptoms
  • Those older than 65 years with symptoms and any symptomatic household members
  • Symptomatic workers unable to work from home, alongside their symptomatic family members.

By 18th May, eligibility for testing under pillar 2 had expanded to include anyone with symptoms.

On 1st May, the Secretary of State for Health and Social Care announced that the government had achieved its goal of carrying out 100,000 tests per day, with 122,347 tests ‘made available’ across the UK on 30th April. This included 83,143 tests across pillars 1 and 2 processed by laboratories, as well as tests posted to private homes and care homes that were not necessarily completed. By this stage, the description of pillar 1 and pillar 2 test had been updated to:

  • Pillar 1 tests – those carried out in hospitals or as part of managing outbreaks
  • Pillar 2 tests – those available to the wider public

The challenges facing the national NHS Test and Trace programme include:

  1. Covid-19 is difficult to control because of how readily the virus can be transmitted. Without interventions such as lockdowns or social distancing, it is estimated that each infected person would, on average, infect a further 3.8 individuals
  2. For the Test and Trace programme to work effectively, people must follow the guidance on isolation, there must be widespread awareness, trust, and use of the system which has been underpinned by routine public messaging and PSAs
  3. The Test and Trace infrastructure in England at the start of the pandemic quickly became overwhelmed with the number of Covid-19 cases and the effort required to trace close contacts. This has eased with the introduction of additional private sector-led laboratories and use of the wider PHE laboratory network.

What next?

As winter takes hold, the government needs to consider how to increase the number of contacts it reaches, and to rapidly learn from the test and trace journey thus far. Further measures have included the public messaging campaigns around flu vaccinations and the second national lockdown enforced from 05th November.

For NHSTT to improve its performance, case identification has to improve. Despite the huge efforts to increase test capacity over the past 6 months, much work still needs to be done. Improving reach in respect of close contacts of positive cases is pivotal to preventing further spread and enforcing self-isolation.

Far more is needed to protect and support the social care sector. Social care teams and vulnerable adults receiving care have been disproportionately impacted by Covid-19. Ongoing delays to the introduction of routine testing of all care home and community care staff and service users, not to mention some providers receiving used testing kits, suggests that the social care sector is still not receiving the attention in so desperately needs.

Conclusion

The challenges with implementing an entirely new national programme should not be underestimated. Over a half a million tests are now being conducted every week in England alone, and over 10,000 cases and 40,000 contacts are being reached each week by a system that was established as quickly as the virus spread globally.

But it is not yet the world-beating contact tracing programme that was promised and significant scope for improvement remains. As cases continue to rise and until an effective vaccination programme is in place, a well-functioning test and trace system is increasingly urgent for keeping schools and businesses open, and to effectively target support and resources to those most in need.