If test and trace is to succeed, a centralised approach won’t work

9 Oct

Despite being initially hailed as the main way to manage Covid-19, test and trace has proven something of a nightmare for the Government. From technological flaws in its contact tracing app, to u-turns on whether to use Apple and Google’s technology, the papers have been filled with negative stories about progress in this area.

Perhaps it could be said that this week has provided the biggest headache so far for ministers, beginning with the news that 16,000 people who tested positive for Covid-19 between September 25 and October 2 disappeared from official records in England.

This was reportedly due to Public Health England (PHE) using an outdated version of Microsoft Excel to process data. The spreadsheet could only handle a limited amount of information, hence why so many contacts were missed.

The result is that there are potentially tens of thousands of infectious people who have not been contacted; indeed, NHS Test and Trace apparently had to track down an estimated 40,000 Covid-19 cases.

Matters were made worse by the fact that Ring Central, NHS Test and Trace’s call system, allegedly failed to work too – locking workers out of their profiles for prolonged periods.

As if that wasn’t troublesome enough, yesterday it was shown that NHS Test and Trace contact rate figures have reached their lowest rate yet, with 68.6 per cent of close contacts of individuals who’d tested positive for Covid-19 in England reached in the week ending September 30 (the system needs to reach 80 per cent of contacts in order to be considered viable). 

Furthermore, it was shown that fewer than one in four people testing positive for Covid-19 receive their results in 24 hours – a far cry from Boris Johnson’s initial pledge that, by the end of June, results of all in-person tests would be back within that timeframe.

With all of these events, the Government can look forward to even harsher criticisms from Keir Starmer and the opposition on testing, which has repeatedly been called a “shambles”.

No doubt many members of the public, too, are wondering how many more of these problems are to come in test and trace; whether the strategy will ever work, and what it means for their livelihoods in the meantime. So what exactly has gone wrong?

Several hypotheses have been put forward to explain the repeated weaknesses in the contact tracing system.

The first, straightforward one is that the Government simply did not plan enough for a pandemic. Whereas countries like South Korea were able to deploy pre-existing infrastructure for contact tracing, the Government started from scratch – creating NHS Test and Trace, which has had to “learn” on the job.

Even more significantly, NHS Test and Trace highlights an instinct of the Government that has run throughout this crisis; its tendency to create large-scale, centralised solutions to managing Covid-19, rather than utilising existing systems (one of the main examples being its initial desire to build a centralised contact tracing app – instead of going with Apple and Google’s technology).

Many will remember Dido Harding announcing of NHS Test and Trace at its inception: “This is a brand new service which has been launched at incredible speed and scale.” But it is this speed and scale that might explain why there have been so many issues – as rushing something out of this complexity in a pandemic represents huge logistical challenges.

It could be said that the Government has missed a trick by not tapping into local teams and networks to carry out processes such as contact tracing. This is why Germany, Italy and much of Asia have got ahead, using large-scale local investment and resources to do contact tracing.

And indeed, when England started to switch to using local contact tracers, it made a massive difference to success rates. In the week to September 30, for example, these teams were able to reach 97.1 per cent of contacts, much higher than NHS Test and Trace’s rate of 68.6 per cent (done via online messaging or phone calls).

The added advantage of local teams is that they can help ensure compliance in those contacted, some of whom may want to avoid call centres – wary that a number beginning 0300 could mean a tracing team is getting in touch.

It’s not only that devolving responsibilities can enhance the tracing process, but decentralisation can boost testing too – which smaller labs in universities and the private sector initially offered to help the Government with. Instead, it has mostly relied upon PHE labs and NHS trusts to carry out this work.

While the Government should be praised for how quickly it managed to scale up testing, there have been problems with laboratories being too slow to process results (allegedly as a result of over-reliance on post-graduate science students to analyse lab results, who were only there over summer), and incompatibilities between systems – both of which might have been addressed with a more decentralised approach, and flexibility about which labs were used.

Robert Buckland, Secretary of State for Justice, since said that the Government would open 100 more test centres, including a “mega lab” on the way to enhance capacity.

But maybe this brings us back to the initial point – that the Government’s quest for new systems, as opposed to tapping into local and/ or existing solutions, might ultimately hold it back in accelerating testing. Instead of devolving powers, the Government’s instinct has always been to take more responsibility.

Will there be a change to the direction the Government is going in? The shift to using more contact tracing teams is certainly promising – and should be built upon, but given the amount of money, energy and investment that has gone into Test and Trace – along with the Government’s recent plan to merge PHE and NHS Test and Trace into the new “National Institute for Health Protection” – centralisation seems one area it is reticent to u-turn on.

Andrew Gimson’s PMQs sketch: Puritans try to smash Johnson’s images

23 Sep

Planet Fact takes on Planet Freedom. Sir Keir Starmer’s questions are evidence-based, utilitarian, grown-up, serious and underlain by the conviction that this is the only moral way to do politics.

Boris Johnson’s answers are imaginative, irreverent, disdainful of inconvenient facts and underlain by the conviction that this is the only tolerable way to do politics.

Sir Keir gives us the world as it is. Johnson responds with the world as we might wish it to be.

The Leader of the Opposition pointed out a clear contradiction between the Prime Minister’s declaration three months ago that “test and trace can be a real game-changer for us”, and Johnson’s statement yesterday of the “complete opposite”, with test and trace able to contribute “very little or nothing”.

“Which one is it?” the ruler of Planet Fact demanded.

The ruler of Planet Freedom declined to engage with this pedantry.

Sir Keir, in his sternest tone, said that “pretending there isn’t a problem is part of the problem, Prime Minister,” and posed another either/or question: did the PM agree with “the Dido Harding defence” of the problem with track and trace (not enough capacity) or “the Matt Hancock defence” (too many people applying for tests who don’t need them)?

No Cavalier could allow such an insult from a Roundhead to a damsel in distress to pass unavenged, and Johnson’s sword leapt from his scabbard: “The continual attacks by the Opposition on Dido Harding are unseemly and unjustified.”

What we want to see, Johnson went on, “is more of the spirit of togetherness that we had yesterday”, instead of this constant knocking from the sidelines.

Starmer was stung. He pointed out that his wife, mother and sister all work or worked for the NHS. He would take no lectures from the PM on the subject.

Ian Blackford, for the SNP, said the Scots did not want Johnson to put his arms round them.

Johnson: “I can imagine that he doesn’t want a hug from me…that was a metaphor.”

On Planet Freedom, the use of imagery is regarded as delightful, while literal fact is ignored.

Puritans are enraged by this, and want to smash Johnson’s images. Their difficulty is that as they do so, they sound a bit self-righteous, and may even find the images are quite widely venerated.

With NHS Test and Trace repeatedly failing to meet targets, confidence in the Government’s tracing strategy is faltering

8 Sep

From the beginning of the Coronavirus crisis, contact tracing has been hailed as the main way for countries to get back to normal. The World Health Organization says this strategy can “break the chains of transmission”, and many watched in awe as South Korea successfully delivered its programme. The Government has since been under a huge amount of pressure to get its own system up and running.

The UK process

Although there are different programmes in the UK, they all follow roughly the same idea. If someone comes into contact (defined as being within two metres for more than 15 minutes) with another person who has Covid-19, they will be notified by their respective health authority (or a phone app, in the case of Northern Ireland) to self-isolate for 14 days. They must then stay at home for 14 days while avoiding others, even those that they live with.

NHS Test and Trace (England) advises that if the person gets symptoms of Covid-19, they should take a test as soon as possible, and anyone they live with must self-isolate until the result comes back. Even if they test negative, they must keep self-isolating for the rest of the 14 days, but those they live with can stop if they don’t have symptoms. If they test positive they must self-isolate for at least 10 days from when their symptoms started, and anyone they live with must self-isolate for 14 days.

Local teams

Some of these systems are facilitated by local contact tracing teams. Scotland’s Test and Protect scheme uses these, for instance, as well as having a National Contact Tracing Service to identify close contacts of an infected person.

And while England originally relied on thousands of call centre workers to carry out tracing, it has since switched approach after it was found that local teams could trace 98 per cent of contacts (compared to 56.1 per cent for call centres). These staff members can knock on people’s doors to obtain close contacts’ information.

Success rates

As with much of the Covid-19 crisis, there have been different results across different regions. The Government has come under huge criticism, however, over two things. 

The first is that its contact tracing app didn’t work (all the while 300,000 users have downloaded Northern Ireland’s). It originally wanted to run a centralised app – something tech experts warned would cause problems, and they were proven right; hence the Government is having to rehaul its initial plan.

The second area of pressure for NHS Test and Trace is its inability to meet a target of 80 per cent for finding close contacts (of those who’ve tested positive for Covid-19). New figures show, in fact, that only 69.4 per cent of contacts were reached (down from 77.1 per cent the previous week). As The Huffington Post points out, it’s the tenth week running that the target has been missed.

The Welsh government’s Test Trace Protect programme, on the other hand, showed that out of 237 positive cases that were eligible for a follow-up, 228 (96 per cent) were reached and asked to provide details of their recent contacts (in the week of August 23 to 29). 

When quizzed about the figures, Dido Harding, who heads NHS Test and Trace, said that “we reach 80 per cent of all contacts we have information for”. In other words, the lower figure is because some people haven’t provided details for their close contacts.

Interestingly, The Telegraph recently found that a third of cafes and restaurants are failing to obtain customers’ contact details, so it’s worth bearing in mind that compliance is a big factor, as not everyone is on board with the process.

And perhaps this problem is amplified in countries with bigger populations. Indeed, differences between sample sizes may skew the percentages reached, with some of Wales’s statistics taken from 4,610 people, versus 31,388 for England. Even with bigger teams of contact tracers, they are dealing with enormous numbers of people.

To bolster track and trace, the Government is investing £500 million in increasing testing capacity. Using a range of pilot schemes, it will expand its network of testing sites and invest in new technologies to reach even more people.

This should help things substantially, as one issue that has been identified is regional imbalances in the availability of track and trace. There have been reports of people being directed to centres over 100 miles away to get tested, and one article suggests that the system failed to reach over half of contacts in Hackney and the City of London since it was introduced (compared to other boroughs such as Merton, where 73 per cent of close contacts were reached).

Whether health officials can get up to their target of 80 per cent remains to be seen, and pressure on the Government is only going to ramp up. But the area it will be most criticised over is its contact tracing app, which is currently in trials. With Northern Ireland having a degree of success with its own, and Scotland set to use the same technology, it will only lead to more questions of why ministers cannot get the NHS Test and Trace app moving faster too.

Luke Evans: My Coronavirus report from near the Leicester lockdown front line

1 Jul

Dr Luke Evans is a member of the Health Select Committee, and is MP for Bosworth.

As I sit down to write this week’s column I hope that you will excuse it’s slightly erratic nature and its stream of consciousness tone. Forgive me.

As a Leicestershire MP, the last 48 hours have been taken over by the news of the Government’s local lockdown of Leicester and, at first, considering the approach which should be taken should any of my own Bosworth constituency be included in the lockdown area; and subsequently what steps we may have to take locally now we know that we are not.

Over the weekend, rumours started circulating in the media that ‘Leicester’ might become subject to the first localised lockdown since the imposition of Coronavirus legislation. There is a cluster of outbreaks – which must be taken seriously.

Like many cities, ‘Leicester’ is quite difficult to accurately define. Did rumours relate solely to the local government area that is the ‘City of Leicester’, or could it include the suburbs which stretch out towards the rural areas which are covered by Leicestershire County Council’s jurisdiction, and of course the constituencies of our seven Conservative MPs?

I set out on Monday morning to do my due diligence by speaking with regional public health leads, our chief constable and the chair of our local resilience forum, to get the actual facts on the ground.

During the day, it became increasing clear that a local lockdown would be imposed imminently, and I was invited to a Zoom call with other Leicestershire MPs, the elected Mayor of Leicester, the Leader of the County Council, Dido Harding, senior leaders in Public Health England and Nadine Dorries, the Health Minister.

During the course of that conversation, it became quickly apparent that the data is worrying enough in Leicester to make a local lockdown was inevitable; with an R rate stubbornly stuck at one, it was clear that, unless something was done now, this outbreak could get considerably out of hand…and quickly. To be safe, lockdown would include parts of the county – potentially including my own constituency.

Although incidents of Coronavirus are showing a marked national trend downwards, it is obvious that this isn’t the case in parts of Leicester. Nationally, for every 100 people tested for Covid-19 – that is those displaying symptoms –  two receive positive tests; in Leicester, that figure increases to ten.

Leicester now accounts for 10 per cent of Covid-19 admissions nationally and, crucially, the trend is not downwards.

Clearly, it is important that we understand why the trends in Leicester are so different from the national ones. The health specialists were in agreement that it is not due to the national release of lockdown (otherwise you would expect hot spots popping up all across the country), so something else must be going on.

At this point, the uptick appears multifactorial, and plenty of work is going on to establish categorically what these factors are, but right now our focus is much more about practicalities and what to do.

How do we guarantee health safety, effective enforcement of lockdown, protecting businesses and support for livelihoods? How do we communicate all of this to the public, preventing spread and make best use of shared working?

Questions like these all immediately sprung to mind, and were evidently shared by all fellow MPs on the call.

Post-meeting, it was straight onto a statement from the Health Secretary, and then my first step was to speak with members of my team with a plan, followed by courtesy calls to councillors whose wards and divisions were likely to be affected and local leaders.

I’m very conscious that an MP never works on their own, and I very much rely on my team and local activists. I said in my maiden speech that healthcare taught me that “empowering those who can and helping those who can’t” is critical; this situation ably demonstrated this again.

In the wake of the Secretary of State’s statement, as you might expect, calls continued well into the night.

Yesterday morning started with a very early meeting with the Health Minister and Leicestershire MPs to digest the news, update and then talk about practicalities.

As Tuesday progressed, further questions come to forefront.

With worried residents, particularly those living in the city commuter belt, it would have been preferable if a map of the lockdown area had been produced far quicker than it actually was. There are many questions about how we can prevent those living in the lockdown area from visiting areas, including my own, where restrictions are being lifted this weekend.

Government was clear it was for local decision makers to decide the extent of the boundary, given that they are best placed to know natural geography, and how communities function in real life not just on a map. (The map is not the territory coming through here from last week!)

Ultimately, I see my role as being that of an honest broker in a fluid situation. I’m determined not to put information out because I want to be first with the news, but rather believe it is best to wait until updates are properly verified.

Instead, what are the worries of my constituents both regarding their safety and their livelihoods? My job is to do my best to secure both.

Over the course of yesterday, I had further meetings and calls with officials from the Department of Health, Home Office, Treasury and local leaders from the police, council and LRF, to name but a few.

Like any emergency situation faced, you want to deliver clear, accurate information, even if that maybe no further news, that is an imperative.

The situation reminds me of my early days as an A&E doctor. The relatives of a very sick patient will always want updates quickly, yet medical uncertainty about how the patient will respond is difficult, added to which the demands of my bosses might be altogether different; but at the end of the day you can lay out what you know, what you are doing and why, and how you expect the poorly person to respond.

The outbreak in Leicester city is no different….now we have two weeks to watch for signs of response, and I will continue to be communicating them to my constituents, working with all the teams involved to get the best outcome; a safe time to return the easing of lockdown.