The plan set out by the Westminster government for dealing with Covid-19 made it plain that there was no prospect of a return to normality until vaccines and effective anti-viral treatments became available:
“It is clear that the only feasible long-term solution lies with a vaccine or drug-based treatment”,
while at the same time acknowledging this may never happen:
“A mass vaccine or treatment may be more than a year away. Indeed, in a worst-case scenario, we may never find a vaccine . . . . as vaccines and treatment become available, we will move to another new phase, where we will learn to live with COVID-19 for the longer term without it dominating our lives”.
The government focus was therefore only to:
“ . . . enact measures that have the largest effect on controlling the epidemic but the lowest health, economic and social cost . .”
hoping that:
“ . . . rolling out effective treatments and/or a vaccine will allow us to move to a phase where the effect of the virus can be reduced to manageable levels,
begging the question – what might this look like in practice? The answer was that we would have to live with a background level of new infections and deaths; surges in cases and reintroduction of lockdowns; public transport, schools, pubs and restaurants all operating at limited capacity; a huge rise in unemployment; considerable disruption to all areas of life.
Rather than seeing mass testing and contact tracing together with current non-pharmacological interventions as a powerful package of Public Health interventions that could effectively suppress the virus, ‘test and trace’ was presented as something that offered only a limited prospect of success, such that it:
“may allow us to relax some social restrictions faster by targeting more precisely the suppression of transmission”
In fact, illustrating just how seriously government took the issue of ‘Test & Trace’, Johnson used the colourful analogy of the arcade game ‘Whack-A-Mole’, where plastic moles pop up at random from each of five holes and the player forces them back down by hitting them directly on the head with a mallet. His score has been predictably low, with the initial proportion of contacts of new cases being reached of only 25%. Almost six months later it is still nowhere near the 80% recommend by the government’s own Scientific Advisory Group for Emergencies (SAGE). In addition, while it is imperative that test results are available quickly so that cases can be isolated, and their contacts notified within 48-72 hours, by September less than a third of test results were available in 24 hours. Lack of adequate financial support for many workers and the inability to isolate within overcrowded homes further undermined the effectiveness of contact tracing measures and require immediate attention. The financial disincentive for many contacts to self isolate is recognised as a huge issue even by conservative MPs.
Government fails to meet its own goals
Back in May, the government listed the following as essential to any effective infection control system:
- widespread swab testing with rapid turn-around time, digitally-enabled to order the test and securely receive the result
- local authority public health services to bring a valuable local dimension to testing, contact tracing and support to people who need to self-isolate
- automated, app-based contact-tracing through the new NHS COVID-19 app to (anonymously) alert users when they have been in close contact with someone identified as having been infected
- online and phone-based contact tracing, staffed by health professionals and call handlers
Nearly six months later, it can be argued that none of these requirements have been realised and some still seem but distant aspirations. There continue to be major problems with communication of results, while government misinformation exaggerating the extent of testing earned a rebuke from the Royal Statistical Society. Local authority public health services have been marginalised despite their expertise in contact tracing through communicable diseases and environmental health teams. £300 million was made available to support new test and trace services locally, but this amounted to an average of only around £870k for each council.
Hancock’s Half App
Mobile phone apps are part of the modern epidemiologist’s armamentarium in the fight against infectious disease. South Korea has had one of the lowest case mortality rates in the world and together with widespread testing also employed mobile phone technology to track peoples movements. Early on in lockdown, Health Secretary Matt Hancock heavily promoted a UK home grown mobile phone app, saying it would be crucial in getting “our liberty back” and suggesting the public had a “duty” to download once available. The app, installed on a smart phone, would be designed to automatically track when users come into contact with each other, using Bluetooth technology. If someone using the app disclosed that they had developed COVID-19 symptoms, this would trigger an anonymous alert to anyone they had recently been in contact with, providing they were also using the app. This would prompt testing and self isolation, and if enough people were to use it (>60% of the population) and follow public health advice, it was expected to bring about a reduction in infections.
The security of the app was quickly challenged, and journalists reported development was being dogged by problems including a data-hungry approach, an attempt to defy Apple and Google, intra-agency bickering and a problematic test run on the Isle of Wight. The app used a centralised model, meaning that the data was not just kept on an individual’s phone, but collected centrally by government, unlike most other European countries – such as Germany, Italy and Ireland – where a more privacy-protecting decentralised model was chosen. The UK approach was heavily criticised by Amnesty International among other organisations, and lack of trust seemed guaranteed to reduce its appeal among the public.
The deadline for being rolled out in mid-May passed quietly, and in June, the app was downgraded to only ‘the cherry on the cake’ – no longer a key part of the contact tracing strategy. On 18th June, after £12 million spent on technology that experts had repeatedly warned would not work, it was made clear that the project had finally been abandoned. Despite data on the Isle of Wight trials never being made public, a new app for smart phones has now been launched. This will alert users to level of coronavirus risk in their district; allow scanning in at venues to see if they could have been exposed to infection; check symptoms; book a free test and get results; and count down time to end of self isolation. However, one expert remarked:
“Unless you can get testing and return on testing down to about three days, then the app isn’t going to do anything useful. It’s not a magic bullet.”
While originally it was suggested at least 60% of the population would need to download, but no figure is now put on this.
‘NHS’ Test & Trace
‘NHS Test and Trace’ is not in fact ‘NHS’ but an outsourced service provided to the National Health Service in England, established in May 2020 to track and help prevent the spread of COVID-19. It is part of the National Institute for Health Protection; the service and the institute are both headed by Baroness Dido Harding. The service provides temporary sites where samples are taken from individuals, processes the samples at a newly created network of laboratories, and communicates the results.
Dido Harding is a businesswoman, who in 2017 was drafted into NHS Improvement despite having no credentials in healthcare, and then misleadingly described by the prime minister as a “senior NHS executive”. Harding was severely criticised when, as chief executive officer of mobile phone company TalkTalk, there was a major data breach involving the personal and banking details of around 4 million customers. She has been described as one of the elite club of chief executives who consistently manages to fail upwards. Her other roles include being a director of the Jockey Club which runs the Cheltenham racecourse and attracted 250,000 people to the Cheltenham Festival only days before the long overdue lockdown was imposed. She is married to John Penrose, a Conservative MP who sits on the advisory board of the think tank “1828”. According to The Mirror newspaper, 1828 argues for the NHS to be replaced by an insurance system and called for Public Health England to be scrapped.
One of the lucrative contracts for contact tracing was given to Serco, a company that had just been fined £1m for failures on another government contract. In no time at all Serco had its own data breach, inadvertently revealing the email addresses of new employees. The junior health minister, Edward Argar, happens to be a former Serco lobbyist and the company’s chief executive is Rupert Soames, grandson of Winston Churchill. Serco’s long history of misdemeanours in relation to public sector contracts is well documented in a ‘must read’ article published in the Lowdown. Even when the contract tracing was awarded in early June, optimistic NHS officials didn’t expect the scheme to be fully operational until September or October. A leaked email from Soames revealed that he anticipated the contract would cement the position of the private sector in the NHS supply chain.
Early data on Serco’s record with ‘Test & Trace’ showed that only a woefully inadequate 25% of contacts were identified compared with the 80% target. A poll also showed that involvement of the private sector in contact tracing undermined public confidence, with 40% of those surveyed saying this made them less likely to hand over private data. How undocumented migrants can be brought into the system when they are worried about bills they cannot afford to pay and falling foul of the Home Office is a further challenge. Looking at both the disastrous app saga and the knee jerk outsourcing of contact tracing to Serco, it is difficult not to ask whether systems have in fact been designed to fail and ‘herd immunity’ somehow remains at the heart of government thinking. Such a philosophy is closely linked to the ‘let the old die and the young get on with it’ school of thought, roundly condemned by Professor Gabriel Scally of the Independent SAGE committee.
An alternative view: Independent SAGE
An effective COVID‐19 ‘Test & Trace’ programme is absolutely essential to the struggle to contain coronavirus infection. Independent SAGE (ISAGE) prefers to refer to ‘Find, Test, Trace, Isolate and Support’ (FTTIS) rather than ‘Test and Trace’, since this unites all the essential features of the system. FTTIS is indispensible for economic recovery, protecting livelihoods and securing longer‐term wellbeing and health provision. It is worth reiterating some of the early ISAGE key recommendations:
- LOCAL: To be effective FTTIS must be led locally, coordinated by Directors of Public Health, using both the Local Authority and NHS including health commissioners, primary care, local hospital laboratories, school nurses and environmental health officers.
- TRUST: The success of a FTTIS system is based on trust, requiring accountability mechanisms and effective community engagement.
- DATA: FTTIS findings must be embedded within existing NHS, local authority and Public Health England data structures, with rapid access to enable local response. It is important to ensure governance and safeguards for privacy and data misuse, and any supporting apps must be implemented within such a framework.
- ISOLATE and SUPPORT: This is critical if reduction in infection spread is to be realised. There must be facilities available for such isolation, material support including food and finance, and appropriate guarantees from employers, to ensure that those in isolation are not disadvantaged.
- KEY PERFORMANCE INDICATORS (KPI): A set of key performance indicators should be reported weekly, including data that are timely, relevant, and useful to support local decision‐making.
The same report also argues that if current restrictions are to be relaxed:
“ . . we must try to find every new case, test them, trace their contacts, and then ask the new case and their contacts to isolate for 2 weeks to prevent further spread, with the support they need to continue with their lives in these new circumstances. We must go beyond a narrow response of simply testing people suspected of being infected and tracing their contacts, which is implied by the Westminster government’s use of the term “test and trace”.
“If COVID-19 is to be eliminated, as New Zealand has shown is possible, then at least 80% of all close contacts of someone with COVID-19 infection must remain isolated for 14 days so that they are unable to pass on infection to others . . . . We argue that the current government approach to what is called Test and Trace is severely constrained by lack of coordination, lack of trust, lack of evidence of utility, and centralisation, such that achieving the goal of isolating 80% of close contacts is impossible.”
Careless contracts cost lives – bring public health back into public hands
The privatised ‘Test and Trace’ system, far from being ‘world beating’ is clearly failing. It has been set up not as part of the NHS, but in parallel:
“ . . . as a network of commercial, privatised testing labs, drive-through centres and call centres. The chaos this has brought has resulted in huge gaps in information available to local services, causing delays in accessing results and hampering efforts to control the outbreak. Instead of putting local public health experts and NHS services in charge of contact tracing, the health secretary, Matt Hancock, handed over responsibility to private companies such as the outsourcing giant Serco . .”
In addition to the huge undisclosed contracts given to Serco and Sitel for contact tracing, Deloitte operate testing sites where people can be swabbed. Other private firms involved with testing include Sodexo, Boots, G4S, Levy, Randox and Amazon. Community (Pillar 2) samples are analysed by the four new “lighthouse” labs, which involve pharmaceutical companies AstraZeneca and GlaxoSmithKline. Randox analyses the samples from its home test kits, with a contract for £133m (compare this with the £86.9m provided to Public Health England for infectious disease surveillance and outbreak management in 2018-19).
Never slow to profit from weaknesses in the national system, accountancy firms are also making profit out of the pandemic. McKinsey was paid £563k to review ‘Test and Trace’ future governance, while Deloitte is now involved in selling separate contact-tracing services directly to local authority health officials in the UK. Sitel have recently been criticised for lack of training given to NHS 111 call handlers where errors in advising symptomatic patients may have resulted in severe harm. Even a government minister has objected to the £92 million spent on covid-related work by management consultants. What is needed is an end to all this outsourcing and for local authorities, NHS, and public health laboratories to be sufficiently resourced to take the lead on contact tracing and testing, with general practices being resourced to support patients, and all under central coordination. Meanwhile the government, unable to get the basics right, fantasises about operation Moonshot involving 10 millions tests a day at a cost of £100bn. The Moonshot documents give no evidence of any careful analysis of the benefits, harms, and opportunity cost of a mass testing approach and planning does not appear to have included relevant medical experts.
Learning from other countries and starting again
In Ireland, a group of over 1,000 scientists launched a campaign to eradicate new cases of coronavirus, called “crush the curve”. This drew inspiration from countries such as South Korea, Iceland, Australia, Austria, New Zealand, Greece and China, and called for a new strategy in Ireland aimed at complete suppression of the virus. They argued that this was a realistic objective and could be achieved by continuing public health measures, including the use of masks, active fast contact tracing and testing, and sensible restrictions on travel.
The goal would be to suppress the number of new cases to zero as soon as possible, and to keep them there. With political leadership, an agreed and scientifically sound strategy, and cooperation from the public they argued that
this was potentially achievable. When this goal is reached, new infections have to be closely monitored for the foreseeable future through a robust, rapid, and vigilant FTTIS infrastructure. South Korea has managed to achieve this feat with a population similar to that of England. There were some parts of the UK where good contact tracing showed that infection could almost disappear such as Ceredigion, Guernsey and the Isle of Man. At present we are spiralling into another crisis with local lockdowns proving ineffective, government messaging continuing to be chaotic, and every prospect of a surge in cases once again putting huge pressures on the NHS. We are likely to be living with COVID-19 for the foreseeable future making it all the more important that there is a fundamental re-examination of government policy and a new and coherent plan even at this late stage.
Conclusion
The Westminster government needs to set its sights much higher than it has done with ‘Track & Trace’, replacing it with a ‘Find, Test, Trace, Isolate and Support’ system that aims not just to make life manageable until an effective vaccine or anti-viral drug materialises, but to eradicate new cases of COVID-19 altogether. This is why one of our key demands must be ‘bring back public health into public hands’.
As our Executive Committee member Louise Irvine has said in launching her petition: ‘Private test and trace is failing – hand it back to the NHS’:
“I’m calling for testing to be taken out of private company hands . . . Not having access to testing has huge adverse effects on society as people with symptoms and their contacts self isolate and stay at home, or simply infect others in the absence of any certainty they are infected. In the health sector much needed colleagues have had to self-isolate when they could be at work because they can’t get a test, while worried parents are keeping children home with simple colds as they can’t know for sure what is wrong, meaning they miss out on even more education. I know first-hand how deadly this virus is, having lost a close family member during the first wave. We must get a handle on testing to avoid further tragedy.”
Sign the petition: Change.org/TakeBackTesting