A crisis on the scale of the covid-19 pandemic requires a national response. But in a country as large and diverse as the United Kingdom, where the impact of the virus varies between areas, a national response is insufficient. Local leadership is also essential, drawing on the expertise of devolved governments in Northern Ireland, Scotland and Wales, local authorities, NHS bodies, and many other public sector agencies.
A major weakness in the government’s handling of the crisis has been its failure to recognise and value local expertise. First ministers in the devolved governments and local government leaders have expressed their frustration in not being in the room or consulted when decisions have been made. Elected mayors in Greater Manchester and the Liverpool City Region have been particularly vocal, arguing that the impact of covid-19 in their areas has neither been understood nor taken into account at key stages.
The NHS Test and Trace service illustrates these challenges. In the initial stages of its development, ministers looked to the Department of Health and Social Care on testing and Public Health England on contact tracing to plan a major expansion of capacity. These agencies put in place parallel national programmes using private companies, largely ignoring the contribution of local government and the NHS at a local level.
Dido Harding was appointed to take charge of NHS Test and Trace in May as the easing of the lockdown approached. She immediately appointed experienced leaders from the NHS and local government to reshape the service. These leaders have done so by seeking to give the NHS more say over testing and local government a leadership role on contract tracing in a reverse takeover of a service that had previously been developed from the top down.
In the case of contact tracing, most of the work is now being done by regional teams in Public Health England and local health protection teams led by directors of public health employed by local authorities. Recent statistics show that in its first three weeks of operation, NHS Test and Trace reached around 113,925 people who were in contact with those who tested positive, of whom around 90 per cent were traced by Public Health England and local health protection teams.
The remainder—amounting to just 12,247 people—were reached by the national telephone-based service run by Serco and Sitel, which employs around 25,000 staff. This raises serious questions about value for money in the use of public resources in a contract reported to be worth up to £108 million. In my view, bringing these staff under the control of local authorities is overdue.
Challenges are also evident in the national testing programme. Swab testing to see if people are infected is being delivered by NHS laboratories known as Pillar 1 and commercial laboratories known as Pillar 2. The government’s aim in expanding testing was to deliver the target of undertaking 100,000 tests a day by the end of April in line with a commitment made by Matt Hancock, the secretary of state for health and social care.
Claims that the target was achieved have been challenged by evidence that not all tests sent out have been returned and analysed. As an example, data for 24 June reported by the Department of Health and Social Care show that Pillar 2 carried out just over 90,000 tests of which 12,200 were processed. The remaining 77,749 were sent out, but it is not known how many of these tests were returned and analysed.
The testing programme has encountered other challenges. These include requiring staff and others needing tests to travel to inconvenient locations in some instances and being slow in making tests available to staff and residents in care homes. The focus on expanding the number of tests also distracted from issues such as the speed with which tests are analysed and the results reported. This is especially important as the lockdown is eased to enable contacts to be identified and traced rapidly as a way of containing the spread of the virus.
The limitations of centralised control have long been recognised by military strategists. General Stanley McChrystal’s analysis of how the US army combated al-Qaeda by decentralising decision making, shortening lines of communication, and creating a “team of teams” to avoid siloed working is a case in point. Adaptability and flexibility took the place of command and control and are as relevant in the battle against covid-19 as in the war against terrorists.
Learning these lessons, the priority now should be to accelerate decentralisation of decision making in NHS Test and Trace, strengthen the voice of local leaders in how the service is developed, and build a team of teams across all the agencies involved. This must be done locally through Local Resilience Forums and other partnership boards, regionally through emerging Integrated Care Systems in England, and nationally through Dido Harding’s team working with all the agencies involved.
Lines of communication between local, regional, and national teams should be streamlined to support rapid learning about what’s working and the spread of best practices. Local leaders should have much more say over the use of available capacity, including the ability to deploy mobile testing units rapidly when the need arises. The work of national contact tracers should also be brought under the control of local leaders to ensure effective use and coordination of scare resources.
Even at this stage, it is not too late for the United Kingdom to align more closely with countries like Germany where regional and local leaders have played a significant role in limiting the impact of covid-19 on the public’s health. Local leaders, including devolved governments and elected mayors, are much better placed than the Westminster government to engage their communities in limiting and responding to future outbreaks. To do so effectively, these leaders must be given control of test and trace to rectify the flaws in the government’s ill judged design.
Chris Ham is non-executive chair of the Coventry and Warwickshire STP and non-executive director of Royal Free Hospitals. He was chief executive of the King’s Fund from 2010 until 2018.
Competing interests: None declared