Public health directors across England are now leading the response to covid-19, working with the support of Public Health England’s health protection teams. My discussions with directors in areas where cases have been rising have convinced me that the knowledge they possess of their communities is a huge asset in containing outbreaks and breaking chains of transmission. Leicester, for example, has now come out of local lockdown after working with community leaders to reach people affected, tracing their contacts, and mobilising testing to reduce infection rates.
Despite this success, public health directors are concerned that they lack the resources and staff to respond effectively as we move into autumn and winter. It is one thing to contain a time limited outbreak in a defined community, but an order of magnitude more difficult to do so on a continuing basis across the population. Some local authorities are responding by redeploying staff in services like fire and rescue, but a more fundamental reorientation of contact tracing and testing is needed to create a robust and sustainable system.
In the case of contact tracing, this means that staff working in national roles should be brought under the control of local authorities. These staff are a legacy of the government’s misguided decision back in March to outsource contact tracing to private companies using a call centre approach. Evidence shows that the staff employed to do this work are massively underused. They have also been far less successful than contact tracers in local government in reaching people and supporting them to isolate where appropriate.
Testing also needs to be brought under local control. Leicester and other areas dealing with local outbreaks have been able to deploy testing to target and support people in affected communities. This has involved ensuring that tests can be accessed by those who need them using mobile and home testing and other means. As outbreaks spread across England, it is critical that other areas can do the same instead of depending on large and sometimes inaccessible drive through centres.
Local control over contact tracing and testing will only work if there is sufficient capacity in the laboratories the government has commissioned as part of NHS Test and Trace. These laboratories are currently unable to meet rising demand for tests, and there are also delays in reporting results with the 24 hour standard now being missed in almost 70 per cent of cases. Public health directors are flying blind if they do not know who has tested positive, and they are also unable to trace contacts and identify the sources of outbreaks.
Providing public health directors with real time and person-centred data drawn from comprehensive community testing is therefore essential. Failure to gather and provide this data risks increasing transmission in the community at the very time when the need to stop spread is greater than ever. If people unwittingly transmit the virus to family members and people in the same household because they have been unable to get a test, there are obvious risks to the public’s health.
With the government expected to announce plans to prioritise access to available testing capacity imminently, it is essential that areas experiencing local outbreaks are high on the list. If they are not, then current worrying trends of rising numbers of cases, and reports of hospitals in areas like Tameside experiencing increases in admissions and deaths among covid-19 patients, will extend to other places. Many of the gains of recent months will then be lost and the prospect of even tighter local restrictions or indeed a second national lockdown will become more likely.
All of this could have been avoided if the government had planned effectively for a resurgence of covid-19 of the kind seen in some other countries. Specifically, ministers should have expanded testing capacity in anticipation of rising demand as schools and universities returned and people went back to work after the summer break. To argue that delays in people getting tested are the result of tests being used “inappropriately” is an unfortunate attempt to shift responsibility from NHS Test and Trace and the politicians to whom they are accountable.
The dangers that lie ahead are considerable. Test and Trace, put simply, is our collective insurance policy. Where it works well, it enables the economy, schools, and universities to open up while at the same time protecting the public’s health. Where it works badly, it risks the imposition of further damaging restrictions on the economy and society, and an exponential increase in cases, leading to a resurgence of pressures on the NHS and social care and further deaths.
The government needs to get a grip by ensuring that testing bottlenecks are unblocked. They should draw on all available capacity in the NHS, universities, research institutes and elsewhere. We have arrived at a Dunkirk moment in the fight against covid-19, when mobilising all available small boats offers the best hope ahead of new laboratories coming on stream. The limits of centralised planning are now in plain sight and the time has come to give back control to local leaders by ensuring they have the tools to do the job.
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