Test and trace has been hampered by a failure to draw on international experience and a lack of engagement with public health professionals says Martin McKee
Not for the first time in 2020, the UK prime minister Boris Johnson’s words are coming back to haunt him. Just as he is struggling with the not inconsiderable task of explaining what happened to his “oven ready” free trade deal with the EU, his confident statement to Parliament, in May 2020, that the UK would have a “world beating” test, track, and trace system is being replayed on social media. A new report from the National Audit Office (NAO), published in December 2020, has raised serious questions about both implementation and the choice of delivery model involved in this scheme that has an eye watering budget of £15.1 billion.
Although many were sceptical from the beginning, given the UK government’s less than reassuring record in responding to the early stage of the pandemic, ministers continued to express confidence in the system in England. For example, on 19th August, Matt Hancock said that “Test and trace is getting better and better and is now performing extremely well,” although the figure that he gave did not withstand scrutiny from fact checkers. Yet others were less convinced. In September, SAGE concluded that it was having only a marginal effect on the spread of the virus. MPs on the joint Science and Technology/ Health and Social Care Committee examining lessons learnt from the coronavirus response were more than a little sceptical when Baroness Dido Harding, responsible for Test & Trace, gave evidence to them in November, given the mismatch between her positive accounts and the less rosy accounts by those on the ground. Others have also expressed concern, including Independent SAGE and the Association of Directors of Public Health (ADPH), who have described the situation as “unacceptable”. So what did the NAO find?
One of the most common criticisms of the government’s approach is that it failed to draw on the existing expertise in contact tracing in the NHS and local authorities. Contact tracing demands particular skills as the tracer is seeking to unravel often complex family and social relationships. Contact tracers in sexual health clinics recognise the challenges involved. Yet the NAO reports that “We have not seen evidence that they considered whether to make use of local authority capacity for call handling”. Worse, the ADPH and the Local Government Association reported that national bodies involved in developing the new system had not engaged sufficiently with them “on key decisions about the design of test and trace services or the practicalities of implementing these services.” The Board of what is misleadingly termed NHS Test & Trace (as the NHS plays very little role in it), had also commissioned a review of international experience which found that none of the other 15 countries studied had adopted an outsourcing model. Thus, in several important respects, there was a failure to draw on crucial evidence.
The system that was created is complex, with an organogram filling four pages of the NAO report. The report expresses particular concern about the unclear decision-making process, which it considers “bring risks of confused decision-making and, ultimately, could impair governance and accountability”.
The NAO had particular concerns about the fragmentation of the system and the limited initial engagement with local government. Test & Trace had established a good practice network with 11 local authorities, but its members reported that they “were unclear about how their views had informed policies and decisions.” The problems were exacerbated by difficulties staffing the system. It was reported that “The ADPH has found it difficult to liaise effectively with NHST&T due to a lack of clarity about individual roles and the reliance on short-term secondments and consultants.” This contributed to the difficulties that arose from the system’s lack of public health expertise, which led to “test centres being set up in places that many people had difficulty getting to.”
Unsurprisingly, given the widespread failures of procurement that have characterised the UK’s covid response, the report had much to say about Test & Trace’s 407 contracts with 217 suppliers. It noted lack of oversight over what it was purchasing, failure to manage conflicts of interest, and examples of work starting before a contract had been awarded.
Inevitably, the report goes into some detail on the well known problems with scaling up capacity and, in what some might interpret as an implicit criticism of ministers who have continually used the metric of testing capacity, notes that “capacity is not the same as the actual volume of tests processed each day.”
It is, however, the national contact tracing system that attracts most criticism. Confirming previous reports that tracers had little to do, the NAO found that the utilisation rate of staff in Tier 2 was only 4% (contracted health professionals) and in Tier 3 (call handlers using a script) was only 1%. This was largely because it was anticipated that each case would provide names of 10-30 contacts when in fact they named an average of 2.4, itself an indicator that the system was not working.
The NAO’s report is interim, so it cannot cover everything. There are many deeply problematic aspects of how the national Test & Trace system works, including its focus on individuals rather than households, so that each individual within a household could receive multiple calls, or the loss of several thousand records following a spreadsheet error. These may be addressed in the final report.
The failings of the Test & Trace system have undoubtedly contributed to the UK’s poor performance in the pandemic. But maybe this was inevitable? For many years, successive governments have inflicted deep cuts on the civil service. Ministers looked to private outsourcing companies to perform what many felt were core functions of government. One after another, these schemes failed, most visibly at the 2012 Olympics when the Armed Forces had to step in to provide security. As the NAO noted, ministers failed to consider using what capacity already existed in the public sector. The fact that these companies had no relevant expertise was irrelevant. It was assumed that they had generic skills that could make things happen, whatever it was.
The government could have specified a product that would have delivered what was needed. This would have required the companies involved engaging with existing public health teams in local government and laboratories in the NHS and veterinary sector. But to do so, they would need staff with the specialised knowledge to negotiate these arrangements. And, given the complexity of such a task, and in particular the difficulty of pressing a bid that would ensure that they made a profit, they would be unlikely to take it on. Instead, the only products available were things they could be confident, even if the confidence was misplaced, in delivering. At this point, it became inevitable that laboratories would be stand-alone, disconnected from the existing infrastructure. Contact tracing would be based on call handlers, many who in more normal times would be involved in telephone sales, direct marketing, or debt collection. This model could never deliver the backwards contact tracing, which focuses on the search for settings and events where transmission takes place, and which has proven successful elsewhere. This, of course, is the model adopted by the much more successful schemes developed by local public health teams.
Ideally, someone in authority would have challenged this approach, recognising that it was flawed by design. This raises important questions about the government’s advisory structures. From the outset, those involved have clearly separated scientific advice from operational and policy issues. Yet, from a public health perspective, such divisions are artificial. There are many things to take away from the NAO report, but perhaps two of the most important are the failure to draw on international experience, even when it had been commissioned to inform decisions, and the lack of engagement with public health professionals. Sadly, these two weaknesses characterise much of the U.K.’s disappointing response.
Martin McKee is professor of European Public Health at the London School of Hygiene & Tropical Medicine and a member of the UK Independent SAGE.