Today’s interim report from the National Audit Office (NAO) finds that the government has rapidly scaled up COVID-19 testing and tracing from a low base. It is not yet achieving all its objectives, with too few test results delivered within 24 hours, and too few contacts of infected people being reached and told to self-isolate.1
The Department of Health & Social Care (DHSC) rapidly increased testing capacity in England from April and launched the NHS Test and Trace Service (NHST&T) at the end of May to lead the overall test and trace programme. As a result of NHST&T’s work millions of people have discovered whether they have COVID-19 and whether they should self-isolate.
NHST&T’s budget for 2020-21 has grown over time and now stands at £22 billion. Of the £15 billion of funding confirmed before the November Spending Review, around £12.8 billion (85%) is assigned to testing and £1.3 billion to tracing. DHSC has identified much of the additional £7 billion budget allocated in the Spending Review as being needed for mass testing, which was formerly referred to as Operation Moonshot.2 Up to the end of October, NHST&T had spent £4 billion, around £2 billion less than forecast, due to underspending on laboratories, machines and mass testing.3
Contracts worth £7 billion have been signed with 217 public and private organisations to provide supplies, services and infrastructure, including test laboratories and call handlers for tracing. NHST&T has plans to sign a further 154 contracts, worth £16.2 billion, by March 2021. In total, 70% of early contracts by value were directly awarded without competition under emergency measures that were in use across government.
International comparisons show that outsourcing is a part of many testing systems but is unusual for tracing. A range of stakeholders have queried why the government did not involve local authorities more in its initial approach to tracing, given their previous experience in this area. The government did not document with a business case the basis for the delivery model it initially chose until September. NHST&T told us that, in the time available, the only feasible approach was to focus first on building up tracing capacity centrally. Local authorities have become more involved in tracing over time. For example, from July, some local authorities started to set up their own contact tracing schemes, in conjunction with NHST&T, for cases that the national service could not reach. By the end of October, 40% (60) had one in place with a further 46% (69) planning to set one up.
NHST&T’s testing capacity increased five-fold between May and October, setting up hundreds of new testing sites and expanding its network of laboratories, but the number of tests being processed daily is below reported capacity. It reached its public target of having capacity for 500,000 tests per day on 31 October and is working to reach 800,000 by the end of January 2021. However, on average the number of tests carried out was only 68% of the published maximum between May and October. NHST&T recommends that laboratories use a maximum of 85% of their published capacity in normal times.
A target to provide results within 24 hours of in-person testing in the community has not been met. Turnaround within 24 hours peaked in June at 93% but subsequently deteriorated to reach a low of 14% in mid-October before rising to 38% in early November. Turnaround times for tests conducted in hospitals and care homes are faster, with around 90% of results returned within 24 hours, though this is calculated on a different basis to in-person tests in the community.4
NHST&T did not plan for the sharp rise in testing demand in September when schools and universities reopened. Laboratories processing community swab tests were unable to keep pace with the volume of tests and experienced large backlogs, which meant NHST&T had to limit the number of tests available and commission extra help from other laboratories. Rationing of tests meant some people were told to visit test sites hundreds of miles away.
DHSC quickly set up a new national tracing system from the end of May to reach people who had tested positive for COVID-19 and their close contacts. Since it began, NHST&T has reached over 630,000 people testing positive for COVID-19 online or by phone to ask them for details of their contacts. It has also reached over 1.4 million of their close contacts, to advise them to self-isolate. The proportion of people who tested positive and were reached increased from 73% at the end of May to 85% at the end of October. The proportion of close contacts reached dropped from 91% in the last week of May to 60% in the last week of October. This partly reflects a change in the types of cases, with a smaller proportion being linked to outbreaks where it can be easier to reach a large number of contacts (for instance, all residents and staff in a care home).
It is important to get hold of people with COVID-19 or who might have been exposed to it quickly so they can self-isolate, but the service saw increases in the time taken to reach people between May and mid-October, before improvements in the last two weeks of October. For example, the proportion of contacts reached by the national service within 48 hours stood at 87% at the end of May, before dropping to 64% in the middle of October, and rising to 81% by the end of that month.
There has been no shortage of central tracers. At times, parts of the national tracing service have barely been used. In May, DHSC signed contracts for the provision of 3,000 health professionals and 18,000 call handlers. The call handler contracts were worth up to £720 million. By 17 June, the utilisation rate (the proportion of time that someone actively worked during their paid hours) was low for both health professional (4%) and call handler staff (1%), indicating that they had little work to do. DHSC had no flexibility to reduce the number of call handlers under the original contracts, which ran for three months. It negotiated new terms in August and reduced the number of these staff to 12,000, but utilisation rates remained well below a target of 50% throughout September and for much of October. This means substantial public resources have been spent on staff who provided minimal services in return.
National and local government have tried to increase public engagement with tracing, but surveys suggest that the proportion of contacts fully complying with requests to self-isolate might range from 10% to 59%. NHST&T acknowledges that non-compliance poses a key risk to its success and has taken steps to increase levels of self-isolation, for example by making follow-up calls to people while they are self-isolating. For as long as compliance is low, the cost-effectiveness of NHST&T’s activities will inevitably be in doubt.
As NHST&T rolls out further changes in COVID-19 testing, it needs to learn lessons from its experience so far to ensure it can make a larger contribution to suppressing the infection. This includes planning against a range of outcomes to ensure it is prepared for spikes in demand, increasing its focus on compliance with self-isolation, and setting out a clear strategy for how national and local tracing teams will work together.