Explainer: Test and Trace Service
Introduction
The Association of Directors of Public Health (ADPH) has consistently advocated for a ‘team of teams’ approach to contract tracing and testing, with the responsibilities of each part of the system, whether local or national, clearly articulated and properly resourced.
Establishing a new Test and Trace Service, at the scale necessary, was a significant undertaking. The report recently published by the Health Foundation details the journey so far. ADPH remains committed to being as constructive as possible but as challenging as necessary when engaging with, and supporting, its development. The simple reality is that the current system is neither “fully operational” nor “world-beating.”
This briefing outlines the purpose of the Test and Trace Service, progress made so far and today’s challenges, including around performance, structure and culture, system learning, funding and resources, and finally poses the question of creating a new model for the future. The purpose of this briefing is not to articulate a detailed new model but to suggest that, given the shortcomings of the current Test and Trace Service, now is the time for a serious conversation about a more human and local system that is closely rooted in the daily lives of people and communities.
Purpose
The Test and Trace Service is an important tool within the overarching goal of reducing and then limiting the spread of Covid-19.
The role of the Test and Trace Service is to:
- ensure that anyone who develops symptoms of Covid-19 can quickly be tested to find out if they have the virus.
- trace close recent contacts of anyone who tests positive for Covid-19 and notify them that they must self-isolate at home to help stop the spread of the virus.
- identify and effectively target potential clusters which could lead to new outbreaks.
- understand key routes of transmission and identify high-risk settings where more focussed action is necessary to prevent and reduce transmission (i.e. through ‘backward contract tracing’).
Since Covid-19 can be spread before symptoms occur or when no symptoms are present, case investigation and contact tracing must be speedy and the information as complete as possible. The ability to subsequently encourage and support cases and contacts to self-isolate is also vital. Broad community engagement is therefore needed to develop greater awareness, trust and acceptance of these measures locally. Financial and practical support for self-isolation is likewise fundamental for many. All these elements are important components of a whole system response to Covid-19.
The Test and Trace Service is not a magic bullet and its effectiveness will vary depending on the rates of infection in the community. As the number of cases rise exponentially, the Test and Trace Service becomes less effective and other measures that restrict social interactions become increasingly necessary. Given the potentially large and increasing number of cases and contacts, there will need to be some prioritisation of efforts, for example of certain complex settings. The system currently only deals with people as individuals, divorced from connections to others – rather, given how infections link people to each other and to certain settings or events, the system needs to recognise people as part of a household, or part of an outbreak or cluster of Covid-19 cases
We need to continue to act on multiple fronts to achieve our overarching goal of reducing and limiting the spread of Covid-19. ADPH has separately outlined a comprehensive “combination strategy” to guide Directors of Public Health in considering a range of measures and interventions when making decisions locally.
Progress
Establishing and maintaining a new Test and Trace Service during, and through, a global pandemic is a substantial task and notable strides have been made across three areas:
- Data flows
Data is a fundamental tool for protecting lives and keeping people safe from Covid-19. In July, the ADPH published an explainer on data to set out the perspective of Directors of Public Health on the challenges at that time and a data manifesto to guide future discussions.
Data flows from national to local systems are more comprehensive and quicker compared to the early months of the pandemic. For example, the months it took to gain access for Directors of Public Health to daily postcode-level data on tests, positive cases and contacts, was largely resolved.
While ADPH values the progress being made and the hard work of our PHE colleagues, there is still more to do. We are committed to working collaboratively with PHE, the NHS Test and Trace Service, and the Department of Health and Social Care to improve data and intelligence sharing across the system.
- Testing capacity
The overall volume of testing and available laboratory capacity has risen substantially, and this represents an impressive logistical achievement. Access has gradually widened and there is more local influence of allocation.
However, the continued focus on the number of tests being carried out and the common assumption that this alone can allow a return to life as normal is overly simplistic.
It is vital that testing capacity is optimised and appropriately targeted, and that barriers to testing, such as lack of access and trust in the Test and Trace Service, are understood to maximise its impact and effectiveness.
As new forms of testing become available it is also essential that these changes are communicated clearly to the public, and that the operational implications of mobilising different types of testing locally are well planned and resourced. This includes reviewing the implications for existing delivery infrastructure (i.e. Regional Testing Sites (RTS), Mobile Testing Units (MTU), mass testing and home testing) and what other delivery routes may need to be in place.
- Valuing local
There has been an increasing recognition of the role and value of local authorities and public health teams in terms of guiding changes in people’s behaviour through skilled and bespoke messaging, providing advice to public and private sector organisations to reduce the risk of transmission, promoting and enabling testing and supporting self-isolation. Local intelligence on potential routes and sources of transmission has also helped with the early identification and management of outbreaks.
The relationship between local authority public health teams and regional PHE health protection teams is joined up and strong in most areas, and structures in the devolved nations ensure even closer partnership working between public agencies.
Today’s challenges
In this section we outline the main challenges for the Test and Trace Service.
- Performance
Performance of the Test and Trace Service should broadly be judged by three simple key metrics: speed (time from a test being carried out to the result being confirmed and contacts being followed up) and reach (is it reaching deeply into each and every community) and finally value for money (which we address later).
Current performance of the Test and Trace Service is unacceptable, and, on all counts, major improvements are beyond urgent.
The government’s Scientific Advisory Group for Emergencies (SAGE) recommended that at least 80% of close contacts of positive cases must be reached for the system to be effective. SAGE also expressed the importance of contacts of individuals who have Covid-19 isolating within 48 hours. The latest figures show that the national system is far from meeting these requirements.
While there have been improvements in data flow, several issues remain. For example, the case data that is passed to local authorities, is too often delayed, inaccurate or incomplete (for instance, missing information in terms of employment and workplace).
There is also a concern about the gap between the number of tests being requested and those delivered, and the impact of this.
Finally, a great deal of political attention has been given to mass testing. The concept raises significant scientific, operational, resource and ethical questions. Given the huge strain on the Test and Trace Service this should be pursued cautiously through pilots in the first instance.
- Structure and culture
The structure of the Test and Trace Service is opaque, and it is unclear where responsibility lies for different functions. As a result, it is challenging to direct requests or concerns to the right part of the system, or engage constructively in finding solutions, and responses are often slow or formulaic.
There is a difference in culture between local partners and parts of national government. There is a tendency towards big announcements, such as on mass testing, prior to conducting meaningful dialogue about the merits and practicalities of implementation. The lack of understanding about the skills, knowledge and experience that exist in local public health teams often results in that input being overlooked or undervalued.
There continues to be a concerning lack of public health expertise and advice at all levels and the reliance on short-term secondments and consultants, often with little background in or knowledge of public health, severely limits the opportunity to build and maintain constructive relationships. Stakeholder engagement can be rushed and fragmented. Historic underfunding of the local government, public health system and voluntary sector has been brought into sharp focus.
- Local and human
Public trust has been hugely compromised by the performance of the Test and Trace Service. As ‘pandemic fatigue’ increases a more human approach that works with people and communities is essential to achieving engagement and compliance.
Currently local PHE and local public health teams manage the complex cases escalated to them by the national call centre operation. Locally supported contact tracing of the more straightforward cases that the national call centre operation can’t reach, is an initiative which many local authorities have agreed to undertake. The local public health teams are being effective in managing to locate and engage with many of these cases. Local teams are also able to provide a more ‘wrap-around’ service, directing people to local self-isolation payment systems and other support, such as food bank provision and voluntary sector support. However, as cases rise nationally, there is a concern that they will be expected to pick up many more of these cases, without the resources that the national operation has.
The local voice, knowledge and links to reach and support people from diverse and disadvantaged backgrounds are adding huge value. Further reflection and discussion are needed to understand what functions are best performed at what level; local, regional or national, and by who.
Accessing a test, engaging with the contact tracing process and self-isolation must be made as straightforward as possible. Significant work is needed to understand the end-to-end journey of a person using the Test and Trace Service, the various behavioural responses and how barriers can be removed to make the process simple. Utilising behavioural expertise would help improve the training that call handlers receive and the quality of their interactions.
- Funding and resources
The overall funding envelope for the Test and Trace Service is £12bn. However, only small amounts of funding have been allocated to local councils to carry out local contact tracing. No transparent process or mechanism is in place for understanding the funding and capacity needs of local councils and then allocating appropriate resource to them.
Where additional resources have been made available for local contact tracing, it has been one-off, reactive handouts when an area has reached high levels of infection, rather than a universal package to all local councils to carry out an agreed set of activities over a sustained period. In contrast, vast sums of money are being paid to consultancy firms with no prior experience of public health or local government and little accountability for performance, which raises legitimate questions about value for money and further undermines the credibility of the whole system.
- System learning
Any new system needs to have an open, active and rapid approach to continuously learning and refining what it does and how it does it. Prominent examples have demonstrated that there is much work to do in this area – both to identify issues quickly and to utilise the right expertise to find solutions.
In relation to data, an error in September meant that 15,841 cases between 25 September and 2 October were left out of the UK daily case figures. This delayed or prevented contact tracing taking place and raised questions around clinical governance which have not been answered.
The volume of calls that some individuals, and households, are receiving from the national Test and Trace Service continue to be hugely problematic, as recent examples demonstrate. Repeated calls to the same individuals to check that they are self-isolating is an inefficient use of resources and risks antagonising rather than encouraging people to do the right thing.
As cases continue to rise, the government and other partners within the system need to reflect and learn from the journey so far. This will help to ensure that tests are available to those who need them, and that policies aimed at improving contact tracing do not further exacerbate the inequalities exposed by Covid-19.
ADPH is committed to playing its part in system learning and improvement by collating and sharing the views of Directors of Public Health and their local good practice both between themselves and with partners nationally. Clearer opportunities for collective and transparent learning is vital to improving performance and outcomes.
The future
The set of issues presented here represents areas where we believe improvements can be made quickly and collaboratively to help us navigate through the winter period. We need to be honest and prepare for a Test and Trace Service which will have to remain in place for a considerable period, potentially years.
Therefore, we should adopt a twin track approach to change – working on both immediate fixes and a more ambitious overhaul in respect of the operation and culture of the Test and Trace Service.
The purpose of this briefing is not to articulate a detailed new model but to suggest that, given the shortcomings of the Test and Trace Service, now is the time for a serious conversation about a more human and local system that is closely rooted in the daily lives of people and communities and makes it easier for us all to take the right action to keep ourselves and those around us safe.
Read the test and trace service explainer.
If you have any questions about this briefing, please contact policy@adph.org.uk.