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NHS Test and Trace

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Not to be confused with the NHS contact-tracing app.

NHS Test and Trace
Agency overview
Formed28 May 2020
JurisdictionEngland
Agency executive
Parent departmentDepartment of Health and Social Care

NHS Test and Trace is a government-funded service in England, established in 2020 to track and help prevent the spread of COVID-19. It is run by the National Institute for Health Protection; the service and the institute are both headed by Baroness Dido Harding.

The service provides temporary sites where samples are taken from individuals, processes the samples at a newly created network of laboratories, and communicates the results; infected people are instructed to isolate themselves from others and asked to provide details of their recent close contacts, who are also told to isolate. Almost all of the work is outsourced to consultants and contractors, although some of the laboratories involve other government bodies and universities. NHS Test and Trace is separate from the pre-existing infection control function of Public Health England, which works with NHS laboratories.

The service is in the jurisdiction of the Secretary of State for Health and Social Care and the Minister of State for Social Care.

Background

During the early stages of the pandemic, contact tracing was carried out by Public Health England, working with local authorities; PHE is an agency of the Department of Health and Social Care and is not part of the NHS. Tracing efforts largely ceased on 12 March 2020 in view of the wide spread of infection in the population.[1] Around the same time, testing NHS patients and staff was made a priority, and took all available test capacity.[2]

Overview

NHS Test and Trace's remit is to find people who have come into close contact with those infected by the virus, thus enabling the lifting of blanket lockdown restrictions and a potential shift towards more localised measures should they be required.[3] The organisation employs a team of (initially) 25,000 contact tracers who contact people who have newly tested positive for COVID-19 and ask them about their recent movements, before identifying others they may have come into contact with. Those people are then asked to go into self-isolation for two weeks.[4] The contact tracers are employed by Serco, who in turn (as of September 2020) have 29 subcontractors;[5] Serco were paid £108 million for the first phase of the work, up to late August.[6]

The call centre is operated by American specialists Sitel, who were paid £84m for the first phase.[7] In November 2020, Dido Harding described it as "the largest outbound calling centre in the UK".[8]

All components – administering tests, processing samples in laboratories, and contact tracing – are contracted to private companies. Multinational consultants Deloitte handle testing logistics, including collection of statistics, and in turn appointed outsourcing companies Serco, Mitie, G4S and Sodexo, together with the Boots pharmacy chain, to run drive-through or walk-in test centres. In October 2020 over 1,100 Deloitte consultants were engaged, and the system was reported to have a budget of about £12 billion.[9] The Guardian reported:

Management consultants are being paid as much as £6,250 a day to work on the British government’s struggling coronavirus testing system, sources have confirmed. Senior executives from Boston Consulting Group (BCG) are being paid fees equivalent to £1.5m a year to help speed up and reorganise the £12bn network that Boris Johnson said in May would be “world-beating”.[10]

Mobile testing units (MTUs) were designed, prototyped, bought and operated by the army in April.[11] By 20 July there were 218 in operation in England, Wales and Scotland, and the units were then handed over to undisclosed civilian contractors.[12][13] Mobile units in Northern Ireland were operated by civilians from the outset.[12]

Deloitte also coordinates the centres known as Lighthouse Labs where samples are processed.[14] Test kits for use at home (and at some test centres) are provided and processed by Randox under a £133m contract,[15] with logistics by Amazon[16] and some identity checking by American consumer credit agency TransUnion.[17] Randox has a lab in Northern Ireland, although in May some samples were processed in the United States owing to lack of capacity.[18]

The system works in parallel with Public Health England's local health protection teams, who in turn work with local authority staff. Cases involving institutions such as hospitals, care homes and prisons are handed off to the local teams, who give advice to the institution rather than the affected individuals. Less complex cases are handled by NHS Test and Trace: the infected person is contacted by text, email or phone, and asked to give details of their recent close contacts. They may either enter these contact details into the Test and Trace website, or give them over the phone to a contact tracer.[19] If they do not respond, in some areas NHS Test and Trace passes their details to a team employed by the local authority, who make further attempts by phone or text and in some cases by home visit.[20]

Since early July 2020, establishments where people come into prolonged contact with those from other households are asked to collect and keep for 21 days records of staff, customers, and visitors, although this is voluntary and no check for accuracy is required. Contact-tracers request these records if the premises are suspected to be the site of a COVID-19 outbreak. Applicable establishments include all hospitality outlets except takeaway food and drink, tourism and leisure, community facilities, places of worship, and close contact services such as hairdressers.[21]

Geographic scope

The scope of the NHS Test and Trace contact-tracing service is England only, the other United Kingdom administrations making their own arrangements. However, the laboratory network operates UK-wide.[22]

Lighthouse labs

Before the COVID-19 pandemic, tests for infections in England were carried out at laboratories within either Public Health England or the NHS (the latter often sited at hospitals, and reporting results to PHE's surveillance system).[16] In early April 2020, the government reserved the capacity of these labs for testing NHS patients and staff, calling this "pillar one" of their testing strategy.[23]

"Pillar two" provides mass testing – at first to key workers, later to the general public – using a new network of large processing centres operated by commercial companies and universities.[23] Initially three of these sites were planned, at Milton Keynes, Alderley Park and Glasgow. They are collectively named "lighthouse labs" since they employ the PCR test which uses fluorescent dye to detect the virus.[22] As of August 2020, five sites were in operation:[24]

In September, additional labs were planned near Loughborough in Leicestershire,[25] and at Newcastle and Bracknell.[26] In November two further 'mega labs' were announced as due to open early in 2021 at Leamington Spa and 'an unconfirmed site in Scotland'.[27]

Phone app

A venue poster showing a QR code to use with the NHS COVID-19 app

The system was designed to work in conjunction with the NHS COVID-19 app, which was originally announced for mid-May but subsequently delayed due to technical issues during its testing phase.[28] The app enables those who have been in close contact with a person with COVID to be identified using their mobile phone. Prior to this, information would be gathered by questioning people about their recent movements.[29]

Following a further delay, Liberal Democrat MP Daisy Cooper tweeted on 28 May: "Dido Harding just told me that the #NHSX app described by PM a week ago as 'world-beating' is in fact just a 'cherry on top' of the tracing system: which itself won’t be fully operational until end June... 4 weeks after lockdown restrictions ease. This is a high risk strategy."[30] Replying to a question at the government's daily briefing on 11 June, Hancock was unable to give any date for rollout of the app, saying it would be brought in "when it's right to do so".[31] On 18 June, development of the app was abandoned in favour of a different design using the Apple/Google Exposure Notification system.[32]

Public trials of the second version of the app began on 13 August 2020,[33] and it was made available to the public on 24 September.[34]

Users of the app can scan a QR code at participating venues. It is mandatory for hospitality, tourism and leisure venues, hairdressers and similar services, and local authority amenities to display a code.[35]

History

The programme was outlined by Matt Hancock, the Secretary of State for Health and Social Care, at the UK government's daily briefing on 23 April, when he stated that 18,000 contract tracers would be hired; at that time the name given to the programme was 'test, track and trace'.[36] At the 4 May briefing, Hancock said he hoped to have the system in place by the middle of the month, and that 3,000 of the recruits would be medical staff.[37] It was reported that Serco and Sitel had been contracted to supply 15,000 call centre workers, who would have a short training period, and Hancock was criticised for not making use of around 5,000 environmental health workers in local authorities.[38] In April 2020, Ceredigion council had developed their own contact tracing system using local trained staff and volunteers, with better results.[39]

On 7 May, Hancock appointed Baroness Dido Harding to lead the contact tracing programme for England, with a remit to oversee the implementation of the programme itself, and a contact tracing app.[40] On 18 May, Hancock said 21,000 tracers had been hired.[41] On 20 May, Prime Minister Boris Johnson told Prime Minister's Questions that a team of 25,000 contact tracers would be ready to begin work on 1 June.[42] The launch of the contact tracing service for England began on 22 May, when the government announced eleven pilot areas, including Norfolk, where the service would be initially rolled out. A £300 million investment package was also announced to help local authorities support the service.[43]

Deployment

The launch of the system in England – branded for the first time as NHS Test and Trace – was announced by Boris Johnson, the Prime Minister on 27 May 2020, and it went live the next day,[44] before it was fully ready.[45] Initially officials believed it would have the capacity to identify 10,000 people a day.[4] News that the service would be established without the phone app led to concerns manual tracing alone would not be effective enough to slow the spread of the virus.[46]

On the day of its launch, contact tracers began the process by contacting the 2,013 people who had tested positive for COVID-19 the previous day. Some tracers initially reported difficulties in accessing the system, but the UK government said it had not crashed and the problems were being resolved.[3]

On 28 May, Harding told MPs that the system would not be "fully operational at a local level" until the end of June.[47][48] Contractor Serco stated in internal communications that they believed it would not be fully operational until September.[49]

By 1 June, Hancock described the system as "up and running" but was unable to say how many cases had been handled.[50] On 3 June Channel 4 News reported that 4,456 confirmed cases of COVID-19 were reported to Test and Trace between 28 and 31 May, with those people passing on 4,634 contacts, and of those it said 1,749 had been contacted by tracers. The government described the data as outdated. On the same day a contact tracer said in a BBC interview that although she had worked for 38 hours she had not been asked to speak to anyone since beginning work, and had spent her time watching Netflix. In response the government said her story did not reflect the work taking place.[51]

In early July, NHS Test and Trace began to publish statistics for the numbers of tests performed and the time taken to return results. Before this, unreliable data had been published so as to ensure that the numbers of tests rose for each daily press conference. Decisions were made in order to achieve target numbers, rather than effective disease control systems.[52] Various government departments, agencies and consultants struggled to navigate a maze of different computer systems.[53]

Evolution

A reorganisation of the contact tracing element was announced on 10 August, following criticism that the service was not making use of local knowledge. The number of tracers in national teams would soon be reduced from 18,000 to 12,000,[54] and some staff would work in teams linked to local authorities, at first in areas with high prevalence;[55] the number of clinically trained advisors would not change.[56] Harding said "We have always been clear that NHS Test and Trace must be local by default ... we work with and through partners across the country".[57]

Andy Burnham, Mayor of Greater Manchester, said on 2 September that resources from the national test and trace system had not yet been released to local authorities.[58] Earlier, authorities including Blackburn and Oldham set up local systems involving GPs and Public Health England, as it was taking up to 96 hours for cases to be transferred from the national system.[59][60] On 11 October, it was reported that local contact tracing had been trialled for several weeks in over 60 council areas, with local personnel picking up on "difficult cases".[61] A government press release on 5 November stated that local tracing partnerships were in place for 148 local authorities, with a further 150 planned.[62]

By 21 August there were around 370 testing sites, of which 38 were "walk-in" and 236 were mobile test units.[55] On 10 September the total was 400, with a target of 500 by the end of October;[63] this target was exceeded, with 600 in operation at 2 November.[64]

By mid-September, more than 11% of people living in England had been tested at least once.[65]

August 2020 restructure

An announcement by Hancock on 18 August established the National Institute for Health Protection by combining NHS Test and Trace with parts of Public Health England.[66][67]

Key people

Conservative peer Dido Harding has led Test and Trace since its formation.[40] She has led NHS Improvement since 2017, and was announced as the interim chair of the National Institute for Health Protection on its formation in August 2020.[67]

Tom Riordan was appointed to lead contact tracing for three months in mid-May 2020, alongside his role as CEO of Leeds City Council.[68][69] Mike Coupe, former CEO of Sainsbury's supermarkets, was appointed as short-term leader of testing from October 2020,[70] replacing Sarah-Jane Marsh, chief executive of Birmingham Women's and Children's NHS Foundation Trust, who was appointed in May.[69] Susan Hopkins, a director in Public Health England's National Infection Service,[71] held the position of Interim Chief Medical Adviser in September 2020.[72]

Test capacity

In late August 2020, the Lighthouse labs were overstretched and sought assistance from NHS labs.[73] A rapid increase in COVID-19 cases in early September led to the demand for tests outstripping supply in some areas which caused delays in accessing the appointment system, and in some cases, people were being asked to travel longer distances to get tests.[74][75]

The leader of the testing programme, Sarah-Jane Marsh, apologised on 8 September 2020, saying the "pinch-point" was laboratory processing.[76] The following day the senior director of public health in a local authority was quoted as saying "I am not interested in an apology. I want them to pull their finger out and sort this mess out or hand it over to us and get out of the way."[77]

Matt Hancock, commenting on the same issue, suggested that the reason people were unable to book tests was that the proportion being booked by people who were not eligible to have them had risen to 25%. He said "[w]e have seen an increase in demand including from people who are not eligible for tests, people who don't have symptoms".[78]

In mid-September, the Independent reported that the Lighthouse labs had been partly staffed by university technicians and students, who had since returned to their universities; there were also logistical difficulties with movement of test samples.[79] A report by The Guardian described testing sites attended by hardly any people, staffed by personnel frustrated at not being permitted to test people from nearby who turn up without an appointment. It was reported that people attending a site without appointment were advised informally to get an appointment anywhere using a false postcode, and download the QR code for it; with such an appointment they can be tested.[80]

Analysis by Sky News on 17 September found three factors causing strain on the system: the decision to reserve 100,000 tests per day (50% of capacity) for care home residents and staff; a surge in demand from schools; and the resurgence of the pandemic earlier than the expected October or November.[81] Questioned on the same day by the Science and Technology Committee of the Commons, Harding stated the current test capacity was 242,000 per day, and said that the increase in demand had not been expected.[82] A 21 September paper from the Department of Health and Social Care listed the priorities for swab tests, and stated that members of the public without symptoms should not ask for tests.[83]

Daily test capacity exceeded 500,000 by the end of October, aided by a further Lighthouse lab at Newport.[64]

Contact tracing statistics

The Department of Health & Social Care publishes weekly statistics on contact tracing. Numbers shown below include the complex cases handled by local health protection teams as well as those handled online and by the call centre; the first week's report stated that a "high number" of contacts were managed by the local teams.[84]

By the end of July the percentage of contacts reached had decreased, which was said to be primarily due to a decrease in the number of complex cases handled by local teams, where the success rate is higher. Of the 3,688 cases handled in the week to 29 July, only 249 (7%) were classed as complex. After their close contacts were identified, in complex cases 93% were reached, while in non-complex cases 61% were reached.[85] Following more targets not being met and the percentage of close contacts traced being at a record low of 69.2%,[86] Dido Harding said "NHS Test and Trace is working and every week we consistently reach the majority of people testing positive and their contacts".[87]

The number of cases increased rapidly in September. By 23 September, the proportion of complex cases recorded by the system was small: 624 people reached, compared to 20,077 non-complex. The complex cases, by their nature, had many close contacts: 19,000 (an average of 30 per case) of whom 97.6% were reached. In contrast, there were 68,500 non-complex contacts (3.4 per case) of whom 61% were reached.[88]

Contact tracing statistics for the 12 weeks to 4 November 2020
Dates Positive COVID-19 tests

referred to Test and Trace

People reached Contacts identified Contacts reached
6–12 August[89] 4,803 3,787 (79%) 16,897 12,053 (71%)
13–19 August[90] 7,941

(incl. some tested in previous week)

5,767 (73%) 24,197 18,274 (76%)
20–26 August[91] 7,683 6,257 (81%) 31,388 21,773 (69%)
27 August to 2 September[92] 8,908 7,367 (83%) 32,359 22,381 (69%)
3–9 September[93] 15,526 12,831 (83%) 61,790 45,653 (74%)
10–16 September[94] 21,268 16,523 (78%) 77,556 57,918 (75%)
17–23 September[88] 29,037 20,701 (71%) 87,587 62,674 (72%)
24–30 September[95] 34,494 25,531 (74%) 101,782 69,815 (69%)
1–7 October[96] 87,918 (incl. approx 11,000 tested in previous week) 67,511 (77%) 216,627 135,661 (63%)
8–14 October[97] 96,521 78,903 (82%) 253,991 152,495 (60%)
15–21 October[98] 120,442 97,014 (81%) 284,701 171,554 (60%)
22–28 October[99] 139,781 115,660 (83%) 327,203 196,067 (60%)
29 October to 4 November[100] 141,804 120,512 (85%) 314,817 190,129 (60%)
Cumulative since 28 May[100][101] 767,074 630,309 (82%) 2.13 million 1.41 million (66%)

Appraisal

Effectiveness

In May 2020, the SAGE advisory body stated that, for the system to be effective, at least 80% of the contacts of an index case would need to be contacted.[102]

In July, medical academic Prof Allyson Pollock wrote that the programme was "about as far from integrated or effective as you can get" and called on the government to publish details of its contracts with outsourcing companies.[103]

On 19 September, the Guardian reported that the government was preparing to "shore up" the programme by drafting in teams of management consultants.[104]

The British Medical Association (BMA) asked 8,190 doctors and medical students in England about their concerns about COVID-19; the results were published on 14 September 2020. 86% of respondents expected a second peak, and it was the main concern for 30%. 89% of respondents agreed or strongly agreed that the failure of test and trace risked causing a second wave.[105][106]

On 21 September, a paper submitted to and endorsed by SAGE described the test, trace and isolate system as "having a marginal impact on transmission at the moment", owing to relatively low levels of engagement with the system, testing delays and likely poor rates of adherence with self-isolation.[107]

In late October, the i-Sense research collaboration (funded by the Engineering and Physical Sciences Research Council) estimated end-to-end effectiveness to be 16%, as follows:[108]

  • Take 100 newly infected people
  • Of these, 60 are estimated to be symptomatic
  • Of these, around 39 are tested and receive a positive result
  • Test and Trace reaches around 31 (81%), of whom 27 (85%) provide details of contacts
  • Test and Trace reaches 16 (60%) of the contacts and advises them to isolate.

Use of underqualified staff

In late October 2020, as the second wave of infections put the service under strain, a spokesperson for the Department of Health and Social Care said that "experienced call handlers" were being reallocated to gather contact information from infected people, and an internal email said they would work alongside nurses and clinical staff.[109]

Scams

Concerns were raised by members of the public and the media about how someone receiving a call from a contact tracer could be sure of it not being a scam. Speaking at the UK government's daily coronavirus briefing on 31 May, Dr Jenny Harries, the Deputy Chief Medical Officer for England, acknowledged those concerns but said it would quickly become apparent the call came from a professional, who "will make it very clear to you that they are calling for a particular reason. I think it will be very evident, when somebody rings you, these are professionally trained individuals and sitting over them are a group of senior clinical professionals."[110]

During the contact tracing app trial on the Isle of Wight, the Chartered Trading Standards Institute found evidence of a phishing scam. Victims would receive a text stating that they had been in contact with someone with COVID-19 and were directed to a website to input their personal details.[111]

Data protection

Concerns over data security and data protection have been raised. At launch, the programme did not have a Data Protection Impact Assessment, which is required by law.[112] In July, it was reported that workers on contract were sharing patients’ confidential information on social media support groups, due to a lack of alternative means to solve problems within their teams.[113]

On 20 July, privacy campaigners the Open Rights Group obtained an admission from Government lawyers that NHS Test and Trace was operating unlawfully and breached General Data Protection Regulations (GDPR) because an over-arching impact assessment had not been carried out. In response the UK Government said there was no evidence that data had been shared with third parties.[114]

International comparisons

Although countries keep records in different ways, the Our World in Data research team from the University of Oxford say that the UK is performing more tests than many other countries.[74] As of 14 September 2020, they show that at 2.76 tests per 1,000 people, the UK rate was ahead of most countries, including the major European countries: Belgium (2.3), Russia (2.1), France (2.07), Ireland (2.07), Norway (2.03), Germany (1.79), Sweden (1.78), Spain (1.77), Switzerland (1.42), Netherlands (1.36), Austria (1.35), Italy (0.91) and Poland (0.46).[115]

Testing and tracing in other UK countries

NHS Test and Trace as such is an English programme, but testing and tracing is carried out by programmes in the other countries of the UK. Northern Ireland became the first constituent country of the UK to reintroduce contact tracing when, on 23 April, its Chief Medical Officer, Michael McBride, announced that a scheme was "active".[116] Following a pilot, the system became fully operational in Northern Ireland on Monday 18 May.[117] On 23 July, Northern Ireland's Department of Health confirmed the release of the contact-tracing app, StopCOVID NI, for as early as 29 July. Northern Ireland was the first part of the UK to launch a contact-tracing app,[118] which was launched on 30 July.[119] The app runs on both the IOS and Android operating systems, but the developer said that it would not work on iPhone 6 or older Apple devices.[120]

Plans for Test and Protect, a contact tracing service in Scotland, were published by the Scottish Government on 26 May,[121] and it was launched on 28 May, shortly after NHS Test and Trace went live;[3] a companion app "Protect Scotland" was launched to the public on 10 September.[122][123]

The Welsh Government began a pilot scheme in some health board areas on 18 May. On 27 May, Wales announced that its contact tracing service would launch on 1 June.[124]

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