- Strategy, planning, measurement and reporting
From the outset of the pandemic, NHS Providers along with others, has been concerned about the lack of a clear and comprehensive testing strategy. We therefore welcomed the NHS Test and Trace business planreleased on 30 July, which was the first serious attempt to set out the strategic direction of travel on testing and tracing activity since the early stages of the pandemic. However, as the environment is constantly changing, the strategy needs to evolve. A lot of effort has gone in to develop the regularly published NHS Test and Trace data, working with stakeholders including the Office for National Statistics (ONS). Thanks to this work, we are well past the legitimate debate that surrounded the veracity and accuracy of the statistics on whether the government had met its 30 April capacity target or not. But, in our view, wider measurements of success and regular reports against NHS Test and Trace’s end July business plan are now needed.
We need: Government and NHS Test and Trace to publish a clear and regularly updated strategic direction of travel, to bring all the elements of the testing and tracing system together. We also need a detailed plan for each objective so different organisations within the NHS and the private sector know what their contribution should be, along with an agreed set of easily understood success measures. These measures should capture the totality of the NHS Test and Trace task. They should also include clear target thresholds for the key elements of the NHS Test and Trace task so we can have a full and proper debate about what success looks like. Reporting performance without these targets means unhelpful public confusion on whether NHS Test and Trace is performing successfully or not. - A better national / local balance and the right level of support for local outbreak response capacity
It is important to strike the right balance between national and local co-ordination of testing and tracing efforts. The overall strategy, mobilisation of resources at scale and pace, and the support of attempts to develop new and innovative tests can only be done nationally. At the same time, it is essential that appropriate local infrastructure is in place, particularly to deal with what are likely to be larger scale, more frequent, outbreaks. The ability to contain local outbreaks relies on robust local plans that can be stood up at a rapid pace using the insight and relationships with local communities that only exist at a local level. There is now widespread agreement that the initial national/local balance of control struck by NHS Test and Trace was too heavily skewed towards national control. NHS Providers therefore welcomed NHS Test and Trace’s decision, in August, to move 6,000 of its staff under the control of local public health teams. NHS Test and Trace needs to continue to listen carefully to the needs of local public health teams and prioritise and fund these accordingly. Given the current well publicised financial pressures that local authorities are currently facing, ensuring appropriate funding is available locally is vital.
We need: The right balance between national and local support to be fully in place before winter arrives. We also need appropriate resources, funding and support available at local level. A good measure of this will be the degree of satisfaction or dissatisfaction being expressed by local authority leaders and their public health directors. - Capacity growth and matching demand and supply
Growing testing capacity is an important priority but this is only one element of an effective testing system. It is not an end in itself. The events of the last few weeks have shown that there is currently insufficient capacity to meet testing demand and it is a reasonable prediction that demand is likely to grow significantly as winter nears. The government has set a target of 500,000 tests per day by October, and senior figures at NHS Test and Trace suggest that around 1,000,000 tests per day will be needed by the end of December. This involves a very challenging quadrupling in capacity over three and a half months.
The recent problems show that there is a complex combination of factors required to grow capacity and meet demand, including accurate predictions of demand, a clear plan of how capacity will grow and the physical delivery of the extra capacity across the different elements required, such as testing and processing capacity, including access to supplies and staff.
Recent events have also shown the need for effective public communications in the event of supply/demand mismatch, and rapid and clear prioritisation in the event of any shortages, which is translated into how the service is then operationally delivered.
There is also a need for effective co-ordination across government on decisions in areas outside of health and care which impact on the demand for tests. Recent examples include the ‘leisure demand’ generated by holidaymakers from the UK either requiring a negative test to reach their destination, or to return home without isolating. Another was the demand driven by the re-opening of schools, universities and workplaces as parents and colleagues strive to protect themselves and those around them.
We need: testing capacity to be expanded as fast as reasonable demand requires. But we also need public clarity on the longer term capacity needed beyond the end of October. We need more detail on how this capacity growth will be achieved, including milestones showing what is expected from each class of test provider, and how any staffing or supply constraints will be overcome. In the event of further mismatches between demand and supply, we need rapid, clear, and honest communications and effectively operationalised prioritisation of testing access. - Location of testing
There is a real risk that in focusing only on headline testing capacity figures, the availability of tests in different areas across the country receives insufficient attention. Those who need a test need to be able to access one sufficiently close to where they live or work. For NHS Trusts, it is vital that staff, their families and patients needing treatment get easy access to tests. Yet, as demand for tests has picked up, we have seen significant difficulties with some people only being offered tests hundreds of miles away.
The NHS Test and Trace business plan produced in July made a top level commitment of “the majority of urban populations being able to access a test within 30 minutes walk by end October”, but there are no detailed plans of how this will be delivered and how it will be measured. The government has just introduced a new measure of pillar two (i.e. non NHS/PHE laboratory testing) distance to a test. We will need to assess whether this is sufficiently robust to measure what really counts – how easy it is for those who need a test to access one.
We need: greater clarity on what access standards NHS Test and Trace will offer. We need more detail on how testing locations will be built to meet these standards. We need clear measurements and targets of how this access will be assessed and publicly reported. - Turnaround time
For tests to be effective in preventing virus spread, they need to be processed rapidly and results returned the next day. Test turnaround times are still too slow for many, and our recent survey of trusts showed there is large variation between different parts of the testing system. One of the particularly worrying features of recent problems has been the deterioration in test turnaround time in pillar two in the 14 days between the last week of August and the second week of September. For example, the percentage of 24 hour test turnaround dropped by half from 67% to 32% in regional test sites, from 53% to 20% in local test sites, and from 73% to 37% in mobile testing sites. The international standard is for all tests to be turned around within 24 hours but it’s unclear whether the government shares this measure of success or not.
We need: agreed targets for the proportions of various test types and routes being turned around within appropriate times. Data should be regularly published against established targets to show whether this is happening or not. Any deviation from the international standards of next day turnaround needs clear and public explanation. - Clarity on prioritisation process of allocating swab tests
It is probable that the mismatch between demand and supply for testing we have seen over the last few weeks will persist into, or reoccur, during winter. This means that clarity on prioritisation of access to tests will be key. It is vital that, having decided on an appropriate prioritisation, this is effectively operationalised in the way that testing on the ground is actually delivered.
This is particularly important for health and care patients and staff. Given the current level of workforce shortages NHS and social care providers are currently experiencing, we must avoid repetition of the enforced absence of health and care staff that we have seen over the last few weeks because they and their families have been unable to access tests. At the same time, effective care, patient safety and clearing current care backlogs all require rapid and consistent patient access to tests.
The government has frequently updated testing access criteria on a tactical basis. The latest update was issued on September 21. But many have argued that these week to week tactical prioritisations needs to sit within a clearer, higher level, strategy so that the long term direction of travel is clear and those who provide and process tests can plan accordingly. We know that testing capacity is due to expand significantly over the next few months but no-one is clear about how that capacity is going to be used. Government should be setting out its plans now so that appropriate preparations can be made.
We need: a clearly defined, longer term, strategic, prioritised, plan of who will be eligible for a test as testing capacity grows. We need effective short term, well communicated, tactical prioritisation when shortages occur – these need to be ready in advance and published as soon as needed, rather than unduly taking too long to emerge as has happened recently. These approaches to prioritisation should be implemented rapidly and effectively. - Appropriate regular testing of all health and care staff
From the moment the need for mass COVID-19 testing became apparent in March 2020, there has been a strong argument for moving to regular testing of health and care staff. There is good evidence that COVID-19 is a nosocomial virus, exposing those in health and care settings to a higher level of risk. This risk is significantly heightened by the number of asymptomatic cases – people who are spreading the virus without knowing they have it – particularly in the 48 hour period before they themselves experience symptoms. Many have argued that these risks should be controlled through regular testing of all health and care staff and, on 6 July, the Government started rolling out regular weekly testing for all care home staff.
NHS Providers has consistently argued that NHS trusts need clarity on whether they will be required to move to regular testing of all their staff because of the complexity and scale of the logistical task involved. But, despite frequent requests, there is still no clear plan on when or whether NHS staff will be regularly tested.
Many NHS leaders believe that government has been unwilling to properly engage in a public debate about these issues because the fundamental constraining factor is lack of capacity to undertake the required number of tests. But trusts have to plan. They need either a clear statement that regular testing of all NHS staff will never be a priority, whatever the capacity available. Or they need a clear statement of what capacity is required before regular NHS staff testing will start, and when the government believes this capacity threshold will be reached. The lack of forward clarity in the government’s current position is unsustainable.
We need: a clear plan setting out the government’s intended long term approach to regular NHS staff testing. If the government’s intention is to move to regular testing of all NHS staff, the plan needs to set out the current best guess of when and how this will happen and how it will be resourced. - Improving end-to-end contact tracing
We need continuous improvement in each stage of the tracing process – growing the percentages of those:
- who test positive being transferred to the tracing system
- who are reached and asked to provide contacts
- who provide details of their close contacts
- close contacts who are reached
- contacts who then actually self isolate
Each of these stages is important, both in isolation as well as in relation to the others. Currently when the weekly statistics are released it is unclear what the target performance should be for each of these stages and there is confused public debate about whether the figures are good or poor. Because current reporting is against each of these stages, there isn’t currently a single measure of success that summarises the whole process, and a discussion around whether this is suitable and, if so, what form it might take, would be helpful.
We need: agreed target thresholds for each stage of the process, and these need to be regularly achieved. If we are going to see separate data to differentiate between local and national contact tracing, relevant thresholds of success for each must be outlined. - Tailored support for communities
The data shows that, in some local outbreaks, contact tracers from the national system are finding it more difficult to reach the people they need to reach. We know that areas of deprivation can be at higher risk of worse outcomes from the virus. We also know that people from Black, Asian and minority ethnic groups can be at higher risk from COVID-19. Different cultures and communities where English may not be the first language will need different types of support, for example from local community leaders with whom they have trusted relationships. This means we need to think carefully about the approach to reach different local communities. Data shows that NHS Test and Trace is finding it difficult to achieve success rates in terms of levels of contacts and self isolation in some local communities compared to the national average. Local authorities are well placed to provide additional support here.
We need: high levels of positive cases and close contacts reached across the board. We particularly want to see a significant reduction in the number of low outliers in contact tracing, many of which appear to be in local communities which Test and Trace are finding harder to reach. - Data flows
There have long been complaints that the national testing data is not being provided to local authorities in sufficient detail to allow them to do their job ‘on the ground’. Additionally, there are concerns that data from Pillar two tests (swab testing for the wider population) is not getting into all relevant patient health records at sufficient speed and with sufficient consistency, which means subsequent treatment is less efficient for some patients.
We need: the right data to get to the right point, in the required format, to the time and quality that is needed. Again, feedback and levels of satisfaction or dissatisfaction from both NHS clinicians, and local public health directors, is a good measure of success here. - Successful deployment of new tests
There has been much recent focus on the new tests and techniques being considered to expand and improve testing. This sits alongside continuing concerns about the reliability of the current polymerase chain reaction (PCR) swab tests. Some lessons were learned when a large number of Randox tests had to be returned in July because of safety concerns, but it is essential that any new approaches are fully tested and verified before they are rolled out. There are additional considerations for staff training and supply chain logistics to allow deployment at pace once the green light is given for new approaches. Currently, there is little visibility of what is being planned. While commercial sensitivities understandably play a part here, more detail is needed to effectively plan how and when new tests can be used.
We need: a clear strategy on which new tests are going to be developed, with a transparent roll-out plan for any new tests that are going ahead. There should be regular reporting on the process to introduce new tests, including key milestones and clarity on the scale of deployment. - Public confidence
The national test and trace effort will only work if the public know what they need to do and have confidence that if they do the right thing, others will be doing so too. They also need to have confidence that NHS Test and Trace is playing its role effectively and this is borne out in practice every time they interact with the service.
In our view, NHS Test and Trace made good and appropriate progress between its creation in late May until mid to late August. The launch of the app this week is another important milestone. Recent problems have, however, knocked public confidence. In our view the government has seriously misplayed the communications around these issues, initially trying to downplay or ignore the existence of problems that were clearly being experienced by significant numbers of people.
It was disappointing that the government failed to observe the basic principles of customer facing communications in the event of operational problems – acknowledge the problem, apologise, explain the reasons for the failure, set out what is being done to correct it and provide regular, open and honest progress updates. It took far too long for this to happen and, even then, senior government ministers were publicly reported as describing the legitimate raising of these important service failures as "carping".
This was the latest in a series of government communication failures in which they have consistently over-promised and under-delivered, potentially reducing public confidence in the service. For example, it was deeply ill advised for the Prime Minister to state, as NHS Test and Trace was being set up, that we would have a world class service by the end of June. Given the need to build public trust and confidence in this new service, this was equivalent to shooting NHS Test and Trace in the foot just as it was leaving the starting blocks.
We need: sufficient investment in national and local communications about NHS Test and Trace to ensure the public is clear about what is expected of them. We need to ensure that the public has confidence in the service. This should be measured and regularly reported via formal testing of public opinion. The government needs to rethink its approach on how it publicly communicates on NHS Test and Trace’s operations, recognising that ensuring public confidence in NHS Test and Trace is vital to its success and needs to trump political considerations.