James spoke to Radio Norfolk about the Public Accounts Committee report on NHS Test, Track, and Trace covering the incredible speed with which it has built testing capacity as well the need to reduce spend on costly consultants and publish more data to demonstrate its effectiveness.
James said: "Test and Trace was set up at incredible speed and significant cost to taxpayers and it has successfully built daily testing capacity of 800,000 from scratch and traced millions of people who tested positive and their contacts. However, it needs to cut spending on costly consultants and publish more data so that people can properly judge its effectiveness. The Department for Health and Social Care needs to ensure there is a legacy from the billions spent on the programme."
Summary of the Report
A well-functioning test and trace programme is key to our success in the fight against the COVID-19 virus. Since May 2020, the NHS Test and Trace Service (NHST&T) has led the national programme for testing and tracing in England, aiming to help break chains of transmission and enable people to return to a normal way of life.
The scale of NHST&T’s activities is striking, particularly given its short life. Between May 2020 and January 2021, daily UK testing capacity for COVID-19 increased from around 100,000 to over 800,000 tests. NHST&T had also contacted over 2.5 million people testing positive for COVID-19 in England and advised more than 4.5 million of their associated contacts to self-isolate.
NHST&T, however, still has work to do to ensure it meets its critical targets and objectives in a timely and cost-efficient manner. We appreciate that NHST&T had to be set up and staffed at incredible speed, but in particular it now needs to wean itself off its persistent reliance on consultants and temporary staff. Up to November 2020, NHST&T had spent £5.7 billion, although it has been allocated far more (£37 billion over two years).
The Department of Health & Social Care justified the scale of investment, in part, on the basis that an effective test and trace system would help avoid a second national lockdown; but since its creation we have had two more lockdowns. There is still no clear evidence to judge NHST&T’s overall effectiveness. It is unclear whether its specific contribution to reducing infection levels, as opposed to the other measures introduced to tackle the pandemic has justified its costs.
A major focus for NHST&T in early 2021 was the mass roll-out of rapid testing in different community settings, but there have been particular setbacks for the roll-out to schools. Both the Department and NHST&T must learn lessons from this about their role in engaging stakeholders and setting out how rapid tests can be used. The Department must also remain one step ahead in setting the future strategy for the national test and trace service, including how to secure long-term benefits from the vast expenditure it will have incurred.
This is our first examination of NHST&T and its performance. We intend to follow up on progress on the test and trace programme later in the year.
Conclusions and recommendations
1.NHST&T publishes a lot of performance data but these do not demonstrate how effective test and trace is at reducing transmission of COVID-19. For NHST&T to be effective in breaking chains of COVID-19 transmission, it must identify as many people as possible who are infected with or exposed to the virus, as quickly as possible. SAGE, the Government’s Scientific Advisory Group for Emergencies, advised that contacts should be reached within 48–72 hours of the original case developing symptoms, i.e. from ‘cough to contact’. NHST&T’s effectiveness also relies on people self-isolating in line with requirements. NHST&T quotes findings from an “independent verified analysis”, which suggested that its activities in October 2020 may have contributed to a reduction in the “R number” (the number of other people a person with COVID-19 infects) by 0.3 to 0.6, provided that people with the virus start self-isolating once they develop symptoms, i.e. before even engaging with the test and trace system. Most of the reduction arises from the assumption that people self-isolate as required, in particular between developing symptoms and receiving their test results. In reality full compliance with self-isolation rules can be low. NHST&T also has plans to increase the proportion of cases identified through the mass testing of people without symptoms. However, the interim report on the Liverpool mass testing pilot did not find clear evidence that the pilot reduced positive COVID-19 cases or hospital admissions. Professional bodies, such as SAGE and BMA, have raised concerns about the effectiveness of the programme in reducing transmission. NHST&T publishes weekly performance data, but these do not provide an overview of the speed of the process from beginning to end (“cough to contact”) and thus do not allow readers to understand the overall effectiveness of the programme.
Recommendation: NHST&T should improve the data it publishes so people get a better sense of its effectiveness. In future, its weekly statistics should include the total time taken to reach contacts after an initial person develops symptoms (the “cough to contact” metric), how many actual days NHST&T asks people to self-isolate for, as well as the latest indicators of people’s compliance with self-isolation. NHST&T should also publish periodic evaluations of its impact on infection levels.
2.NHST&T still struggles to consistently match supply and demand for its test and trace services, resulting in either sub-standard performance or surplus capacity. We accept the need to build surplus capacity into test and trace services to handle unexpected, sometimes exponential, surges in infections. However, the percentage of total laboratory testing capacity used in November and December has remained under 65%, at the lower end of what NHST&T states is best practice (between 60% and 85%). Even with spare capacity, NHST&T has never met the target to turn around all tests (in face-to-face settings) in 24 hours. In September 2020, NHST&T significantly underestimated the increase in demand for testing when schools and universities returned, resulting in poor performance. When the demand for tests surged again over Christmas, NHST&T feels it managed access to tests better, but there were still dips in turnaround times despite apparent spare laboratory capacity. For tracing, the Department accepts that, with hindsight, it did not need to scale up central tracing services for May as much as it did. While it has sought to reduce capacity and increase flexibility since then, low utilisation rates—well below the target of 50%—persisted into October.
Recommendation: For all aspects of its testing and tracing operations, NHST&T should identify opportunities to make better use of the capacity it has paid to create. Where it retains surplus capacity, this should be for a clear and explicit purpose. It needs to strike a better balance between meeting surges in demand, maintaining timely services, having eligibility criteria that allow it to identify as many people with the virus as possible, and not paying unnecessarily for surplus capacity.
3.Although it had to act quickly to scale up the service, NHST&T is still overly reliant on expensive contractors and temporary staff. To scale up the test and trace service rapidly, the Department and NHST&T worked with a wide range of public and private sector partners, including consultants. By the end of December 2020, the Department had signed over 600 contracts for NHST&T-related services. At the beginning of November 2020, a ministerial announcement said there were 2,300 consultants and contractors working on NHST&T. When we took evidence in mid-January the Department estimated that from Deloitte alone there were still around 900 contractors on the books. In early February NHST&T said it was still employing around 2,500 consultants, at an estimated average daily rate of around £1,100, with the highest daily rate paid of £6,624. It is concerning that the DHSC is still paying such amounts—which it considers to be “very competitive rates”—to so many consultants.
Recommendation: NHST&T should put in place a clear workforce plan and recruitment strategy which aim to reduce significantly, month by month, its reliance on costly consultants and temporary staff. NHST&T would benefit from learning lessons on how other NHS bodies manage the need for additional personnel, for example, through staff banks and should explore incorporating these into its approach.
4.The introduction of rapid-results testing was supposed to be a ‘gamechanger’ but confusion persists over why and how it should be used in different community settings. Around one-third of people who have coronavirus are asymptomatic. There is now a widespread roll-out of rapid tests (primarily lateral flow device (LFD) tests, which give results in 30 minutes) for local authority use and in other community settings, such as schools and workplaces. To support this roll-out, the government allocated a further £7 billion to NHST&T in December 2020 on top of £3 billion already budgeted. The Department had already purchased 384 million LFD test kits. However, a number of reports have raised concerns about the effectiveness and risks of mass testing using LFD tests, given their lower accuracy compared to laboratory-processed tests, particularly the higher risk of ‘false negatives’ (people who actually have the virus getting a negative result). NHS T&T told the committee that a negative test result means that an individual is around 77% likely to be negative for Covid-19. Initial NHST&T and PHE guidance for schools suggested that they could use LFD tests for daily tests as an alternative to self-isolation, but this advice has now been withdrawn. On 21 January, PHE announced that it would pause or scale back the roll-out of mass testing in schools, with further evaluation needed because of the emergence of the new, more transmissible variant of the virus. Following the Prime Minister’s announcement on 22 February, schools will test students and staff regularly using LFD tests, but guidance on rapid testing in schools is yet to be updated.
Recommendation: The Department and NHST&T should set out clearly how and why mass rapid testing should be used in each of the settings where roll-out is planned, alongside clear targets and updates on progress in the various sectors. Any plans should take account of the approved purpose and accuracy of rapid tests, and how to manage the risks associated with false assurances the tests may provide. If LFD testing is not suitable in some circumstances, NHST&T should urgently bring forward other plans for identifying more asymptomatic carriers of COVID-19.
5.NHST&T claims to be a learning organisation, but since last May many important stakeholders have at times felt ignored by it. NHST&T emphasises to us that it is “constantly learning what works and what does not” and that it is critical to develop “an integrated team of all the different organisations, institutions and individuals in the country”. However, a range of stakeholders have queried why local authorities and NHS primary care bodies were not more directly involved in testing and tracing activities at the outset, given their existing networks, experience and expertise. Local authorities have subsequently become much more involved, for example undertaking contact tracing for people who are hard to reach. We are also concerned by a lack of engagement with school heads and education stakeholders in the roll-out of rapid testing, and the lack of general public health expertise at senior levels of NHST&T. NHST&T will need to focus more on engagement and collaboration with other sectors if the rapid testing expands to cover an increasing range of settings.
Recommendation: NHST&T should review how it engages with and draws expertise from the wider public health establishment and other sectors that are especially dependent on its work. This should include, but is not limited to, local government, the schools sector and the hospitality industry.
6.As we hope for longer-term and sustained reductions in infection levels, the Department needs to think about the future shape of national test and trace services, and how it will secure lasting benefits from its spending. NHST&T will be part of the newly formed National Institute for Health Protection (NIHP). However, the Department has not set out the details or timetable for the establishment of NIHP, scheduled for April 2021. In allocating additional funds to NHST&T, the 2020 Spending Review outlined that this funding will be subject to review as the vaccine programme is rolled out. The Government is now accelerating the roll-out of vaccines across the country, but we have not seen a future strategy for test and trace in response. NHST&T anticipates a continuing need for large-scale testing and tracing alongside the vaccine programme and the Department says it still needs to think through how best to wind down capacity at the appropriate time. The Department and NHST&T talk about leaving a legacy for the NHS through the vast investment in testing capacity, but they have not articulated even at a high level what this will be. We challenged NHST&T whether large testing centres were the best way forward for the NHS, compared to having more testing capacity in local hospitals. NHST&T explained “there is not a single model” and that it is yet to “work through how it should evolve in a post-COVID world”.
Recommendation: Within the next six to nine months, the Department should outline publicly its future strategy for testing and tracing services in England, including:
- its timetable for transitioning to the new National Institute for Health Protection,
- its exit strategy when infection levels reduce, including downscaling, mothballing and reallocating national and local capacity;
- how it will cost-effectively maintain a degree of readiness for future surges of COVID-19 and other influenza-like infections; and
- how it will work with the NHS, public health and local government bodies to secure continued benefit from the assets and infrastructure it has created
The full report can be accessed here https://publications.parliament.uk/pa/cm5801/cmselect/cmpubacc/932/93202.htm
