Test and trace: Where did it all go wrong?

It was, Boris Johnson promised in the spring, the route out of lockdown and the best way of “getting our country back on its feet”.

Failings of the £10Bn private sector led omnishambles exposed – Owl

Billy Kenber, Investigations Reporter | Chris Smyth, Whitehall Editor www.thetimes.co.uk

A nationwide system of testing and tracing to identify infections and stop the virus spreading; requiring a small minority to quarantine so that we could “release 66 million people” and allow Britain to return to something approaching normality, Mr Johnson said.

Instead, six months later, the country is back in lockdown and NHS Test & Trace, set up at great expense by a coterie of management consultants and outsourcing giants, has failed in the task the prime minister set it.

Earlier this year the Scientific Advisory Group for Emergencies (Sage) estimated that a successful testing and contact-tracing system could reduce the crucial R number by 0.4, similar to the impact of closing every school in the UK.

By the autumn it concluded it was having only a “marginal” effect. Sir Patrick Vallance, the chief scientific adviser, said that cases were now too high for the system to work and even Mr Johnson expressed his “frustration” and said this week that he was “perfectly willing to accept the failures of Test and Trace”. This is what went wrong.

Scramble to launch

Identifying those who have come into contact with someone diagnosed with an infectious disease and asking them to self-isolate has been an established public health tactic for centuries, and Public Health England began contact tracing as soon as the first coronavirus cases in Britain emerged last February.

Within weeks, however, a lack of testing capacity led the government to abandon these efforts. It took another month before Matt Hancock, the health secretary, announced plans to resume contact tracing. This time, he said, the government would recruit thousands of staff to run a brand new contact-tracing system.

In choosing a centralised approach, ministers followed the path they had taken with testing when it was decided that the only way to reach the scale required was to start from scratch, overlooking the “small boats” strategy of using lots of smaller existing facilities around the country.

In doing so, they ignored calls from local leaders to draw on the expertise of local public health teams, trading standards and sexual health services for whom tackling outbreaks of food poisoning, measles or sexually transmitted diseases was “bread and butter work”.

Like the large “lighthouse laboratories” set up to increase testing, Downing Street elected to hand over responsibility for this new tracing system to private contractors, awarding large contracts to the outsourcing giants Serco and Sitel. The task of running it and launching a planned contact-tracing app went to another veteran of the private sector: the Tory peer Dido Harding.

Baroness Harding of Winscombe, 52, who is married to a Conservative MP and went to university with David Cameron, had limited public health experience. Her corporate career, which included stints at Tesco and Sainsbury’s, was best known for her disastrous handling of a data leak at the telecoms company TalkTalk. Nevertheless, sources said she felt unable to decline the role, which she saw primarily as a logistical challenge, when she was personally asked to take it on by Mr Johnson.

“She is someone who is a very effective doer and she was told to do it through national structures,” a friend said.

The “army” of contact tracers hastily assembled included as many as 18,000 call centre staff paid no more than £10 an hour and in some cases drafted in from providing customer service for a package holiday company. They were to be tasked with calling the close contacts of those who had tested positive for coronavirus.

Alongside them were a few thousand “tier 2” clinically trained staff hired to make first contact with those whose test results showed they had caught the disease. A smaller number of senior “tier 1” staff were recruited to handle complex cases, such as those involving care homes or hospitals.

The online training offered was chaotic and at times appeared ill-suited, with staff required to complete a module on workplace fire safety despite working from home. With no access to the software they would use to read scripts and enter people’s details, staff were unable to practise their roles.

The phoney war

On a Wednesday evening in late May, as the scandal over Dominic Cummings’s lockdown trip to Durham continued to swirl around Westminster, newly hired contact tracers watching the daily Downing Street press conference received some surprising news. Mr Hancock announced that the system would be going live the very next day, four days earlier than the scheduled June 1 date.

The launch the following day was beset by technical problems, with tracers unable to login with the credentials sent out late the night before and Sitel declaring a “critical incident”.

From there, for many staff, the waiting began. Initially data from only certain kinds of testing sites was filtering through and thousands of tracers were left with long, empty shifts with no calls to make. One reported going 20 shifts without speaking to a single coronavirus patient, spending the time upholstering furniture and watching Netflix. It rapidly became apparent that far more staff had been hired than were needed. In briefings with journalists Lady Harding was bullish, saying that it was better to have too much capacity rather than too little.

But fewer and fewer shifts were made available to book, leading some specialist clinical staff to leave in search of steady income from locum jobs elsewhere. By August, as cases died down in the warm summer months, the government announced that 6,000 tier 3 call centre staff would be laid off.

It was the first stage of a gradual retreat from a centralised system, prioritising speed of scale-up, to a localised one prioritising on-the-ground knowledge — a shift that remains incomplete.

‘They’re just bombarding you’

When they did get through, call centre staff were tracing barely half the contacts they were told about, a proportion that has never got much beyond 60 per cent, far below the goal of tracing 80 per cent of contacts within 48 hours of a case being reported.

Things were not helped by the speed with which tests results were being returned and cases were making their way into the system. When they did arrive, coronavirus patients and their contacts could expect a deluge of phone calls. For households with young children, the system’s inability to flag them as linked cases meant they would be repeatedly rung as close contacts of the original case.

“If you have a large family which includes school-age kids, if your husband gets a positive test you’re called as a contact of your husband and then you’re called for every child because they have your phone number and not a seven-year-old’s obviously. Then when you test positive as well you are called as a positive case, your husband is called as a contact of the second positive case in the household and so it goes on every time someone tests positive,” one tracer said.

With no way to flag that all of the cases are in the same household, she said that “if I know it’s a large household I’ve stopped taking phone numbers . . . I just say don’t give it to me, so at least they’re getting repetitive emails rather than repetitive phone calls”.

As lockdown eased, and more contacts were made in everyday life, performance slipped further as ever more of the work fell to the tier 3 tracers. They found that many people simply never picked up, assuming that the missed calls from an 0300 number were unwanted sales calls and ignoring the voicemails being left.

For those that did, compliance with the request to self-isolate for a fortnight was often low. Government surveys have found that only 11 per cent of those asked to isolate by contact tracers are actually doing so for the full two weeks, in what is increasingly seen as a fatal problem.

In recent weeks the service has begun making regular “support calls” to check if someone is still isolating. In early October, Simon Tomlinson’s partner tested positive and one of their two daughters then followed suit, meaning the whole household had to isolate.

“It was just a constant phoning and text messages and emails. They’re just bombarding you,” Mr Tomlinson, 46, said.

“They were calling all times of day. One day we got a text on her phone at 7.05 on a Sunday morning, then some days they would call me two or three times a day. Even when I’ve answered the phone and spoke to them in the morning, they’ve called back again in the afternoon.”

When he explained he’d already spoken that day the caller would continue with their script and ask him to re-answer the same questions checking whether he was continuing to isolate and asking whether he had developed any symptoms, he said.

“It’s just like speaking to robots rather than actual real people. If you don’t answer the phone then they phone every two to three hours leaving exactly the same voicemail.” Mr Tomlinson, who lives in Solihull, estimates that he and his partner, who was listed as the contact number for their two daughters, were contacted by phone, text and email up to 200 times over the course of a fortnight.

“It’s absolutely crazy — just a waste of people’s time and resources,” he said.

Local knowledge

From the outset, there was one part of NHS Test & Trace which drew on local experts. Complex cases in hospitals and care homes were escalated to tier 1 tracers and handed over to local teams employed by Public Health England. They proved far more effective, with success rates of over 95 per cent. But despite this success, the system was slow to hand over a larger role to local authorities.

It took months for local directors of public health to get access to the detailed, postcode-level data on test results and longer for local authorities to get proper access to a central database of cases.

The problem was partly a technical challenge to link up different systems but officials also cited data protection concerns when withholding the kind of data local leaders wanted.

When Leicester became a coronavirus hotspot in June, leading to a local lockdown, the town’s mayor, Sir Peter Soulsby, complained about the lack of specific information on cases. “I made the point personally to the prime minister early in our [local] lockdown that we needed to have the information about positive tests . . . together with ethnicity and place of work and full address,” he said. “And even now we don’t get that full information with the data that’s passed on to us.”

Lady Harding acknowledged the need for a greater emphasis on a local approach, saying contact tracing should become “local by default”, but change came slowly.

Over the summer, the first pilot programmes saw normal Covid cases handed over to the local authorities — separate to local public health teams — for tracing if they could not be reached by national tracers within 24 or 48 hours. The contacts of these cases were then put back into the national system to be called by tier 3 tracers.

These teams, able to go out and knock on doors, proved significantly more successful at reaching people, with success rates of about 90 per cent. They have also proved well-placed to offer the kind of practical help — support accessing government self-isolation payments and getting shopping and medicines delivered by volunteers — which encourages people to comply with isolation.

Sir John Oldham, a former adviser to the Department of Health, said that “the contrast between the central system and the capability and effectiveness of the local public health teams and leadership has been stark. Centuries of experience in contact tracing informs us [that] the local community has to be the hub and should be the immediate focus of reform of Track and Trace.”

In some areas, the local authorities have also been actively carrying out “backwards tracing” where, instead of just seeking to identify who was in close contact with a positive case in the 48 hours before they were tested, staff seek to make connections between cases and trace the likely source of outbreaks.

To do this work, councils drafted in staff who normally performed other duties; in Manchester, firefighters were brought in to boost numbers. But local authority leaders have said they will need more funding from central government if they are to scale up this work.

Others have complained that they are hindered by the speed at which test results reach them. Leicester’s mayor said cases now take an average of six days from testing to being handed to the council for tracing. In eight cases it has taken 14 days, leaving staff no chance of reaching contacts while they might be unknowingly infecting others. Maggi Morris, a public health consultant in the West Midlands, said the council she is working with often hears about cases before they are logged in the national system’s database.

Tussles over access to the Test & Trace database of cases and their contacts also continue. A local service launched in Southend in late October was delayed by several weeks because of difficulties getting access to the data, a local councillor said.

“Quite rightly the national system want to know that people’s data is being handled in a correct manner, and that’s right and proper, but the delays that we were experiencing stopped us from launching earlier,” said Trevor Harp, the council’s cabinet member for health and adult social care.

An autumn rush

As officials were slowly granting local authorities a role in tracing, the return of schools and universities in September brought a huge increase in demand for coronavirus tests. At the same time, the return of universities prompted an exodus of highly trained scientists who had been seconded for six months to help run the lighthouse labs, while the promised expansion of capacity with new facilities in Newport and Charnwood was behind schedule. The combination of events left the system ill-equipped to cope and the resulting bottlenecks in processing tests led to a rationing of testing slots and farcical scenes as suspected Covid cases were told their nearest testing centre with availability was hundreds of miles away. The proportion of test results from walk-in centres that were returned within 24 hours of booking fell from 77 per cent in July to 8 per cent in October.

Meanwhile, the success rate of national contact tracing continued to fall. A spreadsheet error meant that 15,000 cases were initially missed and clinical contact tracers who a few months earlier had whiled away their shifts completing puzzles and reading books now found themselves in huge demand. At present, more than 120,000 people a week are being transferred to the contact tracing service, ten times the figure in early September. In some areas local health teams, without the funding to scale up, have been handing back positive cases who have not been reached because they are overwhelmed.

NHS leaders, witnessing hospital wards filling up as Britain was unable to control cases, have become some of the loudest critics of the tracing system. Last month NHS Providers labelled it as not “fit for purpose” and the NHS Confederation has said its poor performance was costing lives. NHS sources have also expressed irritation at the system’s use of NHS branding when the health service has no role in its administration.

The belated launch of a much-maligned contact-tracing mobile phone app in late September did little to help. A technical problem meant the app gave false alerts to users and those who did test positive could be left confused as to how long to isolate for, with the app giving a different date to the instruction delivered by contact tracers.

As a short-term solution, some call centre staff were upgraded to tier 2 roles, previously filled exclusively by those with clinical training, and were now responsible for making calls to those who had tested positive for coronavirus or the relatives of someone who had just died from the disease.

Existing tier 2 staff were perturbed by the decision, which some described as “potentially dangerous” because of the lack of medical knowledge. “There are things that clinically you pick up on — things like if somebody is quite breathless — where I’ve had to get them to hang up and call 111,” one said. “There have been case workers in the past who’ve had cases collapse on them [during a call] and have had to call an ambulance.”

The service is now looking to rehire some of the previously laid-off workers, with recruitment adverts urgently hunting for those looking to rejoin Test & Trace.

In the meantime, as the system flounders, some institutions and companies appear to have lost confidence in it and are going their own way. Imperial College London has set up its own contact-tracing service and placed an advert for £38,000-a-year clinically trained tracers on six-month contracts. At least one private business is also recruiting someone to oversee contact tracing for its staff.

Jonathan Ashworth, the shadow health secretary, said that “ministers made three big mistakes for which we are now paying the price”, citing use of “a centralised, heavy, top-down system” over “locally led ‘shoe leather epidemiology’ tracing”.

He said that “secondly on compliance, it should be obvious that people would struggle to isolate if financially penalised” — a point also pressed to ministers by Lady Harding, resulting in the introduction of £500 grants in September.

While Mr Johnson praised the system for reaching its target of a capacity of 500,000 daily tests by the end of October, Mr Ashworth’s third criticism is that “it’s still not clear what the strategy is regards testing, other than big headline-grabbing claims”.

Missed opportunities

Looking back, many involved with the system question why more was not done to fix its problems and hand a greater role to local areas in the summer. The problems and the solution, they say, have been obvious for months.

“When the sun was shining, literally, the roof should have been built and it should be watertight. That wasn’t the case,” said Sir Chris Ham, former chief executive of the health think tank the King’s Fund.

“Local authorities, public health teams are trained to do contact tracing . . . and even more important, they know their communities,” he said. “And it’s been very clear . . . in recent weeks and months, unless you are part of a community where you’re doing the contact tracing, then your ability to reach contacts and then support people to isolate is very, very limited.”

Professor Robert West, a member of the government’s Spi-B behavioural advisory group, said the system had fallen short at every stage.

“It’s been a cascade of problems. We’ve not been successful in finding people who are infectious. Then we’ve not been successful in contacting them. Then we’ve not been successful at getting them to self-isolate. That means you end up with a very small number of the people you need in quarantine.”

As the country returned to lockdown, public health experts said it represented a last opportunity to restructure the system and dramatically improve the country’s ability to identify and persuade those likely to have Covid to isolate. A recent report by the Association of Directors of Public Health said: “The simple reality is that the current system is neither ‘fully operational’ nor ‘world-beating’.”

Contact tracers suggested that a publicity campaign was needed to ensure people recognise the 0300 number calling them is NHS Test & Trace and a change to the system “so that we’re not calling people multiple times, constantly calling people — they get fed up of it”.

“Why didn’t they fix it over the summer?” one clinical contact tracer said. “Since May we’ve been saying the same thing, where the hell were they?

“We all joined to try and help and make a difference and I’ve lost confidence in the role because I don’t think it’s helping.

“I need people to pick up the phone to me and not be cross and have some confidence that we’re competent.”

Sir Peter wants the government to hand over all tracing to local authorities. “There is no need for us to jump through the hoops of having a national tracing system,” he said, arguing that it was “failing and chaotic”.

“Mayors and council leaders up and down the land will say if only we were trusted with the information and it came straight to us in a timely fashion we’ve got the resources to do it but also the experience and the local knowledge.”

Sir Peter said that “any local council . . . at a fraction of the cost of the national scheme could easily have scaled up”.

Meanwhile, pressure grows on Lady Harding. She has received praise for her drive and can-do attitude even from critics who questioned whether she has focused on the right priorities. This week she defended her team’s efforts, saying they had “built a system the size of Asda from scratch in five months”. Appearing before MPs on Wednesday, she dismissed the suggestion that the summer months had been wasted, saying they had been used “to great effect to dramatically expand our testing capacity” which grew faster than any other country in Europe. A spokeswoman for the Department of Health and Social Care credited NHS Test & Trace with reaching “1.7 million people who may otherwise have unknowingly spread coronavirus” and said they had worked “hand in hand with local authorities and directors of public health”.

Lady Harding said she was “very supportive” of a “locally led, nationally supported model of contact tracing”.

“We are working really hard,” she added. “We have 150 local authorities working with us on contact-tracing partnerships as we speak and another 150 about to go live and we’re really keen to experiment and pilot with all of those local authorities to do more and more.” Asked why, six months into the pandemic, these schemes were only being piloted, she said “we’re learning all the time”.

Sir Chris Ham argued that perhaps the biggest challenge is not just fixing or restructuring the tracing system but reclaiming the public’s trust.

He said: “Fundamentally, even if we had a fully functioning test, trace and isolating system in place, if each of us is unwilling to play our part in adhering to the rules that have been put in place, then frankly we’re not going to achieve the progress we need to contain the growth of infections and to put us back into a position where the restrictions can be relaxed.”