COVID-19: Test, track and trace (part 1) Contents

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1Operational performance

1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department), including the NHS Test and Trace Service (NHST&T).1

2.Test and trace programmes are a core public health response in epidemics. The basic principles of test and trace are identifying infected individuals, or groups of individuals, through testing, and tracing their contacts as early as possible. Potentially infectious contacts are then encouraged or obliged to reduce interactions with other people (to self-isolate), thereby reducing the spread of disease.2

3.On 28 May 2020, the government launched the new NHS Test and Trace Service (NHST&T), which brought together test and trace services into a national programme, working in conjunction with Public Health England (PHE) and English local authorities.3 The government has committed £22 billion funding to the programme for 2020–21 and £15 billion for 2021–22.4 Up to November 2020, spending to date by NHST&T totalled £5.7 billion.5 Between May 2020 and January 2021, NHST&T rapidly expanded UK testing capacity for COVID-19 from around 100,000 to over 800,000 a day.6 It has also contacted 2.4 million people testing positive for COVID-19 in England and advised more than four million of their associated contacts to self-isolate.7

4.NHST&T leads on the national programme in England. Its overall aim is to help break chains of transmission and enable people to return to a normal way of life. PHE is England’s expert public health agency, with responsibilities for public health advice, analysis and support, and for responding to public health emergencies. Local authorities employ directors of public health who have a statutory duty to control local COVID-19 outbreaks.8 NHST&T is part of the Department of Health & Social Care (the Department), which has overall responsibility for testing and tracing. Throughout the pandemic, the Secretary of State for Health has had ministerial accountability for the test and trace programme. Up to December 2020, NHST&T had an unusual accountability relationship with the Department: it was subject to the Department’s financial, information and staffing controls, but its head, the executive chair, reported directly to the Prime Minister and the Cabinet Secretary. The Department told us this relationship changed on 3 December 2020, with the executive chair now reporting to the Secretary of State for Health.9

Breaking chains of COVID-19 transmission

5.The scale of NHST&T’s activities is striking, particularly given its short life. NHST&T estimated that, around the time of our evidence session, it was administering around 965 swab tests a minute, processing 365 tests and tracing 198 people.10 However, for the test and trace programme to be effective in breaking the chains of transmission, it must both identify as many people as possible who have been infected with or exposed to the virus, and also do so as quickly as possible.11 SAGE, the government’s Scientific Advisory Group for Emergencies, advised that “any delay beyond 48–72 hours total before isolation of contacts” from the original case developing symptoms, i.e. from “cough to contact”, will have a significant impact on the transmission rate.12 To understand NHST&T’s effectiveness, it is important to know both the number of people tested and contacted, and at what stage of infection, or exposure to infection, people are asked to self-isolate.

6.We are pleased that the Department and NHST&T regularly publish data on testing and tracing performance, but these data do not in themselves demonstrate how effective NHST&T is at reducing new infections. The published data include a daily dashboard and weekly statistics on a range of performance indicators including, for example, the number of tests carried out and people contacted, and turnaround times for tests in different settings.13 These indicators cover individual stages of the test and trace process but do not provide information across the test and trace process from beginning to end (“cough to contact”). For example, they do not show the total time from someone developing symptoms to being advised to self-isolate following a positive test; nor the time from someone being in close contact to a person with the virus and being advised to self-isolate.14 In its review of these data, the Office for Statistics Regulation noted that they do not yet allow people to judge “the impact the programme has on reducing the spread of COVID-19”.15 Internal data, reviewed by the National Audit Office, showed that at the end of October the median time taken between an original case presenting symptoms and their contacts being traced and advised to self-isolate was 119 hours. After our evidence session the Department and NHST&T provided updated information for the beginning of February that this now stood at 78 hours, still a little short of the internal target of 48–72 hours. They highlighted improvements in the speed of testing and contact tracing, although we note the reduction may also partly reflect changes in counting when and how quickly household contacts are reached.16 17

7.NHST&T’s effectiveness also relies on people complying with its processes, from coming forward to take a test when they have symptoms, to self-isolating in line with requirements. NHST&T noted that the single most important part of the process was people coming forward for testing.18 The National Audit Office also highlighted the low compliance with self-isolation rules, with estimates of the proportion of people fully complying with requirements ranging from 10% to 59%. We are concerned that lack of compliance is undermining the effectiveness of the test and trace programme.19 When challenged, NHST&T acknowledged more could be done but contended that its actions, such as follow-up calls with people asked to self-isolate, had helped to improve compliance since the programme began. It stressed it was “really difficult” for individuals to self-isolate and it was working with local government and broader society to support people in this. NHST&T noted the difficulty of accurately assessing how well people are complying, and that it was working with the Office of National Statistics to improve its survey-based measures of compliance.20

8.In September 2020, SAGE concluded that “test and trace was having only a marginal impact on transmission”. NHST&T said that the situation had improved, and highlighted that it was now meeting all its operational performance targets for contact tracing.21 22 It also quoted findings from an “independent verified analysis” which suggested that, NHST&T 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 (18–33% of the estimated ‘R number’ in October).23 However, as set out in the analysis published by NHST&T the biggest part of this estimated impact arises from the assumption that people self-isolate for the period between developing COVID symptoms and receiving their test results, i.e. before even engaging with the test and trace system. NHST&T’s model also suggested that only around 10% of the total reduction in the “R number” could be attributed to NHST&T’s contact tracing activities.24 We are also aware that 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.25

Managing supply and demand

9.We found that NHST&T was still struggling to consistently match supply and demand for its test and trace services. In September 2020, NHST&T significantly underestimated the increase in demand for testing, when schools and universities returned.26 Laboratories processing community swab tests were unable to keep up with demand, leading to large backlogs, limits on the number of tests available, longer turnaround times and some people having to travel hundreds of miles to get a test.27 At other times, the issue has been the large amounts of reported capacity, both for testing and tracing, not being used.28

10.The Department and NHST&T emphasised to us the importance of maintaining excess capacity in the test and trace system, due to the difficulty of predicting the pace and direction of COVID-19.29 While we accept the need to build in surplus capacity to handle surges in infections, we remain concerned that significant mismatches in supply and demand do lead to some capacity being persistently under-used. To take the example of laboratory capacity for swab testing, NHST&T intentionally runs this at less than 100%, noting that best practice is to run at between 60% and 85%.30 However, throughout November and December 2020, the weekly percentage of total laboratory testing capacity used (for swab tests administered in community and hospital settings) remained below 65%.31 And even with this apparent spare capacity, NHST&T has never met its target to turn around tests taken face-to-face within 24 hours.32 NHST&T told us its target was to turn these tests around as quickly as possible, with a particular interest in whether people get results the day after they take a test.33 As demand for tests surged over Christmas 2020, NHST&T felt it managed access better than it had in September, but the increase in volumes still led to increased turnaround times, despite apparent spare laboratory capacity.34 One member of the Committee also highlighted an issue of very low numbers of tests being done in his local drive-through testing with site in Cwm.35 The Department noted that the site has a maximum monthly capacity of 26,880, while between October and December 2020, the monthly number of tests taken there ranged from 6,026 to 16,934.36

11.For tracing, the Department accepted that, with hindsight, it did not need to scale up central tracing services for May 2020 as quickly as it did. It highlighted the very uncertain environment in April and May and the limited basis it had for estimating the numbers of people it would need to contact and trace.37 For example, the Department initially assumed that on average each person would have 10–30 contacts to trace, but by June the actual average was 2.4.38 The Department did not have any flexibility to change the level of tracing staff for the first three months, but did include break and review points in the contracts. Following this, from August, it built more flexibility into the contracts and reduced the levels of central call handlers it had contracted for. However, even through to October 2020, utilisation rates of central call handlers remained well below the target utilisation rate of 50%, and as low as 1% in August.39

Use of contractors and consultants

12.NHST&T relies on contractors for many of its supplies, services and infrastructure. The Department stated that, to scale up NHST&T so rapidly, it had used a “blended mix” of civil servants, military support, contractors and consultancy support.40 By the end of October 2020, NHST&T had signed 407 contracts worth £7 billion with 217 public and private organisations, of which 121 (or 70% of the contract value) were assigned as direct awards without competition under emergency measures.41 The Department told us that, in November and December, it had awarded a further 207 contracts worth £1.3 billion, of which around 30 were direct awards under emergency regulations. It anticipated further reductions in the use of these regulations in favour of competitions and tendering exercises in future.42

13.The response to a parliamentary question confirmed that, at the beginning of November 2020, there were 2,300 consultants and contractors working for 73 different suppliers in NHST&T, with a total consultancy cost of approximately £375 million up to that point.43 However, when giving evidence to the Science and Technology Committee on 3 February, NHST&T said that it was still employing around 2,500 consultants.44 When we took evidence in mid-January, the Department estimated around 900 contractors from Deloitte alone were still on NHST&T’s books.45 The Department reported to us that the average cost per consultant was about £1,100 a day, up to a maximum of £6,624 for some consultancy staff.46 It also said it had plans to reduce NHST&T’s reliance on external consultants, although this was dependent on the availability of civil service recruits to fill posts and future demand for test and trace services.47

14.We challenged the Department and NHST&T on the value for money and their scrutiny of these consultancy contracts and associated spend. On day rates, the Department felt it had mitigations in place, including specifying within contracts that services are to be obtained from staff at an appropriate grade, rather than directors and partners by default. It also noted that some consultancies had dropped their normal public sector rates for COVID-19 work.48 The Department felt it had mitigated the risk of profiteering through its approvals and contract management processes, and the way it structured its contracts, e.g. by not committing to fixed levels of volume. It also told us it had “beefed up” NHST&T’s commercial function.49 The Department said that it was as confident as it could be, based on monitoring information, that there was no profiteering, and that it did not have, and had not had, any “red flags” on contractors or contracts linked to NHST&T.50