15.In December 2020, the Department announced that it would roll out mass Lateral Flow Device (LFD) testing for schools and colleges in the New Year, building on its earlier use at universities. LFD tests give results within 20–30 minutes, compared with the standard PCR swab tests, which must be sent to a laboratory for processing. NHST&T confirmed it was also rolling out LFD tests for key workers, such as in care homes or food processing plants, and for community testing, for people without COVID-19 symptoms. To support the roll-out of mass testing, as well as the continued increase in testing capacity, the government allocated a further £7 billion to NHST&T in November in addition to the £3 billion already made available for mass testing for 2020–21. The Department informed us that it had already purchased and taken delivery of 384 million LFD test kits, with a further 239 million to be delivered in February. It was in the process of tendering for up to a further 200 million LFD tests by early March.
16.A number of significant commentators, including the British Medical Association and British Medical Journal, have raised concerns about the effectiveness and risks of mass testing with LFD tests. A particular issue raised is the relative accuracy of LFD tests compared to PCR tests and the higher risk of false negatives. Published evidence indicates that LFD tests had a sensitivity of only 77% (broadly, if 100 people with the infection take the test, only 77 of them will return a positive result). NHST&T considers LFD tests a “very useful addition to our overall testing toolkit”. But the interim evaluation of the Liverpool mass testing pilot found that, when self-administered, LFD tests overall only detected 40% of positive cases detected by PCR tests. In the evaluation, LFD tests did detect a higher proportion of positive PCR tests—around two thirds—when individuals had a higher “viral load” and were more “substantially infectious”. While the authors of the Liverpool evaluation pointed out the benefits of LFD tests in identifying many infectious asymptomatic cases who would otherwise go undetected, they also stressed the need to communicate clearly that when people test negative, it does not provide assurance that they are not infectious.
17.We are aware that the Medicines and Healthcare products Regulatory Agency (MHRA), the government’s regulatory body which approves medical devices, approved the LFD test in December 2020. However, we are concerned at media reports that it had advised the Department against using LFD tests in schools for daily testing of contacts of people with COVID-19 (as an alternative to self-isolation), because of the false assurance it may give to those testing negative. NHST&T contended that it had worked closely with MHRA on “all the rolling out of different testing protocols”, including piloting and rolling out LFD tests in schools. It confirmed that it was continuing with the process of rolling out LFD tests for people returning to school and for weekly testing of school staff, and that by the time of our session “up to 250,000 lateral flow tests were registered by schools”. Despite this, on 21 January, three days after our evidence session, NHST&T and PHE announced that they would pause the roll-out of LFD tests for daily contact testing, in light of the emergence of the new variant of the virus and to undertake further evaluation. 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.
18.NHST&T told us the biggest lesson it had learnt from the last year was that “you can only deliver this sort of service as an integrated team of all the different organisations, institutions and individuals in the country”. It said it had learned a lot about “how to build this coalition between local government and national Government, the NHS, the broader public sector and the private sector—and, ultimately, with the general public as a whole”. However, a range of stakeholders have queried why local authorities and NHS primary care bodies were not more directly involved in the government’s approach to test and trace from the outset, given their existing networks, experience and expertise. For example, the Local Government Association felt that a lack of consultation with local areas had led to test centres being set up in places that many people had difficulty getting to. Since July, local authorities have assumed a bigger tracing role, setting up their own locally run contact tracing schemes to cover the minority of cases that the national service cannot reach, working in conjunction with NHST&T.
19.The Department acknowledged that it took the decision to build up tracing capacity centrally at the beginning because of the need to do this quickly, but it maintained that there had been “a series of conversations” with local authorities and directors of public health. NHST&T stressed that it had always engaged with and had senior representations from local authorities at a national level. As of October 2020, the National Audit Office noted that NHST&T’s Executive Committee included one member from a local authority (out of 15 members). NHST&T told us that it had increasingly involved local authorities in its test and trace programme, for example through rolling out community testing. It has also established contact tracing partnerships with nearly 300 local authorities, and has plans to increase local support for ‘extended’ contact tracing (when tracers seek to identify where an individual was infected, not just their close contacts). However, both the National Audit Office report and evidence submitted by the Local Government Association highlighted a lack of clarity about whether and how much funding was available to local authorities. The Department told us that it had provided a total of £925 million to local authorities since early summer, but we remain concerned that local authorities are hampered by limited funding and resources, and continuing uncertainties around funding levels, in carrying out their share of testing and contact tracing activities effectively.
20.While we welcome NHST&T’s increasing collaboration with local authorities, we see a need for it to expand its collaboration with a range of other sectors, reflecting the wider scope of the roll-out of rapid testing. In our local constituencies, we heard of lack of engagement with school heads in the roll-out of mass testing for schools, although NHST&T told us there were joint working teams with the Department for Education for activity within schools and universities. We also remain concerned at the lack of clinical public health expertise at senior levels within NHST&T. Without cross-working processes at different levels, linking well to regions and local areas, and rooted in sound clinical and practical public health considerations, it will be difficult to develop effective collaborations across different sectors on a consistent basis. NHST&T is not just a large-scale customer service organisation; it is a vital public health intervention.
21.On 18 August, government announced that a new body, the National Institute for Health Protection (NIHP), would subsume NHST&T, the health protection functions of PHE and the Joint Biosecurity Centre. The executive chair of NHST&T is also acting as interim executive chair for NIHP. The establishment of NIHP is due to take effect from 1 April 2021. However, to date, there have been no further details published on the transition arrangements to the new body.
22.The 2020 Spending Review allocated £15 billion to NHST&T for 2021–22, to be kept under review as the vaccine programme rolled out. The government is now accelerating the roll-out of vaccines across the country, but we are yet to see 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, emphasising that vaccines and test and trace are not “either/or” strategies. The Department noted that there were still many unknowns about the vaccine, and that it still needed to think through how best to wind down test and trace capacity at the appropriate time, and what kind, and level, of capacity would be required in the longer-term. If the country does reach a situation where outbreaks of COVID-19 are more localised and sporadic, exhaustive and prompt testing and tracing in those areas will be essential, as outlined in World Health Organisation guidance.
23.Both the Department and NHST&T signalled the opportunity to generate a long-term legacy from the vast public investment in, and expansion of, diagnostic capacity. However, they have not yet articulated how this is going to happen: NHST&T told us it was still working through how laboratory infrastructure should “evolve in a post-COVID world”. It explained, “there is not a single model” for the laboratories it has set up, which range from entirely private facilities to partnerships between the NHS and private or university laboratories. We challenged NHST&T specifically on whether large testing centres were the best way forward in terms of an NHS legacy compared with having more capacity within local hospitals. Its view was that a combination of public and private approaches was preferable, given the different types of testing each undertakes.
51 ; ;
52 Qq 13, 16–17, 118
53 C&AG’s Report paras 1.28–1.29
54 Q 117
55 For example:;
56 See, for example, https://www.bmj.com/content/371/bmj.m4916
57 Q 116; https://www.gov.uk/government/publications/evidence-on-the-accuracy-of-lateral-flow-device-testing/evidence-summary-for-lateral-flow-devices-lfd-in-relation-to-care-homes
61 Q 10; Guardian,
62 Q 10
65 Q 5
66 Qq 86–87; C&AG’s report, para 7
67 C&AG’s Report, para 19, 1.24
68 Qq 86–88
69 C&AG’s Report, para 1.24
70 Qq 16, 24, 37, 120, 145–146,
71 Qs 24, 37, 93, 120
72 C&AG report, para 19; LGA submission
73 Qq 93–95
74 Qq 77–81
75 C&AG’s Report, para 1.24
76 C&AG’s report, para 1.21;
78 Q 111
80 Qq 44, 111
81 Q 113
82 Qq 41–44,126