Coronavirus: lessons learned to date Contents

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4Testing and contact tracing

163.While, as we will illustrate in Chapter 7, the UK’s vaccination programme has been a national success, the record during the pandemic of the test, trace and isolate programme is more mixed. The slow, uncertain, and often chaotic performance of the test, trace and isolate system during the first phases of the pandemic was a drag anchor on the UK’s response to the pandemic. Partly because NHS Test and Trace was only established when daily infections had risen to 2,000, it ultimately failed in its objective to prevent future lockdowns despite vast quantities of taxpayers’ money being directed to it.243 In contrast to the approach to vaccines, which we discuss in greater detail in Chapter 7, NHS Test and Trace had to build a new organisation and respond to changing circumstances while it was operating rather than being able to anticipate these in advance of the system being in operation. In this Chapter, when we refer to NHS Test and Trace we refer to the new organisation set up by the Department of Health and Social Care, initially led by Baroness Harding, in partnership with several public and private organisations.

164.This Chapter looks at a number of different facets of the test, trace and isolate system—though they are illustrative rather than exhaustive. While it describes an unsatisfactory history, there are signs that the UK has now arrived at a more dependable outcome: the UK now has, in principle, the ability to test more than 800,000 people a day, and in the week commencing 23 August 2021 there were more than 5.6 million tests carried out in England, more than any EU/EEA country.244 But there are many lessons to be learned on the way and this notional capacity has yet to be fully tested in action.

165.In this Chapter we consider in particular:

• the initial testing capacity available;
• the decision to abandon testing in the community;
• the 100,000 tests a day target introduced by the then Secretary of State;
• the centralisation of testing laboratories;
• the shortage of testing capacity in Autumn 2020;
• the organisation of contact tracing; and
• the management of “NHS” Test and Trace.

Limited testing capacity

166.During the early days of the pandemic, the Government believed—and told the public—that testing for covid-19 was a field in which the UK had a leading position. This assessment was shared, and possibly arose out of, the views of scientific advisers. The minutes of the very first SAGE meeting on covid-19 on 22 January 2020 stated:

The UK currently has good centralised diagnostic capacity for WN-CoV [covid-19]–and is days away from a specific test, which is scalable across the UK in weeks.245

The following day, on 23 January 2020, the then Secretary of State for Health and Social Care told the House that the UK is “one of the first countries to have developed a world-leading test for the new coronavirus.”246 When the Prime Minister claimed to have “growing confidence that we will have a test, track and trace operation that will be world-beating,” it may be that this early lead was what he had in mind.247 However, it rapidly became apparent that the scientific expertise in identifying the virus and the ability to deploy that operationally were very different. Public Health England was initially responsible for managing covid-19 testing as well as the scientific development of a test for covid-19, but it is in the former that its deficiencies were exposed.

167.SAGE minutes from 28 January 2020 recorded that notwithstanding the scientific lead in establishing a test, PHE only had operational capacity to administer “400 to 500 tests per day” for the whole country.248 Other countries such as South Korea and Hong Kong, who did not benefit from our lead in producing a test, nevertheless rapidly developed a testing capacity to allow a comprehensive testing programme to be put in place during the early weeks of the pandemic.249 By contrast, during the whole, crucial, period between 25 January and 11 March 2020, in which the virus was spreading across the whole country, only 27,476 coronavirus tests were performed in the UK.250 To put this in context, that is less than one test a day for each parliamentary constituency.

168.Professor Martin explained to us that early in the pandemic there were “very severe constraints in equipment and consumables” which acted as a drag on testing capacity:

Bear in mind that those were all new tests coming on stream at the beginning of the pandemic. Effectively, there was not enough to go round. It was global; it was not just the UK. There was a global shortage of the consumables. […] There are big international suppliers that have capped the UK supply of consumables251

169.However, throughout the pandemic, our Committees have taken a great interest in what might be learned and applied from how other countries tackled the virus. In March 2020, the World Health Organisation recommended that nations “plan for surge capacity by establishing decentralized testing capacity in sub-national laboratories”.252 Dr Seon Kui Erica Lee, of the Korea Centers for Disease Control and Prevention, told the Science and Technology Committee in April 2020 that testing capacity in the Republic of Korea had expanded rapidly because of lessons learned from the 2015 MERS outbreak.253 Dr Max Roser also explained to us that “by mid-March [2020], Germany was testing 50,000 people per day”, whilst the UK was “very late” and reached the same capacity one and a half months later.254

170.In evidence to the Science and Technology Committee on 25 March 2020 Public Health England claimed to have formally studied, but rejected, the South Korean approach.255 Despite repeated requests by the Committee no evidence of such an evaluation has ever been produced. We must conclude that no formal evaluation took place which amounts to an extraordinary and negligent omission given Korea’s success in containing the pandemic which was well-publicised at the time.

171.As a result the UK squandered a leading position in diagnostics and converted it into one of permanent crisis. On 12 March, testing for covid-19 other than in hospitals was halted. In part this was because of the inadequacy of the early flu-based strategy—a flu-strategy which mandated ending testing when there was community transmission—but partly also because of a simple lack of capacity. The abandonment of community testing meant that contact tracing—which was fundamental to the success of the Korean approach—also had to be abandoned. If people could not be tested, their contacts could not be traced.

172.Shortly after this seminal failure, in mid-March 2020 responsibility for the testing strategy was taken over by the Department of Health and Social Care from Public Health England.256 It was not until 18 May 2020, when the first wave of covid-19 had begun to wane in the UK, that widespread community testing for covid-19—and therefore contact tracing—was able to resume.257

173.The consequences of this initial failure were profound. Testing not only allowed individuals to be identified who had covid-19—and were infectious—but test results for an invisible virus were the only way to be able to accurately monitor the incidence and spread of the virus across the country, and to understand which groups it affected most and which it affected least.258 The UK was reduced to understanding the spread of covid-19 by waiting for people to be so sick that they needed to be admitted to hospital.

174.For a country with a world-class expertise in data analysis, to face the biggest health crisis in a hundred years with virtually no data to analyse was an almost unimaginable setback. The reasons for this initial inadequacy to translate testing technology into deployable testing capacity are varied. Public Health England seemed to be better at its scientific responsibilities than in its operational response to a mass outbreak of disease and was not clearly instructed to rectify the issue.259 Public Health England reported directly to the Department of Health and Social Care, with only limited operational independence, so the Department too should have been more aware of the issue.

175.We also consider that the Government’s scientific advisers were too passive in accepting assurances that the clinical operational capacity of Public Health England could not be changed. Even in March 2020, Professor Neil Ferguson explained that “much more widespread testing” was required but that SAGE had received “very clear messages from PHE that we would have nowhere near enough testing capacity.”260 It would have been quite possible for SAGE to advise that a significant increase in testing capacity was needed. It may be that continued adherence to the early four-stage flu plan contributed to this absence of effective scientific pressure for more testing capacity.

176.It is clear that there should have been more challenge to Public Health England to increase testing capacity from the outset by Ministers, scientific advisers and the Department of Health and Social Care rather than accepting it as a fait accompli.

Consequences of abandoning testing in the community

177.As noted earlier, the failure to have enough testing capacity in the early weeks of the pandemic contributed to a lack of knowledge as to how the infection was spreading in the country. Speaking to us in November 2020, Professor Sir Chris Ham, Chair of the Coventry and Warwickshire Sustainability and Transformation Partnership, reflected that the decision to halt test and trace in the community had been a practical decision, and that any scientific advice behind it had “not been forthcoming”:

if you go back to March, we simply did not have the capacity for testing, tracing and isolating that we needed in relation to the volume of cases. […] Testing capacity had to be focused on the high priorities—staff working in health and care and patients receiving that care. It was very sad that that decision had to be taken, but it was not about science. It was about practicalities.261

178.The lack of data resulting from suspending community testing also affected the UK’s understanding of the disease at that critical time. Professor Neil Ferguson explained to the Science and Technology Committee in June 2020 that low testing capacity meant it was difficult to estimate the proportion of imported cases which had been missed:

at the time we had a policy of trying to screen people at borders, and we estimated then that maybe two thirds of imported cases had been missed. What we now know, because the epidemic took off in Italy and Spain before anybody had realised, is that probably 90% of cases imported into this country were missed by those border measures, because we were not checking people. […] Had we had the testing capacity […] screening everybody with symptoms coming in would have given us a much better impression of where infection was coming from.262

Arguably this lack of data could have contributed to the delay in the critical decision to instigate a nationwide lockdown. As Professor Chris Whitty explained:

because we had very limited testing capacity, we did not realise quite how far along the curve we were, because we were having to use people in intensive care and who had sadly died, which is quite a late event. If we had the capacity on testing then that we have now, we would have come to very different conclusions using exactly the same science.263

Professor Whitty suggested that one key lesson was to “build our capacity to do testing […] at scale”, which he described would be “a problem with any pandemic we have in the future”.264

Impact on health and social care

179.Professor Chris Whitty told the Health and Social Care Committee in July 2020 that the lack of testing capacity available at the beginning of the pandemic meant that the Government had to focus resources very closely on the hospital sector, and in particular intensive care units.265 Within hospitals, the prioritisation of patients admitted to intensive care meant less testing capacity was available for other patients in hospital, inhibiting the safe provision of non-covid NHS care and increasing the risk of nosocomial infections. The British Infection Association, the professional association for infection specialists, stated that “decisions about who to test and when early in the pandemic almost certainly led to […] nosocomial and [healthcare worker] infections in secondary care.”266 In February, a paper submitted to SAGE by Public Health England and the London School of Hygiene and Tropical Medicine estimated that during the first wave of covid-19 alone, 36,152 people in England contracted covid-19 while in hospital, representing 40.5% of all hospital cases.267

180.The lack of available testing for social care was particularly damaging, as we discuss in more detail later in this Report. Crucially, it was not until mid-April that covid-19 testing was made a requirement for people discharged from hospital to social care—even on 2 April 2020 guidance still stated that negative tests were not required for a discharge to social care.268

181.The Health and Social Care Committee’s Reports on social care and the delivery of core NHS and care services during the pandemic also highlighted the impact of a lack of testing for social care staff in the initial wave of the pandemic. Evidence from across the sector, including from staff themselves, was unanimous that the lack of provision of regular testing for social care staff had meant that social care staff were more likely to transmit the disease within care homes.269

100,000 tests a day target introduced by Secretary of State

182.Following the initial shortage of testing capacity and the slow increase in the availability of tests during the critical first eight weeks of the pandemic, responsibility for the testing strategy was removed from Public Health England and vested in the Department of Health and Social Care. On 2 April the then Secretary of State announced a target of carrying out 100,000 covid tests a day by the end of the month.270 This was a personal initiative on the part of the then Secretary of State, Matt Hancock MP, to jump start substantial testing capacity. At the time witnesses to the Committees distanced themselves from the 100,000 target. For example, even the then Government testing tsar, Professor John Newton, said to the Science and Technology Committee “It is not a SAGE target; it is the Secretary of State’s target […] you would have to ask the Secretary of State himself exactly where he got his advice from.”271

183.Subsequently, Dominic Cummings, in evidence to our inquiry, strongly criticised the then Secretary of State for naming this target, describing it as “an incredibly stupid thing to do.”272 However, Mr Hancock defended the target, saying to the Committees, “that 100,000 target was essential in galvanising the whole system and building a diagnostics organisation and ecosystem in this country.”273 The 100,000 target was announced as having been achieved by 30 April, although to do so required including tests which had been distributed by mail but which had not been processed.

184.Given the painfully slow increase in the availability of testing before April 2020, we consider that the impact of the Secretary of State’s target to have been an appropriate one to galvanise the rapid change the system needed. However, as such a personal and unilateral approach was needed—and appears not to have been supported by other parts of Government—it is concerning to contemplate what would have happened without this unorthodox initiative.

185.As a result of the increase in testing capacity driven during April, the UK Government finally resumed community testing on 18 May 2020, following an expansion of capacity, which included more than a doubling of the NHS and PHE laboratory network capacity.274 In its April 2020 testing strategy, the Department of Health and Social Care set out a “five pillar” plan for how covid-19 testing would be scaled up:

• Pillar 1: Scaling up NHS swab testing for those with a medical need and, where possible, the most critical key workers;
• Pillar 2: Mass-swab testing for critical key workers in the NHS, social care and other sectors;
• Pillar 3: Mass-antibody testing to help determine if people have immunity to coronavirus;
• Pillar 4: Surveillance testing to learn more about the disease and help develop new tests and treatments; and
• Pillar 5: Spearheading a Diagnostics National Effort to build a mass-testing capacity at a completely new scale.275

The capacity for community testing was expanded further primarily under ‘Pillar 2’ of the Government’s testing strategy, through the creation of a series of Lighthouse Lab facilities from early April onwards.276 These “mega-labs” were set up through partnerships between academia, commercial partners, public bodies and not-for-profit organisations, and integrated into a “new national testing infrastructure” and served the entire United Kingdom.

186.Evidence received by the Science and Technology Committee suggested that taking a centralised approach to increasing testing capacity was appropriate as it might not have been practical to focus on boosting local-level capacity alone. For example, Dr Richard Harling, Director of Health and Care for Staffordshire County Council, suggested that the expansion of testing capacity was “unlikely to be something we would have the expertise or specialism to do locally”.277 Similarly, Greg Fell, Director of Public Health at Sheffield City Council, suggested that while Sheffield was “very early in large-scale testing […] we quickly got to a stage where we needed the large-scale labs that we now have”.278

187.However, both our Committees heard that other resources could have been used more effectively in the initial expansion of testing capacity. Professor Sir Chris Ham explained that initially the Government was “very much focused on building capacity in the commercial Lighthouse laboratories” but suggested that this focus was to the detriment of other potential capacity:

if more had been done during the summer months […] for example, we could have made greater use of university laboratories and NHS laboratories—we might have been able to add capacity to avoid the bottlenecks that occurred [in September].279

Sir Paul Nurse also made this point, referring to an earlier press release by the Francis Crick Institute, stating:

We argued very early on, in March it has to be said, that we should mobilise much more locally. We turned the Crick into a testing facility. We used that terrible metaphor of Dunkirk and little ships, and so on, but we produced a testing facility locally within two weeks that was doing 2,000 tests a day.280

Professor Jo Martin, President of the Royal College of Pathologists, suggested that it was not strategically wrong to set up the Lighthouse Laboratory network to process testing on a large scale, but indicated that NHS laboratory testing had also “ramped up hugely”:

At the beginning of the pandemic, the NHS labs were desperate to ramp up testing […] The pathology laboratories for the health services process 1.1 billion tests a year. The NHS does high throughput testing. We do that every year, so we are good at high throughput testing281

188.Despite this, it appeared that there was a disconnect between the testing operation in the Lighthouse Laboratories and NHS labs. For example, the Institute of Biomedical Science suggested that there was a “lack of integration and collaboration” between the laboratories providing Pillar 1 testing (NHS and PHE labs) and Pillar 2 testing (e.g. Lighthouse Labs).282 Further, Professor Martin told us that there should have been “more awareness of the end-to-end process”, pointing to one example of mismatched data systems.283

“World-beating” systems and moonshots

189.Throughout the last 18 months, the test and trace system has had labels applied that have been at variance with the reality. Ministers began by promising the test and trace system would be “world-beating” in May 2020 when the truth was that it was that it was a laggard.284 Antibody tests were heralded in March 2020 by Ministers as “game changers” long before their role in the system was certain.285 In September 2020, the Prime Minister announced a new “moonshot” plan with the ambition to use rapid covid-19 tests with millions of tests processed daily which would allow normal lives to be resumed without the need for social distancing.286

190.In May 2020 the label “NHS” was applied by the Department of Health and Social Care to the test and tracing system, despite it being operated outside the NHS. It was notable that in evidence to our inquiry, the then Chief Executive of NHS England, Sir Simon Stevens, pointedly refused to use the term NHS in conjunction with the Test and Trace operation.287

Mass testing ‘moonshot’

191.The Government has pursued both mass antibody testing (to identify who previously had covid-19) and mass diagnostic testing (to identify those currently infected) as means to return to normality. In its April 2020 testing strategy, the Government said it was “committed to mass testing” and stated its “overall ambition is to provide enough swab tests for everyone that needs one”.288 On 9 September 2020, the Prime Minister announced the Government’s “moonshot” plan with the ambition to use rapid covid-19 tests “on a far bigger scale than any country has yet achieved–literally millions of tests processed every single day”.289 He also stated that this plan would “allow people to lead more normal lives, without the need for social distancing”. The Prime Minister expressed hope that by Christmas 2020, venues such as theatres could benefit from mass-scale rapid testing and that the technology would be “widespread by the spring”.290

192.That optimism does not appear to have been shared by scientists advising the Government, who struck a more cautious note. For example, at the same press conference Sir Patrick Vallance pointed out that the technologies still had to be trialled, saying that it was “completely wrong to assume this is a slam dunk that can definitely happen”.291 Further, a SAGE ‘task and finish group’ on mass testing concluded in late August 2020 that the use of testing as a “point-of-entry requirement” for venues and events could reduce transmission risk but it would have a “minimal effect” on reducing ‘R’.292 Following trials in different settings, most notably a citywide trial in Liverpool,293 it was not until 9 April 2021 that rapid coronavirus testing was offered to everyone in England, including those without symptoms.294

193.As with other aspects of covid-19 testing, the Government has put a significant amount of public money towards mass testing. The NAO’s December 2020 report on test and trace indicated that (leading up to October) £2.9 billion had been earmarked for mass testing, over twice the budget allocated to tracing at that time.295 At the time of the Prime Minister’s mass testing announcement in September 2020, the British Medical Journal reported that leaked Government documents indicated that a mass testing programme might cost over £100 billion to deliver.296 However, the SAGE task and finish group warned that “careful consideration” was needed to justify whether resources allocated to mass testing would achieve a larger benefit, over “investing equivalent resources” in existing test and trace activities and improving adherence to self-isolation.297

The testing shortages of Autumn 2020

194.During the summer of 2020, rates of covid infection declined markedly in most parts of the United Kingdom. Average hospitalisations from covid fell to 119 per day on 1 August 2020 compared to 3,000 per day in early April. Yet as soon as infections began to rise in September 2020—when schools, universities and many workplaces returned after the summer holidays—the test and trace system was found once again wanting. A period of relative calm in August did not appear to have been used to anticipate and prepare for what was likely to be needed during the Autumn.

195.Despite undergoing a large increase in testing capacity over the first lockdown period—reaching over 200,000 daily tests by the beginning of June 2020298—the test and trace service in England then struggled to keep up with a sharp increase in demand following the reopening of schools and universities in September 2020. To tackle that increase, NHS Test and Trace had to “limit the number of tests available, lengthen turnaround times, and commission extra assistance from NHS and ‘surge’ laboratories”.299 The Government was also forced to prioritise testing for those in the NHS and in care homes, as explained by the then Executive Chair of NHS Test and Trace, Baroness Harding.300

196.During September 2020, the Science and Technology Committee heard from Baroness Harding that NHS Test and Trace had “planned for a sizeable increase” but that she “[did] not think anybody was expecting” the level of demand experienced.301 She explained one reason for the surge was that a proportion of ineligible individuals were showing up to receive covid-19 tests:

we have been running some surveys […] 27% [of visitors to walk-in testing sites] said they were there because they had been in contact with someone who had tested positive, but they did not have symptoms themselves.302

This should not have been quite so unpredictable given previous advice by the then Secretary of State for Health and Social Care to get a test “if in doubt and if people think they might have the symptoms”.303 The demand for testing might also have been compounded by an issue later raised by Professor Sir John Bell that “95% of people with [perceived] symptoms do not have the disease”.304

197.The NAO’s December 2020 report pointed out further that NHS Test and Trace was unable to meet demand due to insufficient laboratory capacity as a result of:

• delays in getting new laboratories up and running;
• delays in delivering testing equipment, including supply chain problems with swabs, screening kits and testing reagents; and
• difficulties in staffing new laboratories.305

198.Two months earlier, in July 2020, the Government Chief Scientific Adviser, Sir Patrick Vallance, told the Science and Technology Committee that extra testing capacity would be “essential” ahead of schools reopening.306 However, he suggested that the Government did not have the capacity to meet the potential demand of over 350,000 tests per day, a figure suggested by the Academy of Medical Sciences at the time.307 Nevertheless, Baroness Harding suggested that the level of demand encountered in September was “in none of the modelling” used by NHS Test and Trace to assess capacity.308 She told the Science and Technology Committee that capacity plans had been “based on SAGE modelling for what we should be preparing for in the autumn”, and that it was SAGE’s assessment rather than NHS Test and Trace’s.309 However, she later wrote to the Committee in a follow-up letter to clarify that SAGE had not informed the capacity targets:

SAGE has not been responsible for providing modelling analysis on operational testing capacity […] In order to model and forecast potential demand for testing and therefore what testing capacity will be required, NHS Test and Trace and the Department of Health and Social Care (DHSC) analysts draw on a range of sources including outputs from SPI-M modelling of the epidemic and modelling of the [Reasonable Worse Case Scenario]. Other sources include inpatient testing, screening for screening for elective/non elective admissions to hospital and NHS staff using information and forecasts from NHS England.310

199.Overall, the National Audit Office concluded that NHS Test and Trace “did not plan for a sharp rise in testing demand in early Autumn [2020]” and was therefore “unprepared.”311 Professor Chris Whitty reiterated to both Committees in December 2020 that one key learning was the need to scale up testing capacity, stating that the UK had been “caught out twice now with lack of testing, and three times would be too many”.312 By January 2021 testing capacity had reportedly increased to 800,000 per day and Baroness Harding expressed that she was “very confident” that there was sufficient capacity to handle future potential surges—citing the increased demand over Christmas as an example.313

200.The failure of the test and trace system to rise to meet even the most predictable of demands in Autumn 2020, especially given many weeks to prepare, suggests that lessons that were learnable during the pandemic were not applied. An urgent priority for the Government must be to satisfy itself that there is now a dependable organisation for covid testing that can both anticipate and meet future demands.

The role of Test and Trace in autumn lockdowns

201.In the autumn of 2020, NHS Test and Trace made a series of submissions for a budget to allow it the operational resources it assessed were required during the year ahead. The sums of money were vast. The budget of the operation was established at £37 billion—more than the annual budgets of whole government departments such as the Home Office (£17.7bn) and the Ministry of Justice (£10.3bn), and more than twice the entire UK budget for scientific research (£14.9bn in 2021/22).314

202.For such an unprecedented request, a big justification was mounted, most notably that investing at that level would avoid the need for future lockdowns. New outbreaks would in future be rapidly detected and eliminated, so allowing most of the country to resume much of normal life. The prize was a significant one economically, given that furlough alone was costing the Exchequer on average between June and September 2020 £6 billion a month.315

203.The National Audit Office has stated that in NHS Test and Trace’s retrospective September business case, the aim of the organisation was to “avoid the need for a second national lockdown”.316 The NAO indicated that NHS Test and Trace would seek to do this by contributing to a reduction in the ‘R’ value. Yet despite this aim, which was funded by the Government, England underwent a second national lockdown from 5 November to 2 December, and a third national lockdown was instigated on 4 January 2021.317

204.Even at the same time as NHS Test and Trace was setting out its goals in its business case, SAGE documents concluded that the system was having a “marginal impact on transmission”, although it acknowledged the difficulty in estimating the system’s effectiveness.318 Speaking to the Science and Technology Committee in November 2020, the Chief Medical Officer for England, Professor Chris Whitty, commented that test, trace and isolate efforts were “most effective when the rates [of transmission] are low”.319 In terms of the expected impact on the reproduction number, ‘R’, Professor Whitty explained that “even under perfect conditions, test and trace takes only a proportion of the R”.320

205.However, the Test and Trace Business Plan—published in December 2020—stated that in October NHS Test and Trace had “reduced the R number by around 0.3–0.6”.321 This assessment was based on an “externally reviewed model”, which was not published alongside the business plan. Further, that model had not been made public by the time of a hearing of the Public Accounts Committee on 18 January 2021, despite Baroness Harding referring to the data as evidence of NHS Test and Trace’s “material impact” on ‘R’.322 The analysis remained unpublished when the Science and Technology Committee spoke to Baroness Harding on 3 February 2021. Baroness Harding explained that the technical description of the model was undergoing quality assurance:

Greg Clark: […] Why does it take a month to be able to publish evidence that you put in the public domain by dint of an appearance before the [Public Accounts Committee] of Parliament?

Baroness Harding: Simply because the work on documenting the detailed technical annexes needs to be properly quality-assured so that we are not in any way misleading when we publish all the detail.

Greg Clark: How do you know you were not misleading when you told the Public Accounts Committee that you were reducing R significantly?

Baroness Harding: Because we are quality-assuring not the calculation but the technical description of what we are doing. […] We are extremely mindful that it is important that not only is the calculation correct, which we are confident it is and are not changing, but that the explanation of the analysis that has been conducted is easy to understand, digestible and helpful.323

This technical description—labelled the Rùm Model Technical Annex—was not publicly disclosed until 11 February 2021,324 following a letter from the Science and Technology Committee urging its publication.325 In a subsequent meeting, Dr Johanna Hutchinson, Director for Data and Data Science at the Joint Biosecurity Centre, stated that the document was “ready for publishing by the end of January” before going through “ministerial processes” ahead of its public release.326

206.While it took two months for the technical annex to be published, the analysis was effectively outdated by the time it was released. Dr Hutchinson outlined to the Science and Technology Committee in February 2021 that an update to the analysis was “in design”:327

since we did the October-like effectiveness model, we have seen the new variant come through and we have seen vaccination take place within communities, which are impacts that we have to factor into a model. We have also seen a change in the testing regimes, as we have discussed, with mass testing and daily serial testing. Those need to go in, so every time there is a change—either in the operation, which is usually triggered by a change in our environment, or, as we have seen, the transmission of this disease—we have to recalibrate.328

We note therefore that when Baroness Harding told the Science and Technology Committee in February 2021 that the test and trace service was “on track to reduce R in high-prevalence areas by between 0.6 and 0.8 by the end of March”,329 her statement was based on out-of-date information.

207.One aspect of the effectiveness of the test and trace system that has been of consistent public concern has been the speed at which the system operates. There are several components to an effective test and trace system, and performance has improved against some measures such as the distance members of the public have to travel to access testing, and turnaround times for test results.330 Speaking to the Science and Technology Committee in November 2020, Professor Chris Whitty suggested that the “biggest impact” of test and trace depended on end-to-end turnaround times for the whole test, trace and isolate process:

to reduce R test and trace systems need to get the results back as fast as possible. The faster they do so the bigger the effect on R. That is a critical part of it. One of the reasons that I among others are keen not to have test and trace always being asked to do yet more things is that the shortening of the time is a critical part of it.331

Reflecting this, minutes from a SAGE meeting in May 2020 reported that “any delay beyond 48–72 hours total before isolation of contacts results in a significant impact on R”.332 The advisory body also stated that an effective test and trace system would need to reach at least 80% of contacts of a confirmed case. However, the NAO reported that by the end of October 2020, the “median total time between an original case presenting symptoms and their contacts being traced and advised to self-isolate was 119 hours”.333 It is worth noting that to deal with the surge in testing demand in September (see paragraphs 194–200) NHS Test and Trace had to extend turnaround times.

208.When asked about ‘end-to-end’ times in February 2021, Baroness Harding stated that she did “not fully recognise” the NAO’s calculation, but suggested that she believed NHS Test and Trace was operating within the 72 hour target set by SAGE.334 While the data behind this statement were not published, Baroness Harding indicated it would be made public “as soon as possible”. From 11 February, NHS Test and Trace began to provide details of the “end-to-end journey time” through the system, including metrics such as the time taken for contacts to be reached from the date that a person started experiencing symptoms.335 Data on the “median time from case first reporting symptoms to contact reached”, covering the period of June 2020 to May 2021, showed that the “end to end” time was consistently above 100 hours for most of 2020 and peaked at over 140 hours during the September backlog.336 This reflects the conclusions within the NAO’s December 2020 report. Nevertheless, during 2021 the total time decreased to be consistently below 100 hours, although as of late August 2021 it had not fallen under the SAGE target of 72 hours.337

209.Once again as cases began to rise again in late May and June 2021, NHS Test and Trace performance began to decline again. In the week ending 30 June 2021, 76.9% of in-person test results were received within 24 hours compared to 83.8% in the previous week; the median turnaround time for home tests increased from 41 hours to 44 hours; and 87.9% of contacts were reached compared to 90.7% the week before. This latter figure represented the lowest percentage since the week ending 10 February 2021.338 Median end-to-end turnaround times spiked to 97 hours in mid-April, coinciding with the end of Easter school holidays, but by the week ending 30 June had returned to normal, albeit still above the SAGE target of 72 hours.339

210.Although the speed of the test and trace service is important for the overall effectiveness of the system, Professor Dame Anne Johnson, Professor of Infectious Disease Epidemiology at UCL, pointed out that overall “perhaps the biggest benefit that comes from testing and isolation is the isolation” and that “contact tracing is only part of the system”:

contact tracing is always a leaky system. […] given that we now know that around 40% of cases are asymptomatic, we will never—even with the best system—be able to identify those cases. […] there are losses at every stage of the cascade […] It has always been a leaky system.340

Contact tracing

211.During the period before vaccinations had covered the majority of the population, one of the essential purposes of a system of testing for covid was to be able to trace the contacts of people with covid and to cause them to isolate lest they had contracted the virus and could infect others. The early success of testing systems in other countries—notably in East Asia—was an effective capability to identify the contracts of individual cases.

212.The UK public health system has for many years had, and has deployed, contact tracing for people with communicable diseases. Indeed it is fair to say that it is a core capability of local directors of public health.

Centralised and local capacity

213.The NAO’s interim report on test and trace from December 2020 explained that with the launch of NHS Test and Trace, the Government established a national tracing model comprising a “central pool of contact tracers” to handle the majority of cases, whilst also expanding PHE-led regional teams.341 The Government contracted Serco and Sitel to provide call handlers to increase central capacity rapidly, worth up to £720 million in 2020–21.342

214.It was not until July 2020 that local authorities started to take on a larger role in tracing activities, working with NHS Test and Trace to trace cases that the national service had failed to reach. Both Committees heard from directors of public health of the benefits of locally led tracing activities. For example, Dr Richard Harling explained to the Science and Technology Committee in January 2021 that:

The role that directors of public health and local authorities play in the Covid pandemic is as a lynchpin to access all the many local resources. While there is considerable expertise at national level, what we bring is a very detailed knowledge of the local patch, our local people and how things work around here, so we can get things done usually very quickly.343

This was also reflected in evidence to this joint inquiry given by Professor Dominic Harrison, Director of Public Health and Wellbeing at Blackburn with Darwen Borough Council, who suggested that local public health teams also provided a “wrap-around service”, for example supporting individuals to access self-isolation payments and other local support.344

215.Both Committees received evidence from directors of public health that local tracers had proved highly effective at reaching cases that the national system had failed to contact—with success rates as high as 89%.345 This is corroborated by the NAO’s interim report on NHS Test and Trace, which pointed to analysis by the Local Government Association (LGA) that ten locally run schemes reached between 47% and 91% of cases that the national system could not.346

216.Given the described advantages of locally led tracing efforts, many witnesses have questioned the Government’s apparent initial focus on expanding centralised tracing capacity. For example, Professor Sir Chris Ham criticised the Government’s approach as “biased too much towards the national and [was] too late in providing resources and staff at local level”:

On contact tracing specifically, the Government chose to go down the route of bringing in private sector expertise through Serco and Sitel to run the national system. Only belatedly have they recognised the expertise that exists within our councils and our public health teams. There has been a shift from national orientation back in March and April through to much more local leadership today. […] But it has been too slow.347

217.The NAO’s December 2020 report reflected that NHS Test and Trace had explained that in April and May 2020 it had been “only feasible to focus on expanding centrally first, building on existing PHE technical systems” and that the body “had always planned to build out from the initial system to create an integrated national and local tracing service”.348 Nevertheless, the NAO also pointed out that no formal documentation or public communications had been seen to evidence that this was the intended strategy.

218.Although NHS Test and Trace continued to expand regional contact tracing partnerships throughout summer and autumn 2020,349 the Science and Technology Committee heard in January 2021 that much communication between local and national contact tracing systems was deficient. Greg Fell, a Director of Public Health, explained that clear lines of communication to all parts of the national tracing service were uneven:

most [directors of public health] have very good relationships with Public Health England, which is essentially tier 1 of NHS Test and Trace. […] For tiers 2 and 3 it is improving, but there is still a long way to go to be able to navigate our way through that system. However, that is improving over time. To be clear, it is not fundamentally broken as perhaps it was six or eight months ago.350

This view was endorsed by Dr Richard Harling, another Director of Public Health, who described the relationship with NHS Test and Trace as “relatively remote” and that local public health teams were lacking “well-developed relationships with a local account manager, for example, who we could turn to with issues and problems”.351

219.NHS Test and Trace’s July 2020 business plan stated that its model was “local by default”.352 However, the evidence we have set out in the preceding paragraphs suggests that this approach was not taken forward in practice from the outset, and that the Government pursued a strategy of central first, local later. There is also evidence to suggest that local public health experts were not sufficiently involved in the design and implementation of tracing activities and capacity. For instance, Greg Fell told the Science and Technology Committee that he did “not recall being consulted about the establishment of NHS Test and Trace and the contact tracing system”, and that public health directors had been “told but probably not consulted”.353 More broadly, the NAO has indicated that early on PHE—and later NHS Test and Trace—set up working groups and secondments with local government stakeholders, however the NAO pointed to concerns from the LGA and the Association of Directors of Public Health (ADPH) that “central bodies and their contractors had not engaged sufficiently with local government and public health experts on key decisions about the design of test and trace services or the practicalities of implementing these services”.354

Compliance with self-isolation

220.The effectiveness of a test, trace and isolate system depends on how successfully cases of covid-19 are isolated to prevent onward transmission. As the NHS Test and Trace business plan stated, “effective self-isolation is a critical part of breaking chains of transmission.”355 However, various estimates suggest that NHS Test and Trace has not achieved the levels of isolation required to make the system effective.

221.The National Audit Office estimated in its December 2020 report that the proportion of people fully complying with self-isolation requirements ranged from 10% to 59%, while Baroness Harding stated that surveys on self-isolation indicated that 54% of people self-isolated when asked to do so.356 While Baroness Harding pointed out that partial compliance with self-isolation was still beneficial and that the figures were an incomplete picture, it is clear that there has consistently been a significant proportion of people who did not comply with self-isolation requirements. Most seriously, in evidence to the Science and Technology Committee in February 2021, Baroness Harding suggested that as many as 20% of people testing positive for covid-19 were not self-isolating—possibly representing around 20,000 people per day at the time.357

222.One factor which witnesses to our inquiry identified as particularly important to support self-isolation was financial support. Professor Sir Chris Ham highlighted the need to “give people the right kind of financial support, particularly those in low-paid jobs,” Professor Dominic Harrison stated that “there is a different level of capacity to do so across different communities,” while Professor Doctor Gérard Krause highlighted the importance of the financial support known as “short work” in Germany which enabled people to self-isolate without financial risk.358 Baroness Harding agreed with this, stating:

I agree with Professor Harrison that all the evidence shows that people are not complying with isolation not because they don’t want to but because they find it very difficult, and the need to keep earning and to be able to feed your family is a fundamental element of that. That is why I think the financial support payment is a very good thing. I agree with the underlying driver.359

223.The Government has taken some steps to improve compliance with self-isolation requirements, including the introduction of the £500 Test and Trace Support Payment in September 2020.360 NHS Test and Trace also highlighted efforts to improve non-financial support for those isolating such as support calls and texts to link people with local support.361 However, the payment is only available to people who meet all of the eligibility criteria, which includes the need to be in receipt of, or the partner of someone in your household in receipt of, universal credit, working tax credit, or several other benefits, as well as being able to demonstrate that you will lose income as a result of self-isolating.362 These requirements mean that a small proportion of people applying actually receive support; freedom of information requests made by the BBC found that between 28 September 2020 and 15 January 2021, of 212,000 people who applied for support across 271 local authority areas, only 74,400 were successful (c. 35%).363 We have heard evidence that inadequate financial support was a barrier for some people. It is wasteful to invest up to £37 billion of public money to detect potential virus carriers if they are not then supported to comply with an isolation request and this therefore remains a major weakness in our national pandemic response.

224.Another major impediment to self-isolation by contacts of infected people was the disruption caused by a requirement to quarantine for 10 days, even when symptom-free and without the ability to test and be free to go about normal business if tests—either lateral flow or PCR—were consistently negative. Sir John Bell, the Regius Professor of Medicine at Oxford, criticised this approach saying:

One of the most inefficient bits of this whole process for Test and Trace has been the quarantining of contacts, because you have to lock up people for 70 days to prevent one infection. […] That is why I think a system whereby you can test your way out of being a contact by just doing a lateral flow test every day for seven days would be a massive step forward. I think you would find that people would be much less reluctant to participate.364

225.Yet, extraordinarily, despite the ultimate availability of large quantities of both lateral flow and PCR tests, this regime was not changed until 16 August 2021.365 In evidence to the inquiry, Baroness Harding confirmed that the average number of contacts disclosed by an infected person was only two.366 Not only has this failure to make use of available testing technology put millions of people to substantial inconvenience and cost the economy many millions of pounds, by providing a powerful disincentive to take a covid test and to disclose all contacts, it seems likely that it will have also caused more infections and cost lives.

The organisation of Test and Trace

226.We have seen in this Chapter how the UK’s early lead in the scientific development of a test for covid soon became, through operational inadequacy, a notable weakness in the UK’s response to covid, through most of the pandemic. It seems clear that the impressive scientific capability of Public Health England was not matched by a well-developed operational capability. The decision to move responsibility for testing, tracing and isolation away from Public Health England to a new body named NHS Test and Trace was an understandable move.

227.However, contributors to our inquiry have highlighted the sometimes-fragmented nature of the Government’s public health response during the pandemic, and the relative lack of resources available to PHE, particularly for health protection as opposed to health promotion. For example, the Nuffield Trust suggested that there was confusion over whether or not PHE was responsible for expanding testing capacity in the early part of the pandemic, and that there were similar tensions over PPE where PHE was responsible for issuing guidance over the use of PPE but not for procuring or supplying the material.367 Lord Sedwill described PHE as “a much smaller body” than NHS England and questioned both its level of resource, and whether its structure was appropriate for contingency planning for disease and other health security threats.368

228.This was acknowledged by the then Secretary of State for Health and Social Care, who argued that PHE “[w]as brilliant at the science and the development, but simply had not had the experience or the capacity to scale.”369 Dominic Cummings also highlighted the lack of capacity within PHE to scale up testing as required:

[Y]ou had PHE, this entity that was doing very few tests and had no plan for how to expand it and didn’t think it was possible, for all the reasons we have discussed.370

But if there was an opportunity to build an operational capability based on a team of maturing experience that could serve us well in the future, this was largely not taken.

229.Baroness Harding, appointed to lead NHS Test and Trace in May 2020, was the longest serving senior figure in the organisation by the time she left in May 2021. During that year senior officials were brought in on short-term contracts. The Director of Testing role was occupied by two individuals, each for six months.371 A Director of Contact Tracing was employed on a short-term contract of six months.372 It is regrettable that, during an intense period in which many lessons will have been learnt, none of the senior leaders of NHS Test and Trace were—or, more concerningly, were ever intended to be—in post in the long term. Dominic Cummings, in evidence to us, was highly critical of the Civil Service organisation,373 and the provisional and constantly changing senior leadership of the test and trace operation bears this out.

230.In August 2020 the Government announced that it would be forming a new agency out of the merger of parts of PHE, NHS Test and Trace and the Joint Biosecurity Centre.374 The UK Health Security Agency began operating on 1 April 2021, with Dr Jenny Harries as chief executive.375 The Government’s decision to re-organise PHE in this manner during the pandemic was initially questioned by some; for example, the LGA highlighted concern from local authorities and called for “absolute stability, clarity and consistency in our public health services.”376

231.The new UK Health Security Agency is the third body in little more than a year to be given responsibility for the operation of the test and trace system. So far the body is characterised by opacity, with little information available on its website about its governance, management or strategy, although Dr Jenny Harries does bring long service to a function that for most of the pandemic has been occupied by transient appointments.

Conclusions and recommendations

Conclusions

232.Despite being one of the first countries in the world to develop a test for covid in January 2020, the United Kingdom failed to translate that scientific leadership into operational success in establishing an effective test and trace system during the first year of the pandemic. Public Health England showed itself to be scientifically accomplished, but poor at delivering an operational testing system at the scale and urgency required by a pandemic.

233.Testing capacity was treated too much as a parameter rather than a variable that could be changed by the Department of Health and Social Care and scientific advisers. What was being achieved in other countries, particularly East Asia, appeared to be of little interest in the initial weeks of the pandemic. This was an inexcusable oversight. It took a personal intervention by the then Secretary of State in April 2020 to drive a major increase in testing capacity.

234.The resulting requirement to abandon testing people in the community during the critical early period of the pandemic cost many lives for a number of reasons including because:

a)many asymptomatic carriers were not tested and therefore identified and asked to isolate;

b)many older people were admitted to care homes either from the community or hospitals in ignorance of their covid status or that of staff working in care homes;

c)low levels of testing meant that the UK lost visibility of where the disease was spreading, among which groups and how quickly. For a crucial period our only insight into the spread of covid was by counting people so sick that they had to be admitted to hospital; and

d)the receipt of a positive test result would have been likely to improve compliance with an isolation request.

235.The new Test and Trace operation eventually established in May 2020 was a step in the right direction but set up much too late. Because of that delay there was huge pressure to get results quickly which meant that it followed a centralised model initially, meaning assistance from laboratories outside PHE—particularly university laboratories—was rebuffed. The same was true for contact tracing, where the established capabilities of local Directors of Public Health and their teams were not effectively harnessed during the initial response to the pandemic, despite local approaches providing effective in places where they were pursued. It is now clear that the optimal structure for test and trace is one that is locally driven with the ability to draw on central surge capacity—but it took the best part of a year to get to that point. In short, implementation was too centralised when it ought to have been more decentralised.

236.Vast sums of taxpayers’ money were directed to Test and Trace, justified by the benefits of avoiding further lockdowns. But ultimately those lockdowns happened. Were it not for the success of the Vaccine Taskforce and the NHS vaccination programme, it is likely that further lockdown restrictions would have been needed in Summer 2021.

237.We recognise that the effectiveness of test and trace in reducing transmission is likely to be reduced when the prevalence of the virus is high, as highlighted by Professor Whitty and others, but it is clear from the latest data and the experience of September 2020 that even at the level of operational effectiveness, NHS Test and Trace has been unable to respond to rising rates of transmission of covid-19.

238.The Test and Trace organisation has not, despite its branding, been run by the NHS, and has seen senior executives brought in from external bodies for short term contracts which reduces the institutional learning, from what was an intense period, that has been retained. It is a major concern that the new organisation responsible for test and trace is opaque in its structure and organisation.

239.Partly because it was set up too late, NHS Test and Trace ultimately fell short of the expectations set for it. It has failed to make a significant enough impact on the course of the pandemic to justify the level of public investment it received. It clearly failed on its own terms, given its aim in September to “avoid the need for a second lockdown” by contributing to a reduction in the ‘R’ number. While we acknowledge that test, trace and isolate activities are just one—albeit crucial—component of the measures undertaken to tackle covid-19, NHS Test and Trace (NHSTT) clearly failed to achieve this central objective. NHSTT has also consistently failed to reach the 72-hour turnaround time as identified as necessary by SAGE, including a significant failure in September 2020. Further, although the Government first described the impact of NHSTT on reducing ‘R’ in December, it took an unacceptably long two months before the evidence and analysis behind this assertion was made public. When it was published it became clear that the analysis was outdated, invalidating claims made at the time. The use of inaccurate data and the lack of transparency impeded effective public scrutiny at a crucial time in the pandemic.

240.The National Audit Office has stated that “to achieve value for money NHST&T must be able to demonstrate both that the interventions it delivers are effective in achieving its objective, and that the mix of interventions is the most cost-effective use of public resources.” After 18 months and many billions of pounds of taxpayers’ funds, there is hope that the UK now has a capacity for testing and tracing that is adequate. It is a bitter irony that this point may only have been reached at the point in which the vaccination programme makes testing less of a critical component than it was previously.

Recommendations and lessons learned

241.Scientific excellence is not enough in test and trace programmes: the UK must develop greater operational competence in deployment. In particular, the Government must ensure that both the new UK Health Security Agency and local authorities have the capability and funding to stand up both central surge capacity and locally-driven testing and contact tracing within seven days of a public health emergency being declared.

242.Public Health England and its successor bodies, as well as Ministers and their scientific advisers, should be more willing to study and emulate the practice of other countries with urgency and agility, especially during a crisis. A culture must be established that looks proactively to collaborate with other organisations, rather than to reject assistance.

243.Those responsible for future test and trace programmes should establish a culture and processes to learn rapidly from errors and to act to prevent them being repeated.

244.The reactive, short-term horizon of test and trace for much of the pandemic must be replaced by a capacity for anticipation and preparation—even during the course of an emergency.

245.The organisation of the bodies responsible for testing and tracing should be open and transparent both about their operations and the basis of their decisions.