The need to ramp up testing is a recurring theme, in which respondents describe low capacity in the beginning, and continuous problems with ‘ramping up’ capacity, then reflect on the difference it could have made in key areas (during more reflective discussions in June).
The figures reported in oral evidence were 2000 per day (Harries, Deputy Chief Medical Officer, 5.3.20: q54), 4000 (Vallance, Chief Scientific Advisor, 17.3.20: q78-84), 7000 (Doyle, Medical Director, Public Health England, 26.3.20: q196), and 50000 (Hancock, Secretary of State, 17.4.20: q312), but increasingly in the absence of a definition of testing, which became important when the UK government began to treat all tests sent out as part of meeting its 100000 per day target.
In March, Vallance (17.3.20: q78-84) described capacity as 4000 reliable tests per day, and noted the lack of accuracy of the larger-scale of tests available in the market, to argue that the UK was one of the most frequent testers at the time. Such arguments dated very quickly. Hancock (17.4.20: q306) then describes ‘ramp-up testing’ as the fourth element of the government’s ‘battle plan’ but often with low clarity on how, and who would be responsible. This confusion is apparent when Doyle (26.3.20: q196) describes separate responsibilities, in which PHE would be responsible for testing NHS staff and patients (target 25000 tests per day), while the Office for Life Sciences would take forward the 100000 tests per day pledge.
In most cases, there is broad agreement on the negative impact of the limited testing capacity, including:
Surveillance and modelling
Vallance (17.3.20 and 5.5.20: q435) reflects on the need for more testing to aid initial surveillance, suggesting that they could have acted very differently if the testing capacity was higher. This issue will run and run. The absence of data affected the ability of advisory bodies to model the estimated ‘peak’ of infection (based partly on its doubling-rate) that became so central to the UK government’s initial lockdown strategy. Further, there is much debate on the adequacy of UK modelling. For example, listen to the Radio 4 series More or Less (10.6.20, ‘Antibody tests, early lockdown advice and European deaths’), which argues that, during the 1st press UK government conference (12th March), Vallance misjudged the UK as being 4- rather than 2-weeks behind Italy. Compare with Vallance (5.5.20: q390).
NHS staff and services
NHS bodies describe their reduced ability to operate effectively (throughout the session on 17.3.20 which included Stevens, chief executive of NHS England). Nagpaul (British Medical Association) (26.3.20: q203-4) describes the combination of (a) advice to self-isolate with symptoms, and (b) an absence of testing, as a potential cause of a 10% shortage of NHS staff during the crisis, and this problem is a continuous theme in this day’s evidence. Green (Care England) (26.3.20: q267) and Bullion (Vice-President, Association of Directors of Adult Social Services) (26.3.20: q279) make the same case for a social care sector already at low capacity. Kinnair (Royal College of Nursing) and Pittard (Faculty of Intensive Care Medicine) describe low testing (and limited PPE) as major worries for staff (17.4.20: q297)
Discharges to care homes
One key example – still to be explored fully – is the absence of routine testing of NHS patients during the push to discharge 15000 people from hospital to social care beds in England (Stevens, 17.3.20: q122-3; Green, 26.3.20: q274). Green (19.5.20: q470 and q478) notes that the UK Government prioritised the NHS at the expense of social care, prompting NHS discharges to care homes before proper testing was in place, while knowing that care homes are ill-suited to isolation measures. Note that the NHS was already under capacity pressure before the crisis (Stevens, 17.3.20: q165), and redeploying medical and nursing care from care homes, while Willet (Director for Acute Care, NHS England 17.3.20: q165) describes an already fragmented system of 12500 care homes in England.
Overall, the absence of sufficient information – from routine testing for the virus, and proper analysis of care home capacity – combined with a huge drive to favour NHS care and move people to care homes, contributed to a disproportionately large coronavirus problem in care homes.
This experience compares with many other countries that addressed care homes more effectively. In Germany, patients were not discharged to care homes unless they could quarantine (Halletz, Chief Executive Officer, AGVP (Employers’ Association – Care Homes) 19.5.20: q455). In South Korea, people were taken from care homes to be quarantined (Comas-Herrera, Assistant Professorial Research Fellow, Care Policy and Evaluation Centre, LSE, 19.5.20: q447).
Committee update, 12th June 2020: Figures confirming discharges of hospital patients into care homes, responding to the National Audit Office report Readying the NHS and adult social care in England for COVID-19. The NAO press release states:
‘Patients discharged quickly from hospitals between mid-March and mid-April were sometimes placed in care homes without being tested for COVID-19. On 17 March, hospitals were advised to discharge urgently all in-patients medically fit to leave in order to increase capacity to support those with acute healthcare needs. Between 17 March and 15 April, around 25,000 people were discharged from hospitals into care homes, compared with around 35,000 people in the same period in 2019. Due to government policy at the time, not all patients were tested for COVID-19 before discharge, with priority given to patients with symptoms. On 15 April, the policy was changed to test all those being discharged into care homes. It is not known how many patients discharged to care homes had COVID-19 at the point they left hospital’
Testing and contact tracing
The issue of testing in relation to initial contact tracing is less straightforward. On several occasions, PHE and health department respondents note that there came a point when the number of infections, and rate of infection, ruled out the effectiveness of contact tracing and testing in favour of UK-wide lockdown measures: ‘several weeks ago that ship had begun to sail. Nevertheless, we kept going until mid-March, until we were absolutely sure that contact tracing in that way would not work’ (Doyle, 26.3.20: q198; see also q232 on testing representing only one of many necessary measures).
There is a continuous discussion in multiple sessions on why the UK stopped contact tracing after it became clear that the rate of transmission was very high (e.g. Harries 5.5.20: q415 on the shift from ‘contain’ to ‘delay’ on 12th March, q418 on using limited tests in hospitals where most needed, and q425-8).
Costello (Professor of Global Health and Sustainable Development, UCL, 17.4.20: q303-4) agrees with this approach in relation to London and several other cities where prevalence and transmission were unusually high, but argues that in many places there were very few cases (fewer than 10 cases in 50 local health areas until mid-March) and that they could have been contained. This issue will run and run too (see the discussion on contain/ delay in the run up to the first peak).