With one of the largest pandemic-related budgets, the NHS Test and Trace Service (NHST&T) has expanded its testing capacity, tracing activities and distribution of rapid tests, but has further to go in reducing the overall time taken for reaching all cases and their contacts, according to the National Audit Office (NAO).
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Today's report is the NAO's second on government's approach to test and trace services in England and focuses on the period from November 2020 to April 2021.
For a test and trace system to be effective, it must work quickly. NHST&T has reduced the time taken between a person booking a test and their contacts being asked to self-isolate for in-person PCR tests, which make up a minority of tests. However, NHST&T does not have targets for how quickly the contacts of those testing positive should be reached for other types of PCR tests, such as home-based tests. Furthermore, its internal targets don't cover the period between a person experiencing symptoms and coming forward for a test.
While NHST&T's performance has improved since the end of October 2020, it fell well below its targets when cases rose sharply in December. NHST&T provided results for 90% of PCR tests taken in person in the community within 24 hours in April 2021, up from 38% in October 2020. However, this dropped to 17% during December when testing and tracing activity was increased to manage the surge in infections. NHST&T met published targets for the overall proportion it reaches of people testing positive in mid-March 2021, and of identified contacts from the start of December 2020, although performance slipped a little below both targets during April.
From October 2020, NHST&T rolled out mass testing for people without symptoms, using lateral flow device (LFD) tests to identify COVID-19, but only a small proportion of the tests distributed have been registered as used. NHST&T forecast that between March and May 2021 655 million LFD tests would be used in the UK, but up to 26 May only 96 million (14%) of the 691 million tests distributed in England had been registered. NHST&T does not know whether the tests that have not been registered have been used or not. It has started a programme of research to understand why the registration of test results is so low and is working to increase public awareness of the need to register results and improve its ability to track tests.
Local authorities' involvement in testing and tracing has increased significantly, but challenges to effective partnership working remain. Local stakeholders told the NAO that NHST&T's engagement and data sharing with local authorities has improved, but that they cannot yet access all the data they need. This makes it difficult for them to deal with localised outbreaks.
NHST&T has developed a programme of work to identify and contain variant forms of COVID-19, and currently screens all viable positive PCR tests for variants. NHST&T also provides testing and tracing services in support of border controls, aiming to minimise the entry of new variants to the country. The UK has made a very significant contribution to international efforts to track and understand new variants: about 30% of genomic sequencing results shared internationally come from the UK, making it the largest single contributor. Samples are collected by the NHS and NHST&T and processed by the COVID-19 Genomics Consortium, Wellcome Sanger Institute and the public health agencies in the four nations.
NHST&T reports it has spent £13.5 billion of its £22.2 billion budget in 2020-21, an underspend of £8.7 billion (39%). Of this, NHST&T spent £10.4 billion on testing; £1.8 billion on identifying and containing local outbreaks; and £0.9 billion on tracing. NHST&T told the NAO that the underspend is because a predicted high level of demand for testing in January and February 2021 did not materialise due to the national lockdown. The delay in the rollout of mass testing from January to March also contributed to the underspend, as did some commercial savings.
NHST&T has introduced more flexibility into its contact centre contracts but, across its testing and tracing activities, is still paying for capacity it does not use. NHST&T aims for a 50% average utilisation rate for its contact tracers (the percentage of paid time they spend working) but daily utilisation rates have remained well below this since November 2020, peaking at 49% in January and falling to around 11% in February.
Some testing and tracing services are still being procured under emergency regulations, without competition. Although NHST&T has steadily reduced the number of contracts awarded using emergency regulations (6% in January-March 2021, compared to 46% in April-June 2020), in terms of contract value, the amount awarded has more than doubled (£2.6 billion in January-March 2021, compared to £1.1 billion in April-June 2020). NHST&T continues to rely heavily on consultants and has not reduced this as planned, with 45% of staff at its central office being consultants as at mid-April 2021.
The overall effectiveness of the test and trace process also relies on public compliance, which is still low or variable: only a minority of people who develop symptoms request a test, and not everyone self-isolates in line with requirements. However, NHST&T has no targets for increasing the number of people coming forward for a test or self-isolating.
NHST&T will transition to the new UK Health Security Agency (UKHSA) between April and October 2021 and there is a risk that the restructuring will divert NHST&T's attention away from efforts to contain the spread of the virus. Local stakeholders also told the NAO there is uncertainty about the roles that national and local bodies will play following the transition to UKHSA. While NHST&T has sought to improve its understanding of future testing and tracing needs, it has not yet determined what capacity will be required in the future.
Speed, reach, and levels of public compliance still constrain the effectiveness of the test and trace approach. The NAO recommends that the Department of Health & Social Care, through NHST&T and relevant partners, should set out plans by October 2021 for improving the overall test and trace process, including addressing how to best support citizens to come forward for tests and comply with self-isolation requirements. They should also establish a clear strategy for how to integrate national and local efforts once England is no longer in lockdown.
Gareth Davies, the head of the NAO, said: "Since we last reported in December, NHS Test and Trace has introduced a lot of changes, including mass testing, closer working with local authorities and initiatives to identify and contain variant forms of COVID-19. However, some pressing challenges need to be tackled if it is to achieve its objectives and deliver value for taxpayers, including understanding how many lateral flow devices are actually being used and increasing public compliance with testing and self-isolation."
