Curbing the coronavirus outbreak involves a familiar mantra: test, trace, isolate. As of this week, the government will begin to roll out the second part of this strategy. In theory, contact tracers will call or text people in England who test positive for coronavirus, asking them to provide a list of everyone they have met for longer than 15 minutes, who will then receive a message instructing them to self-isolate for 14 days (Scotland, Wales and Northern Ireland are rolling out separate programmes).
But already, England’s contact-tracing strategy looks set to be hobbled by the government’s reluctance to involve local authorities and regional public health expertise in its coronavirus response from the outset, and its dogmatic commitment to outsourcing health services to the private sector.
Baroness Dido Harding, who is leading the programme of testing and tracing, recently conceded that the system won’t be fully operational at the local level until late June. Elsewhere, contact tracers have spoken of difficulties accessing the government system, describing it as a “complete shambles”. One recruit reportedly said their training amounted to reading a pdf and taking an online quiz - “all of which takes an hour”.
For an idea of how contact tracing works best, look to Germany. When interviewed about the country’s successful contact-tracing programme recently on Newsnight, the German minister of health described how the response had worked through the country’s federal structures and with the 400 different “communities” that are responsible for the track and trace system.
England, on the other hand, started by pursuing a call-centre model run by Serco and staffed with customer service employees paid just above minimum wage. Recruitment agencies tasked with finding contact tracers are reportedly offering an hourly wage of £8.72 to staff with experience of “telephone or face-to-face customer services”. Viewing contact tracers as customer service call handlers may be a good business model for Serco, but I would like to know if a single public health specialist in this country thinks this was a good idea.
Contact tracing is fundamentally a behavioural intervention; when used well, contact tracers don’t just deliver messages about quarantine but also provide reactive advice and reassurance, and can act as important “eyes and ears”, gathering local intelligence that can be passed on to other members of the public health team. In Korea, health authorities deployed teams of specialist epidemiological intelligence service officers. In Massachusetts, local departments of health carried out contact tracing assisted by volunteers from the public health community, graduate students, Peace Corps volunteers, medical assistants and retired nurses, all of whom were paid more than twice the local minimum wage.
This government’s enthusiasm for outsourcing and centralisation has been an Achilles heel in its coronavirus strategy. Although it recently announced an extra £300m to support local authorities in England to deliver the new test and trace strategies, these authorities will have their work cut out to quickly stitch together a coherent and organised programme from a confusing landscape of NHS commissioners and providers, parallel central initiatives, outsourced private contractors, and the recently established Joint Biosecurity Centre (JBC). The JBC’s roles include collecting and analysing data about Covid-19 infection rates across England, identifying and providing real-time analysis about local outbreaks and recommending appropriate responses to spikes in infections – for example, whether schools or workplaces in local areas should be closed, or whether different restrictions should be imposed in different areas.
Details on how the JBC will be staffed or set up to provide real-time data and intelligence for local authorities haven’t been published. Somewhat bizarrely, rather than appointing a public health specialist to lead the body, the government has appointed Tom Hurd, a senior Home Office counter-terrorism official. According to the Institute for Government, the JBC is modelled on the Joint Terrorism Analysis Centre, which analyses counter-terrorism intelligence and sets the terrorism threat level for the country. In much the same way, the JBC will set a coronavirus threat according to five different levels. But as with all centralised bureaucracies, there’s a risk that the JBC will contribute to delays, as data trickles down to the local areas where it’s needed most. There’s also a risk that members of the public will be put off by their data being held by an organisation modelled on a centralised counter-terrorism organisation.
Crucially, test results can’t be anonymised if they are to be used in local disease control management. Once again, trust in the system is vital. Both the JBC and local authorities will have to rely on the various private companies that have been contracted to deliver aspects of the testing and contact-tracing strategy in England, including Randox, Deloitte, Serco, G4S and Sodexo. The detailed specifications of their contracts are not public, and the division of roles and responsibilities between the centre, local authorities and the private sector remain unclear. It’s hard not to wonder why England has created such a complicated and fragmented architecture for itself, rather than following the example of other countries that have involved local authorities from the outset.
I previously worked as director of public health in Hammersmith and Fulham, and I’ve seen the efforts of public health teams in north-east London during this epidemic. Across the country, we have smart, competent and committed public health officers. Indeed, the UK has one of the best specialised public health training programmes in the world. Although we are seeing the emergence of a more prominent role for Public Health England’s regional teams and local authority public health departments, these specialised resources should never have been so neglected. The government’s coronavirus response should have had local authorities and local health expertise at its core all along.
David McCoy is a professor of global public health and director of the Centre for Public Health at Queen Mary University of London
This article was amended on 29 May 2020. A reference to the UK was removed from the headline, as the issues highlighted in the piece apply to England. The opening paragraph has been corrected to make clear that Scotland, Wales and Northern Ireland are all rolling out their own contact-tracing systems.