Lessons from Leicester: a covid-19 testing system that’s not fit for purposeBMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2690 (Published 07 July 2020) Cite this as: BMJ 2020;370:m2690
All rapid responses
Far from being paralysed and divorced from the field of action, as Mike Gill, Devi Sridhar and Fiona Godlee suggest, Public Health England (PHE) has been at the forefront of the COVID-19 response both at regional and national level.
On Leicester, PHE produced the data showing increasing incidence and we provided this to colleagues there from early June when our local health protection team (HPT) acted in support of Leicester Council in producing an analysis of the possible reasons and causes for the increase. Continuing throughout June, both the HPT and wider PHE provided support in undertaking further investigations and advising on control measures. These were not one-off offers, they are routine aspects of outbreak control processes across England, led by local HPT’s supported by wider PHE and working closely with local Directors of Public Health. In Leicester in particular, we went even further and at the request of the local authority, deployed the Rapid Investigation Team, a PHE resource created specifically to assist local teams, in the field, in dealing with outbreaks and situations. We continue to support the local services in Leicester. We therefore have, and will continue to always have, a very direct and active presence in the field of action.
On data, from late April UTLA level data was shared in all local authorities, followed on 30th May by daily NHS Test and Trace activity (noting that it only launched on the 28th May) and from the 4th June we have provided daily exceedance reports which show if an area has a greater rate of infection compared to the usual local background rate. We continue to work with local authorities and all system partners to ensure that where there is a legitimate request for assistance, it is offered
The joint working of regional directors, directors of public health and HPT’s on health protection functions during the epidemic is welcome. These are extremely important relationships which provide different and complementary contributions to the response as part of a local-regional-national public health system. They build on a body of previous joint work on population health. Their continued joint working therefore represents a significant opportunity to improve the efficiency, capability and reach of the system.
Competing interests: No competing interests
We read the editorial “Lessons from Leicester: a covid-19 system that’s not fit for purpose” with great interest (1).We agree with the authors, that there has been a delay in sharing information with local authority teams. However, it has been demonstrated that local contact tracing is much superior to centrally administered system (2) and would like to take this opportunity to highlight the important role of local authorities in the fight against COVID-19.
Executive Director of the WHO Health Emergencies Programme Dr. Michael Ryan recently stressed the significance of contact tracing in the fight against COVID-19, stating “contact tracing and surveillance is a key part” (3) and further emphasised “the primary success of contact tracing has come from a well organised community workforce”.
Documentation of early forms of contact tracing can be found as far back as the 16th Century, in order to trace the spread of bubonic plague in Italy (4). Since then, methods of contact tracing have been refined and have helped us to eradicate smallpox (5), and more recently to contain the outbreak of Ebola (6). ‘Partner notification’ a form of contact tracing is critical to the provision of modern sexual health services (7).
As with any intervention, there are limitations of contact tracing. There is public mistrust in how authorities will use the data gathered as part of contact tracing. Lack of privacy and its consequences for individuals and businesses have been reported from South Korea (8,9). These can have immense impact on individuals and the community including mental and physical health, as well as economic impact.
In order to win the fight against COVID-19 it is imperative to gain public confidence and encourage public cooperation in contact tracing. This can be brought about by improving the public’s understanding of contact tracing and stressing its role in containing the virus.
It is also important for the central government to recognise the challenges each community faces and realise there is no better organisation to face these challenges than the local authorities who knows their population best, and have experience and existing systems to deal with these challenges. National contact tracers may lack local sensitivities as shown in the recent example from the United States of America. Reduced compliance with contact tracing programs in USA has been documented if contact tracers used certain words like “agent” in some communities, potentially acting as a “trigger word for undocumented people” (10).
Furthermore, local authorities have built up rapport and trust with communities in their geographical area over the years. As a result, it may be easier for local authorities to encourage their communities to engage in Test and Trace with local contact tracers. We must learn from our collective past experiences such as contact tracing for Ebola in Sierra Leone in 2015. When an international team of specialists with little local knowledge attempted contact tracing in Sierra Leone there was low compliance, and contact tracing failed. However, when contact tracing was modified to better suit the community e.g. women only contact tracing team, compliance increased and spread of infection curbed (11).
To tackle these challenges in the UK, a three-tier system of contact tracing was proposed (12). This involves contact tracing at a national, regional, and local level to “ensure services were inclusive and meets the needs of diverse local communities”. However, in order for this system to be successful cooperation and communication between the three tiers is essential. Over the past few weeks, there has been criticism regarding lack of communication (13), which has even been attributed to delayed response to spikes in COVID-19 cases in Leicester and its subsequent lockdown (14).
It is the need of the hour to set up fool proof systems to share full and relevant information between the different tiers in the test and trace system. This will ensure local authorities are fully informed and empowered to implement their local outbreak control plans effectively. It is heartening to see information and data flow between the centre and local authorities appears to be improving. At this crucial juncture in the pandemic it is worth reminding ourselves as a nation “United we stand, divided we fall”.
1. Gill M, Sridhar D, Godlee F. Lessons from Leicester: a covid-19 system that’s not fit for purpose. BMJ 2020;370:m2690
2. Mahase E. Covid-19: Local health teams trace eight times more contacts than national service. BMJ 2020;369:m2486
3. Kelly-Linden J. No excuse for poor contact tracing, says WHO, as pandemic reaches grim six-month milestone. Telegraph. 29 June 2020. https://www.telegraph.co.uk/global-health/science-and-disease/no-excuse-...
4. Cohn S, O’Brien M. Contact tracing: how physicians used it 500 years ago to control the bubonic plague. The Conversation. 3 June 2020. https://theconversation.com/contact-tracing-how-physicians-used-it-500-y...
5. Branswell H. What the world learned in eradicating smallpox: Unity mattered. Stat News. 8 May 2020.
6. Saurabh S, Prateek S. Role of contact tracing in containing the 2014 Ebola outbreak: a review. Afr Health Sci. 2017;17(1):225-236.
7. McClean H, Radcliff K, Sullivan A, Ahmed-Jushuf I. 2012 BASHH statement on partner notification for sexually transmissible infections. International Journal of STD & AIDS 2013; 24: 253–261
8. Zastrow M. South Korea is reporting intimate details of COVID-19 cases: has it helped? Nature. 18 March 2020
9. Zick C. Privacy and COVID-19 Contact Tracing – Lessons from South Korea? 28 April 2020.
10. Wetsman N. “Contact tracing programs have to work with local communities to be successful.” The Verge. 10 June 2020. https://www.theverge.com/2020/6/10/21285166/contact-tracing-community-pa...
11. Bah KA. Contact tracing: Learning Lessons from Sierra Leone. African Arguments. 29 June 2020.
12. Gleave R, de Gruchy J. Letter to the Directors of Public Health. 1 May 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
13. BMA media team. BMA calls for rapid data transparency for dealing with local COVID spikes. 1 July 2020.
14. Hickey S. Leicester Mayor has no idea if rumours of isolated lockdown “are fact or fiction”. LBC. 28 June 2020.
Dr Asawari Gupta, GP ST1 in Public Health. email@example.com
Dr Padmanabhan Badrinath, Consultant in Public Health Medicine, Suffolk County Council & Associate Clinical Lecturer, University of Cambridge. firstname.lastname@example.org
Directorate of Public Health, Endeavour House, Suffolk County Council, Ipswich, IP1 2BX.
Disclaimer: The views expressed here are the personal views the authors and in no way represent the views of their employer, Suffolk County Council.
Competing interests: Conflict of interest: Both the authors of this communication work in a local authority Public Health department.
Response from the Data Infrastructure: 'Lessons from Leicester: a covid-19 testing system that’s not fit for purpose'
I read your article, which was released on 7th July, entitled: 'Lessons from Leicester: a covid-19 testing system that’s not fit for purpose'. While you raise many valid points and critiques in the article on why local authorities, notably Leicester’s, did not have access to the data to detect and prevent further localised outbreaks of COVID-19, and ultimately save lives, I am uncomfortable regarding your mention of the National Pathology Exchange (NPEx).
You state: 'Test results have been reaching PHE via a tortuous route encompassing the National Pathology Exchange and NHS Digital and often lack basic essential details such as NHS number and postcode.'
While NPEx is one of the systems feeding data to PHE, I dislike the implication that NPEx is part of, or is itself, a 'tortuous' route. NPEx is, in fact, the very opposite of tortuous and is a data-transfer service which has been used within the NHS and the UK laboratory testing arena for around 15 years. Of the ‘chaotic system’ of which this article speaks, NPEx is one of the few elements which are not chaotic and has been used for its experienced, standardised, widely used, and trusted infrastructure and team. NPEx is part of the architecture of the UK’s pathology service delivery and has stepped up to serve that community in a time of need by improving the processes of delivering COVID-19 results data to the organisations that need them.
So, what is NPEx? When a GP, hospital or laboratory needs to perform a test which it does not have the capacity or capability to do so in-house, these organisations will need to refer, or send away, the test to another laboratory. This process was predominantly manual before NPEx’s inception and relied on laboratory staff to transcribe requests and results; this is not only an incredibly time-consuming process, but it opens up the process to errors and risks patient safety. NPEx is a robust digital service which enables laboratories to electronically exchange requests and reports for send-away tests. Through NPEx, the referral and reporting process is now automated and test requests and results are transferred digitally, directly, and immediately into the information systems of the relevant laboratories and organisations.
It is no surprise, then, that NPEx was mandated by the NHSX, NHS England, and NHS Improvement for send-away COVID-19 tests for Pillar 1 and testing within NHS Trusts. There are over 160 NHS Trusts, private laboratories, Public Health organisations connected to NPEx. If any of these organisations need to send away or receive COVID-19 tests to their laboratory, the referral and result will be directed into the laboratory information systems of the relevant parties. When the results are returned to the Trust that requested the test, the data is available for their use.
Additionally, NPEx has been used for Pillar 2 data transfer. NPEx receives subject data, of which postcode is a mandatory field (which was incorrectly noted in the original article), from the Deloitte system and, typically, within 24 hours the system also receives a result which can be matched to this subject. From here, NPEx passes contact details onto the messaging service, the NHS Business Services Authority, who inform subjects of their results. Additionally, NPEx passes a limited subset of the data to the Messaging Exchange for Social Care and Health (MESH - the system that is used for transferring messages, such as COVID-19 results, between organisations, mostly primary care systems) via the Keystone so it can enter into GP records. Further, NPEx passes a full data set to PHE and NHS Digital. These data transfers happen automatically and almost immediately ensuring all relevant bodies have direct, system-level access to the data they need providing it is sent through NPEx.
NPEx is not part of the ‘delays and diversions’ noted in the article. As a system which streamlines the data reporting process and provides a data infrastructure (which is not otherwise available between the NHS, Trust, and Public Health organisations), data reporting would have been a lot more chaotic without NPEx’s role in the process. It seems unfair, then, to be mentioned as ‘tortuous’, without further elaboration, when NPEx is, simply put, an enabler and an asset to the UK’s COVID-19 testing response.
I hope my letter has been informative and enlightening on just how crucial and nuanced the NHS supply chain is during these times of crisis.
Dr. Susan Clamp
Director of X-Lab
Former Director of the Yorkshire Centre for Health Informatics
Former Senior Lecturer at the University of Leeds
Note: NPEx is the result of a joint delivery model and award-winning partnership between X-Lab, an innovative software solutions company, and The Health Informatics Service (THIS), an organisation hosted by Calderdale and Huddersfield NHS Foundation trust.
Competing interests: No competing interests
Covid-19 is a notifiable disease and the recent lockdown in Leicester is not the first time that Leicester has shown resistance to implementing government measures in notifiable disease outbreaks. In 1877 after an epidemic of smallpox and increasing resistance of the citizens of Leicester to vaccinate their children, the 'Leicester method' was published to help prevent smallpox outbreaks without resorting to vaccination. There were 6 simple instructions:
1. Prompt notification
2. The isolation and segregation of smallpox cases in hospital
3. Quarantine of all persons found to have been in contact with the patient
4. The vigilant inspection and supervision of all contacts during the incubation period of fourteen (now extended to sixteen) days
5. Cleansing and disinfection of clothes, bedding and dwellings
6. The burning of clothes, bedding etc. when necessary
The method worked very well and helped prevent further outbreaks in Leicester without resorting to vaccination compulsion enforcement. The public health balance between sanitation and vaccination is pertinent for the recent outbreak of covid-19 and the Leicester method unfortunately appears to have been forgotten but might be reactivated and applied to Leicester and the rest of the UK to good effect given we have no current vaccine to enforce and the six step message is simple to understand by the general population.
Reference: 1. Biggs JT. Leicester: Sanitation versus Vaccination (London 1912), pp103-104.
Competing interests: No competing interests
As someone who lives and works in Leicester, I was grateful to read your editorial, Lessons from Leicester (11th July) criticizing the government about the time it took to get crucial data about cases to the local public health team.
Leicester citizens are pulling together to lower the number of cases but the strict lock-down came as a shock. By next weekend, we will have been locked-down for a third of the year, longer than anywhere else in the world. A lot of holidays have been cancelled and it is impossible now to book one if you have a Leicester post-code. Cars are being stopped driving out of the city and the police are in evidence at the station and in many of our parks, as are the army, who are running the mobile testing units. It would be easier to resign ourselves to this if there weren’t so many unanswered questions.
One strange fact is that the high number of cases in the community has not been reflected at all in hospital numbers. Although the average age of cases is quoted as being in the late 30s, the initial spike was at the beginning of June, so by now, given that many people in Leicester live in multigenerational households, you would expect older people to have caught the virus, and the more ill to have presented to hospital, which doesn’t seem to be happening. One hypothesis doing the rounds is that the virus may be becoming less virulent; but there may be other explanations.
Some in Leicester think that the high number of ‘cases’ identified is partly down to lots of testing. There have been hundreds of people involved in door to door knocking and giving out tests. The media are quoting the number of cases in Leicester as being up to four times higher than the next most risky location. But if you look at the percentage (rather than the number) of tests coming back positive, Leicester is much less of an outlier. Even this figure may not be comparing like with like, as the testing in Leicester is predominantly targeted on areas of poverty and cramped living conditions.
The media and Government have focussed on conditions in textile factories, which is indeed an issue, but PHE’s report was clear that the spike could not be explained by these factories. Despite this, Robert Jenrick, Secretary of State for Housing, Communities and Local Government, is reported to have started an investigation into the city council, with a potential outcome being that central government take over. The mayor’s view is that they have tried to deal with these factories, setting up the first task force in the country, and instigating and contributing to a special parliamentary committee report, in 2017, into the garment industry. The Government has not acted on a single recommendation.
With Jenrick and the Home Secretary both choosing to highlight this issue and criticise the council, the political antagonism between the city and the national Government is increasing. This risks fuelling racism and social unrest. As a relatively tame, but telling, example, a ‘Stay Away From Our Town’ headline - directed at the people of Leicester - featured in the local paper in Melton Mowbray, 15 miles up the road. Sadly, there is much worse, specially on social media.
It seems to me that Leicester may well have a troubling number of cases, but I fear this is being exaggerated and we are being made a scapegoat, perhaps 'pour encourager les autres', perhaps for party political reasons. We need someone to investigate so we can understand better what’s going on. If targeted local lockdowns are to be part of the nation’s armoury against Covid19, we all need confidence that they will be for the right reasons, not political gestures. They should be properly managed within a properly informed, clear and sensible strategy, delivered by a mature partnership between national and local services.
Competing interests: No competing interests
This is an excellent article.
However, I have concerns about the Editor in Chief of the BMJ being one of the authors.
1. It is unlikely that an article where the Editor in Chief is an author will be rejected - even if "safeguards" and processes are in place.
2. is there is an undeclared "competing interest"? The BMJ is running a campaign criticising the government (probably appropriately) for it's management of the COVID-19 pandemic. The Editor in Chief then writes and publishes an article in the BMJ in support of the campaign.
Competing interests: No competing interests