Covid-19: Is local contact tracing the answer?BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3248 (Published 17 August 2020) Cite this as: BMJ 2020;370:m3248
Last week, the government announced a major shift in its approach to covid-19 contact tracing in England, by giving local council public health teams more responsibility and shrinking the national Test and Trace scheme.
The significant u turn came as the national scheme continues to fall short of reaching the 80% of contacts of people who test positive that experts believe is needed for controls to be effective. Last week, only 61% of the 12 731 contacts identified by staff at national call centres were reached and asked to quarantine.1
The national NHS Test and Trace programme, run by private companies Serco and Sitel, was launched amid much fanfare on 28 May, but has been beset with problems, including the shelving of a digital app and reports that contact tracers have had no work to do.2
The ongoing problems led to the government announcement on 10 August3 that 6000 out of 18 0000 contact tracers currently employed by Serco and Sitel would be released on 24 August (see box).
The national scheme has faced criticism from doctors and public health experts for relying too much on inexperienced contact tracers and not enough on public health teams with local expertise. The shift means that more responsibility will be given to local public health teams to deploy resources as they see fit, and to direct teams from the national scheme to provide back-up where required.
“If the dedicated national team cannot make contact with a resident within a set period of time, local public health officials can use the data provided by NHS Test and Trace to follow up, which in some pilot areas has involved local authority teams and voluntary partners visiting people at home,” the Department of Health and Social Care said.
Directors of public health welcomed the move, but said it was crucial that local teams were given the resources to do this effectively. The government did not announce any new resources beyond the £300m (€331m; $393m) given to local councils in June to support contact tracing.
Jeanelle de Gruchy, president of the Association of Directors of Public Health, said, “Valuing the local contribution of boots on the ground and rooted engagement with communities must mean funding it properly.”
Reaching more people
Some councils in England have already set up their own contact tracing services, citing failures of the national scheme.4
In response to rising rates of covid-19, Blackburn with Darwen council was among the first in England to launch its own local enhanced contact tracing service, sending tracers door to door after 48 hours if they are unable to contact people by phone.
Paul Fleming, the council’s senior officer leading the new programme, said Blackburn’s system complements the national system and can offer local support to people who need to quarantine. “We are already seeing its benefits as we’ve managed to contact people the national system couldn’t,” he said.
Other councils are now following suit. Peterborough—which is also on the government’s watch list as an area of concern—launched an enhanced contact tracing service on 12 August. Environmental Health officers and redeployed regulatory officers who have undergone special training will ensure the service is staffed seven days a week.
Liz Robin, director of Public Health for Cambridgeshire County Council and Peterborough City Council, said she was confident the local service would improve case finding. She told The BMJ, “We know our communities, we know the geography of our areas, we have that local knowledge and local trust. We can add a lot to a national system.”
But while some may question whether a national service needs to be retained, Robin said that some councils may struggle to find enough staff to carry out contact tracing if cases increase, and would need the “built-in resilience” of the national system.
Peterborough received around £1m from the government in June to support contact tracing, but Robin said that this grant “is unlikely to be sufficient,” if covid-19 infection rates go up in winter. “At the moment we have one to three cases a day. People are not spending their whole day contract tracing, they’re factoring it into their other work,” she said. “But assuming that rates of covid-19 go up over the winter, we’re going to need more people and resources.”
Giving councils more say over how resources are spent may allow more targeted action against local outbreaks, which areas such as Liverpool have deployed to some success.
Matt Ashton, director of public health in Liverpool, told The BMJ that specific follow-up with small communities with positive cases had been vital to stamping out a local outbreak in a small ward of the city covering around 20 000 people. “I would argue that through our actions on a local level, we’ve prevented a large outbreak, a city lockdown, and kept our economy going,” he said.
Ashton said giving the council more power to control contact tracing resources would prove helpful as it had done with having more control over testing. But he said there were still problems with the quality and accuracy of contact tracing data from the national service, and an imbalance of resources.
“Obviously there are large national commercial contracts involved, but the balance doesn’t feel right. We need much more control locally and much more investment in local resources to fill in some of the gaps in the data.”
How the national test and trace programme has faltered
The government’s national NHS Test and Trace programme launched on 28 May 2020. Operated by private companies Serco and Sitel, it initially employed 18 000 contract tracers at its national call centres. The system works in parallel with Public Health England’s local health protection teams and local authorities
The national call centres have struggled to reach the proportion of contacts of people infected with the diseases that experts believe is required1
The scheme has been criticised for relying on inexperienced contact tracers. Media reports of contact tracers being left idle and headlines such as “Coronavirus contact tracer ‘paid to watch Netflix’”2 have not helped
On 10 August the Department of Health and Social Care announced3 that 6000 people currently employed to do contract tracing would be released on 24 August
Serco’s initial deal until 23 August was worth £108m5 but could rise to £410m in total if extended. Sitel was paid6 an initial £84m, rising to £310m if extended. A Serco spokesperson told the website openDemocracy that its contract will continue beyond 23 August7