Calderdale Public Health and NHS primary care teams need to run Covid-19 test and trace

This is a long read (about 3k words) about the fact that the most effective way of stopping the spread of Covid-19 is for infected people, and their close contacts, to self-isolate from everyone else including their household members.

This can only happen with proper support for everyone who self isolates for the common good. This support doesn’t exist. It also requires an effective test and trace service, which doesn’t exist either. The Locally Enhanced Test and Trace Service in Calderdale has plugged some big gaps but it now needs full control and proper funding. If you agree, please email your MP to ask them to call for track and traced to be fixed in this way at the lockdown bill vote tomorrowyou can do this easily HERE: https://weownit.org.uk/scrap-serco-and-co-let-public-health-teams-do-track-and-trace

The government has squandered £12bn public money on its shambolic privatised Test and Trace service, chaotically run by people with no public health experience. The Prime Minister and the Health Secretary are now facing legal proceedings for breaching the government’s public sector equality duty under the Equality Act 2010 by filling senior public sector roles with their mates.

Meanwhile the spread of Covid-19 increases, along with hospitalisations, admission to Intensive Care Units, deaths from Covid-19 and an increasingly incoherent set of first local and now national restrictions.

Covid-19 tests must have clinical input and oversight. Otherwise, PCR test results cannot be accurately interpreted in terms of the person’s infectivity, according to a recent article in the Journal of the Royal Society of Medicine. As it is, the government’s Covid-19 test and trace strategy, built on commercial interests, bypasses public health and NHS primary care teams and so generates uninterpretable data for the purpose of infection control.

Without clinical diagnosis alongside the Covid-19 test result, there’s no way of knowing if a negative result is accurate or if a positive result denotes that the person is currently infectious. This means people who may not need to self-isolate are being told to, and people who may need to are being told they don’t.

How to fix an effective ‘Find, Test, Trace, Isolate and Support’ Service

Based on the experience of Calderdale’s locally enhanced test and trace service, it looks as if effective infection control requires:

  • Provision of tests, with clinical diagnostic input from NHS primary care teams, for people as soon as they get Covid-19 symptoms.
  • Giving people their results within 24 hours of the test.
  • Within another day at the latest, providing advice about self isolating and finding out what support they need to do this, and who they’ve been in close contact with.
  • Reaching backwards and forwards contacts swiftly and advising them to enter 14 day quarantine.
  • Providing support (including adequate financial support) for both the person who’s tested positive and the contacts, so that they are able to complete their self-isolation/quarantine. This is vital since Covid-19 disproportionately infects people on low incomes with scant resources to enable them to self-isolate.

But we still don’t have any of this – SAGE’s recent opinion of the privatised Test and Trace service is that

“this system is having a marginal impact on transmission at the moment…”

And that without improvements,

“it is likely that the impact of Test, Trace and Isolate will further decline in the future.”

Locally enhanced test, trace and support services set up by Councils’ public health teams, like Calderdale’s, already run alongside and depend on the national privatised, fragmented system

This dependence limits their effectiveness. Damaging delays in the national system disrupt the process at every stage – but speed is essential to break the chains of transmission.

There are increasing calls, both from the public and local Councils, for the government to hand over national test, trace and support services and resources to local public health teams and the NHS.

Calderdale Councillor Mike Barnes, whose Skircoat ward has been one of the worst affected by Covid-19, posted on facebook,

“Locally, we are demanding more control over the whole [Test and Trace] process as well as the resources to run this. We believe that this is the most effective way to keep residents in Calderdale safe this winter.”

Hasty easing of lockdown led to sharp rise in Covid-19 transmission in Calderdale

Calderdale’s locally enhanced test and trace service was hurriedly put together throughout July by the Council’s public health team, in a race against the spread of Covid-19 that at the time was among the ten highest in English local authority areas.

As soon as the government publicly conceded in mid-August that Councils could run such systems, Calderdale’s was ready to go.

It started two weeks after central government’s sudden imposition of local restrictions on 30th July across the borough and other West Yorkshire areas.

In Calderdale, the restrictions were triggered by an outbreak in a few areas of central Halifax characterised by overcrowded housing, multigenerational families and high numbers of low-waged key workers and others whose jobs put them in constant contact with the public.

At the time, Calderdale’s Director of Public Health Debs Harkin said that too many restrictions had been lifted too quickly in June:

“During lockdown we had some of the lowest infection rates in the country. Although we only have limited information about how and where people become infected…we are seeing COVID-19 cases in people who have been working in essential roles right throughout the lockdown. These are the people who care for us, feed us, serve us and transport us. Since lockdown has eased, these are the people who are more likely to come into contact with COVID-19.”

Calderdale’s locally enhanced test, trace and support service has set up more local testing sites in areas with high rates of infection. It has also reached a high percentage of the Covid-19 cases (people who’ve tested positive) whom the Serco call handlers have been unable to contact.

But so far, the goal of breaking the chain of transmission remains elusive.

Local test and trace at first succeeded in reducing the spread of Covid-19 in the central Halifax areas where the rates of infection were highest. This was down to a combination of the local restrictions imposed by central government and work by Covid-19 community champions talking and listening to residents on the street.

Calderdale Councillor Colin Hutchinson explained,

“If we can’t contact cases by phone, we visit them at home, which usually results in getting useful information, as well as hopefully boosting our profile in communities – people can see that the council is taking this seriously and that we are there to help, rather than enforce.”

Calderdale’s Public Health Director, Debs Harkins also made this point in a tweet:

“So proud of the @Calderdale local contact tracers who reached 82% of cases passed to us from NHS Test & Trace in September. They also check whether people need help to isolate and give us important local insight into how the virus may be spreading.”

Those methods have since being applied in other parts of Calderdale where numbers of people testing positive for Covid-19 have risen.

Detailed local public health support in workplaces and schools

The Council Public Health Team are the primary contact on all things Covid-related (including managing the consequences of positive cases).

Calderdale’s public health team have responded quickly to outbreaks at workplaces and Calderdale Council has been able to use this to close workplaces.

As schools opened to all their students at the start of the autumn term, the local Public Health team set up a process where schools inform them of every single case and they work with school to risk assess and contact trace within the setting.

A member of staff at a Calderdale school said,

“As the experts on outbreak control in schools, Calderdale Public Health are able to respond to what has worked well and what has not worked well in different settings and share that information across different educational centres so that they can be responsive all the time.  

“If there is a positive case in a school then they are advising the head and, if it is a staff member, speaking to them to identify contacts in an expert and informed way.”

This has continued despite the government’s move in mid-September to steer schools and colleges away from Public Health England as their primary contact and to call the Department for Education’s helpline when there is a confirmed case in their setting, instead of contacting local public health teams. The Department for Education later conceded,

“Where more detailed local arrangements are in place with your local authority, and are working, you can continue to receive support through that route to take action in response to a positive case.”

Covid-19 transmission has rocketed despite the locally enhanced test, trace and support service

Despite all this good work, the number of people in Calderdale who’ve tested positive for Covid-19 has more than quadrupled since mid August – up from 1,068 on 16 August to 4,953 on 2 November.

By mid October, data showed the rate of Covid-19 transmission had shot back up in central Halifax, at the same time as the virus has spread across the whole of Calderdale.

Recent test positivity rates have been high: 13.1% in early October, down to 9.2% in the week ending October 17th. These high rates mean the number of people testing positive was bound to be a serious underestimate. According to the World Health Organisation, a positivity rate of more than 5% suggests that not enough testing is being done to know how much of the virus is spreading within a community.

At the end of October, the Calderdale Director of Public Health tweeted that by now an estimated 1 in 40 people in the borough were infected with Covid-19. This is based on the most recent report (30 Oct) from the large, ongoing Covid19 Infection Survey run by the Office of National Statistics and other organisations including Public Health England and Oxford University. She explained,

“The ONS study establishes the true prevalence of the virus including people who have not had a test. We know that lots of people have the virus and never have a test (either because they have no symptoms or have symptoms and chose not to get tested). This has been the case throughout the whole pandemic so the rates based on positive tests are a large under estimate of the true prevalence of the virus.”

The greatest increases in infection have been among young and working age people of all ethnicities. According to Cllr Mike Barnes,

“The council have analysed the data that we are given and identified that exposure is in a wide range of settings – from household, work, leisure and community settings, hospitality and so on. There appears no specific trend.”

Hospital admissions of people with Covid 19 have quadrupled between 5 October and 2 November, when there were 119 covid 19 patients in the two Calderdale and Huddersfield NHS Foundation Trust hospitals – 11 of them in Intensive Care. Over same period, sadly 42 people with Covid 19 died within 28 days of a positive test result in the Calderdale and Huddersfield hospitals. This compares with 170 people over the whole previous period of the pandemic, since March 2020.

“Local contact tracing is only one part of the solution”

Praising the success of Calderdale’s local contact tracers, Public Health Director Debs Harkins tweeted on Oct 10th:

“Latest data shows that 79% of Calderdale cases are reached between NHS T&T and local contact tracers. Highest % in Yorks & Humber region. Great #teamwork between national and local!”

These cases are so-called non-complex cases, who are not part of an outbreak at school, work or any other setting where many people are present.

During September, Serco contact tracers handled 697 Calderdale cases, but transferred 213 of them (30%) to the Calderdale local contact tracing service as they were unable to contact them.

Of the 213, 86% were contacted and completed by local contact tracers. 9% could not be reached, 4% refused to provide details (because they had finished their isolation period) and one person had sadly died.

But Debs Harkins warned on Twitter,

“Local contact tracing is only one part of the solution. Need quicker test processing, data on cases to get to us quicker and a higher % of contacts to be informed they may have been infected. Also need clearer and more cogent restrictions that people can understand and get behind.”

But a succession of restrictions imposed by the government have confused pretty much everyone. On 12 October, the government put Calderdale and the rest of West Yorkshire under its new Tier Two restrictions. The main difference from the previous local restrictions was that households now could not mix indoors, either at each others’ homes or anywhere else.

These measures were ineffective. The virus continued to spread rapidly. On Friday 30 October the government put West Yorkshire, including Calderdale, into Tier 3 restrictions that were due to start on Monday 2nd November.

Just as people were trying to figure out what that was going to mean, the government announced a new month-long national lockdown, due to start on 5th November and superseding the Tier 3 restrictions.

Failings and delays at every stage of the privatised national test and trace system

The effectiveness of test and trace as a means of suppressing the spread of infection – and eventually, eliminating community transmission – depends on swift isolation and support of cases and their contacts. This means every stage has to work quickly and people have to be able to afford to self-isolate.

This isn’t happening – and this is putting people’s lives and livelihoods at risk.

Delays in accessing tests

People with symptoms need immediate access to testing, but this has been fraught with problems for months.

In the early days of so-called ‘Pillar 2’ testing for any member of the public with Covid-19 symptoms, the mutual aid group Upper Calder Valley Contact Tracing and Support heard from people whose elderly parents had been unable to get a test because they didn’t have internet access and didn’t know about calling 119 to find out about booking a test. Their children then had to drive often long distances to do the internet booking for them.

Other people who booked a home test experienced problems getting in touch with the courier service to collect the completed test and didn’t know about designated post offices where you can post completed tests.

Although since then Calderdale’s locally enhanced test and trace service has been able to increase the number of test sites – including some that are walk-up sites for people without cars – some people have still had to wait for days to get tested.

And some who tested at a Halifax locality site were told their tests had been lost.

In mid September, after all students went back to school, Calderdale people – particularly those whose children had been sent home from school with Covid-19 symptoms – were reporting on social media that it was impossible to book tests at home or at local testing sites.

On Sunday 14th September, a Calderdale parent told us they’d been trying and failing all day to get a test for one of their children who’d been sent home from school on the Friday with a cough, and they also had to test their other child and the children’s father, since the children couldn’t return to school or the father to work without a negative test. Their search for a test continued on the Monday, and only succeeded on the Tuesday – a 5 day delay.

All the local walk in centres had become bookable only, on the instructions of the Department of Health and Social Care, so the family managed to book one of 19 available slots at their local walk in centre. When they arrived, they were told the system had crashed, there were no no more slots and they would have to book again.

The Council had not been told that the walk-up sites were now bookable only, so people became understandably confused and stressed as the Council website was not updated with this information.

At 11.45pm the family finally managed to book a test for Tuesday 16th September at a different local testing site the other side of Calderdale. Luckily they had a car. They were told they’d have to wait between 48 hours and 5 days for the result.

Of course, many people have been able to access tests promptly, but such problems are by no means isolated incidents – although anecdotally, it now seems that people in Calderdale are able to get tested quickly.

Delayed test results

There are often 5 or 6 day waits for people’s test results to come through. This undermines the increased capacity for walk-in testing in Calderdale that the Council and the local NHS have created.

It means people with Covid-19 symptoms have to hang about self- isolating when they might be fine to go back to work or school. The waits also delay contact tracing, which really needs to be carried out as soon as possible so that contacts can be notified that they need to enter 14 day quarantine; and equally, so that cases can access support if they need it.

Contact tracing delays

Even when people have received prompt positive test results, at times they have not been reached by contact tracers until after their 10 day self-isolation has ended.

On 10th October, a member of the public tweeted that they’d been contacted by “a really nice chap” from Calderdale council, having been diagnosed with Covid two weeks ago. Another said their partner had tested positive on 3 Oct, received notification via the Covid-19 app on the 5th but had heard nothing from test and trace until a local contact tracer knocked on the door on the 11th.

Calderdale Public Health Director Debs Harkin tweeted back,

“You’re right the delays undermine the effectiveness of the service. We reach most people on the day we get their details or the next day. In some instances that’s days after their test”

This delay in receiving people’s details is down to the Serco’s case finding system.

When the government handed local authorities a bigger role in tracking cases of Covid-19 in early August, it promised to ring-fence Serco call handlers to work on locally-enhanced test and trace services.

Calderdale cases (people who’ve tested positive for Covid 19) are diverted from the national contact tracing system into a special outbreak taskforce of 50 case workers who follow through for 24 hours. Then, if they can’t get in touch with cases, they are supposed to pass the details onto the Calderdale test and trace service, whose local contact tracers take over.

But instead of 24 hours, the transfer often takes place days later. Calderdale Councillor Colin Hutchinson, who is working as a Calderdale contact tracer, recently said,

“Today I haven’t received any cases that are less than 5 days post-test date, and that has been the case for weeks.”

Serco contact tracers, lacking local knowledge, are wasting their time making multiple calls to the same household. One Calderdale household had three people who’d tested positive for Covid-19 and their household contact received masses of phone calls from Serco contact tracers who did not realise that they were all in the same house.

Locally enhanced test and trace services can’t follow up cases’ contacts

Once Calderdale contact tracers have spoken to the cases – either on the phone or on the doorstep – information about the cases’ contacts is then fed back to the national system.

This is another cause of delay. The opportunity is lost for local contact tracers to follow up the contacts they find and to offer support during isolation, which is often much-needed.

Once Calderdale feeds back the information about the cases’ contacts to the national system, the contacts are then followed up by Tier 2 contact tracers.

These are clinicians employed by NHS Professionals, not the Serco Tier 3 call handlers who only phone ‘cases’ – people who’ve tested positive for Covid 19. (Although thanks to a whistleblower, we now know that in at least one Serco call centre, these unqualified, unskilled Tier 3 call handlers have been upgraded to do the skilled work of Tier 2 contact tracers.)

The lack of local control over following up contacts means only about 60% are contacted.
And the provision of support for contacts who are self-isolating is cumbersome, because Calderdale has to pass information about the need for support back to a national ‘Tier 2’ special team, so they can signpost people they contact to local support.

Calderdale’s locally enhanced test trace and support service aims to provide practical support to cases and contacts during self isolation. This is largely down to voluntary. community and mutual aid groups which provide food parcels and help with shopping, dog walking and medicines collection.

Adherence to self isolation/quarantine requires proper support

There are many reasons why people are unable to self isolate. Nationally, rates of adherence to the full duration of self isolation are low – despite high levels of intention to self-isolate.

A recent study found around 18% of cases and 11% of contacts complete the whole period of self-isolation. The data was collected between 2 March and 5 August 2020, and these low rates of non-adherence were largely constant across time.

It’s not clear if levels of completed self isolation in Calderdale are different from the national levels found in the Kings College London study. The Calderdale locally enhanced test trace and support service isn’t collecting any data about the proportion of cases and contacts who successfully self isolate for the required period. Calderdale’s Public Health Director Debs Harkin said,

“We really don’t know…Through local contact tracing and outbreak management we are finding out about cases and contact who aren’t isolating.  We are seeing examples of people not complying.

“We are keen to submit a West Yorkshire – wide bid for funding for a joint approach to behavioural insight to inform our approaches to increasing compliance.”

For people on low incomes and in crowded households, serious obstacles make full self isolation next to impossible. The most obvious blocks are inability to work from home, which leads to unaffordable loss of income, shortage of space and lack of access to clear information.

Covid-19 is not an equal opportunities disease: it disproportionately infects and kills people in low income groups, deprived neighbourhoods and Black and South Asian ethnicities. We are facing a syndemic – not a pandemic.

SAGE’s 58th meeting, on 21st September, stated,

“Measures will be urgently needed…to achieve equity and social justice, some of which could be introduced relatively quickly.”

Overall, the low rates of self isolation were associated with: men, younger age groups, having a dependent child in the household, lower socio-economic grade, greater hardship during the pandemic, and working in a key sector.

In ‘Fixing England’s COVID-19 response: learning from international experience’, the authors state,

“Self-reported ability to self-isolate is three times lower in those who earn less than £20,000 per year or have less than £100 saved. The UK has one of the lowest proportions of pay covered by statutory sick pay in Europe (29% compared to 100% in Germany and 93% in Belgium), and millions do not qualify.

Means-tested £500 self isolation benefit is inadequate

From 28 September, Calderdale Council started administering a government-funded £500 means-tested isolation support benefit for cases and contacts. Introduced at the same time as £10K fines for failure to self-isolate, this is a small carrot – less than the minimum wage. It only applies to the poorest eighth of the population and even then, there are loopholes and obstacles. Many who are a bit above that absolute hardship level will also struggle. Justifiably angry comments by members of the public on local social media confirm these problems.

Eligibility for the benefit requires possession of a notification from Test and Trace saying you need to self-isolate. This is causing problems for parents in Calderdale who are having to take time off work because their child has been told to self-isolate. The Department of Health and Social Care has confirmed they do not qualify for the NHS T&T isolation payments – they would only qualify if their child had a positive test and they were named as a contact and informed by Test and Trace to isolate themselves – then they could apply in their own right.

This eligibility condition also means the 21% of Calderdale cases who still are not contacted by either Serco or Calderdale contact tracers can’t claim the benefit. Calderdale local test and trace says that anyone in this situation can let them know and they will try and obtain their contact details from national test and trace.

Covid-19 disproportionately affects those least able to self isolate in the absence of effective support but the government has so far failed to provide this.

Instead, the DHSC announced recently that local authorities should hand the police data on cases and contacts whom they have reason to believe are not self-isolating. This is deeply socially divisive. It is also likely to be counter-productive in that it is likely to drive people not to get tested.

Calderdale Councillor Colin Hutchinson said,

“This is such a bloody stupid move by the Government.
“If you wanted to increase suspicion of a system that is already distrusted, you couldn’t have planned it better.
“It just seeks to deflect criticism from Serco/Sitel. Today I haven’t received any cases that are less than 5 days post-test date, and that has been the case for weeks. Prompt analysis of tests and referral of failed contacts to local services, within 24 hours of trying is what is needed, not heavy-handed enforcement.”

Locally enhanced Find, Test, Trace, Isolate and Support is far better placed to provide information and adequate support – if government were to make adequate resources available. As it must.

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