How did Britain’s “world-beating” COVID-19 testing system stumble in the face of its very first serious test?
That is the question being asked throughout Whitehall and indeed the rest of the country this week as the Department for Health and Social Care is forced to ration availability of tests throughout the country.
It is a conundrum with extraordinarily important implications.
Earlier this summer, Prime Minister Boris Johnson and Health Secretary Matt Hancock said that Britain’s test and trace system would be crucial in helping the country beat any second surge of coronavirus.
After all, forensically locating infected people and ensuring their contacts are also tracked down and tested is the main way other countries have been able to combat the disease without forcing a nationwide lockdown.
That was the plan for the UK this autumn: test, track and isolate, with, at the worst, only some small local lockdowns as need be.
But now, with many people unable to get tests even when they have symptoms, there are growing fears the system is buckling, providing a dangerous window for COVID-19 to spread unchecked as it did in the spring.
Although infections remain relatively low, epidemiologists warn that they are on the rise, making the next few weeks a pivotal period.
So how is it that now, even as cases rise rapidly in this country and many other European countries face a surge in the disease, once again Britain’s system is struggling to keep up?
The mystery deepens when you consider how much time and investment has been devoted to the system since the spring.
Some £10bn – nearly double the cost of Britain’s two new aircraft carriers – was provided by the Treasury.
Baroness Dido Harding, the much-feted former chief executive of telephone company TalkTalk, was recruited to shape up an operation which struggled in its early days to deliver enough tests.
A new centralised system was built with the help of consultants from Deloitte and thousands of employees were taken on to work in the so-called Lighthouse Labs dotted around the country.
The testing system may have been found wanting in the first wave but, say Whitehall insiders, the same mistakes would not be made over again.
And over the following months everything seemed to be going to plan.
The initial IT glitches were ironed out.
Problems with the databases, which initially struggled to match those being tested with their other details, such as their NHS number, were mostly addressed.
Most importantly of all, the capacity of the system quietly crept up.
The prime minister has occasionally been met with derision when he declares that Britain is testing more than anywhere else in Europe – but he is right.
Whereas back in the spring the UK was carrying out far fewer tests than most other leading nations, in recent weeks this country has performed more tests than any other country in Europe in absolute terms: more than Germany and France, far more than Spain.
Even on a per head basis, this country is carrying out more tests than almost any other major nation save for Denmark.
So how did this system, with more capacity than almost any other country in the world, suddenly run out of capacity?
This article, which is based on conversations with a number of those involved at various parts of the testing apparatus, seeks to answer that question.
As with so much else during this pandemic, there are plenty of competing theses for what has gone wrong, but they can be boiled down into three fateful decisions which have brought us to where we are today.
1. Protecting care homes
The first of them dates back to the spring, when Britain was facing a higher rate of death from the disease than any other leading country.
Among the mistakes made back then was the failure to protect care homes: too few tests were made available both for residents and care home workers.
In an effort to ensure the same mistake was not made this time around, officials at the Department for Health and Social Care (DHSC) insisted that a sizeable chunk of tests would be reserved for care homes.
This was non-negotiable and entirely understandable – but it had consequences on capacity.
The official capacity of the core part of the testing system – pillar 1 (the testing infrastructure, much of it in or around hospitals, which pre-dates the disease) and pillar 2 (the brand new centralised testing network) – is around 200,000-250,000 a day.
However, according to government insiders in recent weeks around 100,000 tests have been given over to those working and living in care homes. That has left only around 100,000-150,000 working capacity for everyone else.
2. Sending children back to school
Nonetheless, even that is more capacity than the UK had in the initial period of the pandemic and more than many other countries have in total, so why has that remaining capacity been eaten up so quickly?
That brings us to the second of the three fateful decisions: to send children back to school at all costs.
This became a key goal for the government during the summer and in the wake of the exam results fiasco: the consensus hardened that whatever happened this autumn, schools would be the last thing to close.
Yet while those involved in the testing system expected a surge in demand, the scale of the surge took them completely by surprise.
Around a half of the rise in requests for tests in recent weeks can be traced back to this “school effect”, according to one source working in the testing system.
As children returned to school, some institutions remained relaxed while others enforced strict rules that pushed up demand for testing.
Some insisted upon immediate tests when a child had a temperature – even in the absence of other symptoms.
Some families felt compelled to order multiple tests for their households to try to ensure their children can be allowed back to school.
The Department for Education has hurriedly sought to issue new guidance, but this has been too late to quell the initial surge, in which demands for kits for children aged five-15 nearly quadrupled.
3. Earlier spread of the disease
Much of the remainder of this surge in demand for tests can be traced back to the fact that the disease is now spreading throughout the country – and indeed the continent.
The third of those fateful calls back in the summer was the presumption that the second surge of the disease would not happen until later this year – perhaps late October or maybe even November. Not early September.
This was a calculated guess: that, after all, is closer to traditional flu season.
Moreover, the government believed that although the disease was spreading in Spain and France from early in the summer it would be able to prevent the kind of spread that seeded it ahead of the first wave.
Strict quarantines were imposed, but even so, as of this week Britain’s case trajectory is broadly in line with France and Spain’s, with around a three-week delay.
That implies the number of cases will rise to around 10,000 within a few weeks. DHSC suspects that around 20% of the current requests for tests are from people without symptoms and simply worried about the surge in the disease.
But since it was predicating everything on the surge in cases not coming for another month and a half, DHSC has yet to reach the capacity it was aiming for.
The plan had been to reach a daily capacity of 500,000, which would be more than enough to deal with current demand.
But, critically, that capacity is not due to arrive until the end of October. Between now and then they expect the shortages of tests to continue, making the coming six weeks all the more uncomfortable.
In the meantime, the plan is to attempt to manage the demand for tests. In short: rationing will continue for some time.
The online booking system has already been filtering between areas with high COVID-19 prevalence and those without for a while.
Those asking for tests in Cornwall have for a few weeks been far less likely to get them than those, for instance, in Bolton.
But as demand has mounted higher, the labs have struggled to deliver tests to all areas of the country.
In some instances it is because of staffing shortages – many were using students as temporary workers but some of them have now returned to university – and in some cases because the labs were simply not prepared for the surge in demand to come so early.
Even so, the system is already proving enormously expensive.
According to a DHSC source, the average cost of a test is around £100.
A crude calculation would suggest that £2bn has already been spent on tests alone.
If it has to function close to capacity for the next six months, the cost of those tests will be beyond £8bn.
In other words, despite having been given one of the most generous allowances of any part of government, the test and trace system may well have burnt through its entire budget by next spring.
That adds another headache: cost.
While Chancellor Rishi Sunak has committed that test and trace will get all the resources it needs, eyebrows are being raised at the Treasury about how quickly that money is being spent, and whether there has been any thought given to value for taxpayers’ funds.
They worry about how much is being committed to unreliable new testing methods that might have little hope of success. Most of all, though, they worry about the system’s failure to prevent a second nationwide lockdown.
Within DHSC, there are growing nerves about the next few weeks. The promising news is that in Spain and France the authorities appear to be bringing the disease under some degree of control – though it is still early days.
However, neither of those countries have the same issues Britain is having with testing.
If, as expected, the system remains at capacity with widespread rationing in the coming weeks, there are two consequences.
The first is unnerving: to some extent we will be in the dark about the speed the disease is spreading.
The daily test numbers will no longer be a fair yardstick of the spread of the disease (though other survey-based measures should give a more reliable sense of community spread).
The second prospect is much scarier: that without a means to identify and track cases, the disease will soon be at large in the community.
At that stage, the prospect of a national – or at least regional – lockdowns may rear its head again.
There may be further closures of pubs and restaurants. Schools would be the last to close, but nothing, according to government sources, is off the table.
Tellingly, whereas a month or two ago DHSC insiders proudly declared that test and trace was among the main defences against a second surge, these days they have changed the messaging.
Behavioural structures, such as the “rule of six”, are the most important thing, they say – the first barrier against COVID-19. Test and trace, they now say, is the second line of defence.
Whether it is on the front line or some way back, this “world-beating” system, which has faced repeated crises during the pandemic, is about to confront the most challenging period of its short life.