Perhaps, the most surprising aspect of the British Covid-19 crisis is the extent to which the Scottish, Welsh and Northern Irish governments, and the English regions, have allowed strategy to be decided by Westminster.
Health and social care are devolved, and this national epidemic is not homogenous. It is made up of hundreds, if not thousands, of outbreaks around the country, each at a different stage . England had its first confirmed case on 30 January, Wales on 28 February and Scotland on 1 March. Some areas – such as Rutland, Hartlepool, Blackpool, Isle of Wight, Tyneside, Durham, Orkney, Western Isles – had no reported cases until late March, and some even now have relatively few cases.
Contact tracing and testing, case finding, isolation and quarantine are classic public health measures for controlling communicable diseases. They require local teams on the ground, meticulously tracking cases and contacts to eliminate the reservoirs of infection. This approach is recommended by the WHO at all stages of the epidemic. It was painstakingly adopted in China, Singapore and Taiwan, with a high percentage of close contacts identified and many housed in hotels. Germany has traced contacts throughout. The leaked UK national risk register proposes it.
Yet Public Health England, the agency responsible for communicable disease control in England, stopped contact tracing on 12 March, having reportedly only contacted 3,500 people, of whom about 105 were found to be positive. It’s now about to resume. But why was it stopped, and how will it be resumed?
We’ve not seen an official explanation for its stopping. But lack of both resources and effectiveness are usually mentioned. Resources are essential, just as they have been for increasing acute care capacity, and the potential pool of contact tracers is vast. There are thousands of environmental health officers in local authorities and other sectors who have the necessary skills and experience. Singapore used its army. Teachers and barristers have volunteered in Ireland. Centralising control and management of the pandemic through NHS 111 has also left 7,500 GP practices underused, and the potential for real-time knowledge of new cases, results of swab tests and insight into the geography of spread has been lost. Yes, it’s true that contact tracing is insufficient, but that’s not the same as ineffective. It should have been supplemented, not replaced. Look at Germany.
We think there are more fundamental reasons. The system of local communicable disease control was established in the 19th century. After the NHS was set up in 1948, it was supported in England and Wales by national, regional and more than 40 local public health laboratories. But since local medical officers of health were abolished in 1974 – replaced by community physicians at different levels of the NHS – the system has been gradually but relentlessly eroded, fragmented and centralised.
Communicable disease control was centralised in the Health Protection Agency in 2003, and local public health laboratories transferred to NHS hospitals. Public health was then carved out of the NHS in England in the 2012 Health and Social Care Act, which abolished local area health bodies, created Public Health England to fulfil the government’s duty to protect the public from disease and charged local authorities with improving public health – but with limited proactive scope for infectious disease control and woefully inadequate resources.
Then came austerity. Local authorities suffered a 49.1% real terms reduction in central government funding from 2010 to 2018. Numbers of community control teams and consultants in communicable disease control have decreased. PHE made “savings” of £500m over five years in the name of “efficiency” and now has nine regional “hubs” serving 343 English local authority areas.
With further waves of the epidemic likely, resumption of contact tracing is critical. Each of the four nations needs to institute scores of locally led, nationally coordinated and funded teams to trace, find and test contacts. Caernarfon isn’t Cardiff, Gairloch isn’t Glasgow, London isn’t Lulworth. Teams in England and Northern Ireland would be based in local authorities; in Wales and Scotland they would be in local health boards. Their composition should be locally determined, drawing on a range of expertise, especially among directors of public health, field epidemiologists, environmental health officers, GPs, local NHS laboratories, NHS 111 and test centres, plus volunteers if required.
Widely used apps with robust data protection could play a supportive, but not framing, role. In addition, the apparently strategy-free plans for 50 mass drive-in test centres need to be decisively directed to support local contact tracing, as well as strategically targeting the most at-risk groups.
We would expect rigorous implementation of these measures now to make an overdue but significant contribution to controlling the epidemic. Restoring and updating local communicable disease control is an integral part of properly funded, publicly provided health and social care.
Allyson M Pollock, professor of public health, Newcastle University, and
barrister Peter Roderick, principal research associate, Newcastle University
