by Jane Lewis
19th February 2021

By any measure of mortality – deaths registered, deaths per 100,000 population, or excess deaths – the UK did not perform well in responding to the first wave of the COVID-19 pandemic.

There have been success stories, mainly to do with the NHS, particularly its rapid reconfiguration of hospitals and the dedication of its frontline staff, and the biomedical researchers seeking drug treatments and vaccines. But there has been relatively little to celebrate regarding ‘control’ of the disease.

Understanding the spread and likely course of the virus has depended on the accuracy of mathematical modelling by epidemiologists who dominated the main scientific advisory committee, SAGE, but policy decisions have been the responsibility of government. In terms of implementing policies on the ground, the work of public health practitioners has long been key for testing, tracing and securing the isolation of those newly infected with the virus. However, this time the part played by public health in the test, trace and isolate (TTI) system has been marginal. The operation of the system was put in the hands of private companies and the results have been disappointing.

Much must wait for the public inquiry that is expected, but commentators and investigative journalists have focused mainly on the failings of government during 2020. While the government’s approach to policy making has certainly been important, it is also crucial to recognise longstanding structural problems, particularly the weakness of public health and the lack of involvement of more local political and professional actors, as well as the continuing preference of government for private sector providers.

The government’s approach can broadly be characterised as reactive. By the time it took action in March, community transmission was taking place and the virus was geographically widespread. Subsequent action was marked by calls to halt economic and social activity and the imposition of a ‘lockdown’ or tougher restrictions, followed by rather rapid release of the brakes in an effort to prioritise the economy, accompanied by stop/go public messaging. There has been little articulation of strategy or plans, and many – the House of Commons’ Home Affairs Committee included – have pointed to lacunae in policy, such as the irregular (compared to other countries) imposition of border controls.

It is difficult to decide how far this approach has been due to poor advice,  poor understanding, difficulty in choosing between restrictions and personal freedom, or the sheer immensity of the task. Government has insisted above all that it has followed scientific advice. But there is always more than one scientific position. Furthermore, as the scientists on SAGE made clear, operational decisions were political, while the experts for this work were likely to be public health practitioners, local government members and officers, and social care leaders. But as early work by political scientists has pointed out, the government’s response tended to be highly centralised and marked by a lack of consultation and coordination between central and local government.

This is crucial for understanding the case of the centrally run, outsourced test, trace and isolate programme. Public health had experienced a decade of austerity prior to 2020. Thus the numbers of environmental health officers, youth service workers and community and neighbourhood teams, which had been important to the successful response to H1N1 swine ‘flu outbreak in 2009, were severely depleted. The Institute for Fiscal Studies reported in 2019 that cuts to local government had resulted in a 17 per cent fall in local councils’ spending on public services after 2009/10. Public health laboratories had also been reduced in number from 50 in 2003 to 8 in 2020, due to mergers carried out by successive governments in order to make efficiency savings. The budget for public health centrally and locally was relatively small, especially when compared to the huge sum budgeted for the outsourced TTI system for 2020/21 – £22bn according to the National Audit Office. Public health services had no capacity to lead on a TTI system large enough to cope with COVID-19. However, this did not mean that it had to be substantially cast to one side.

The ‘NHS Test and Trace’ system (‘Isolate’ was not part of the branding) was set up in early April, and was run by a number of different companies. Data published by the Office of National Statistics and by the National Audit Office showed that testing in the community proved to be particularly challenging in terms of the numbers tested during the early months and the length of time it took to turn around test results throughout the first wave. Nor were data passed routinely to either local public health practitioners or GPs. Tracing the contacts of the person testing positive (run by Serco and using call handlers sitting in call centres) and ensuring self-isolation proved even more problematic. The 80 per cent of contacts that SAGE said should be traced within 48 hours in order to break the chain of transmission were not reached. Local experiments in contact tracing organised by public health practitioners and GPs proved much more successful. As Chris Ham, the former Chief Executive of the King’s Fund, commented on Twitter in August, tracers needed to be local people: ‘they’re part detectives, part anthropologists: they work with leaders in faith groups, in community organisations and public services to understand why there are more cases in a particular area’. In addition, as one of these local groups working in Sheffield under the guidance of a retired GP discovered in May, poorly paid, precariously employed people were unlikely to be able to afford to self-isolate.

An efficient and effective TTI system remains crucial for identifying the spread of infection and enabling targeted measures of control on the one hand, and facilitating a successful reopening of the economy on the other. Even after vaccination has become widely available, outbreaks of COVID-19 will likely persist and require a fully operational TTI system. The system that was set up was outsourced to firms with no experience in public health work. The austerity programme of the 2010s had squeezed public health provision hard, to the point where it was not able to rise to the occasion. But there was, in any case, a longstanding assumption on the part of Conservative governments in particular that the private sector would be more efficient, and that when possible, public services should be outsourced. Yet ministers have commented favourably on the extent to which it has been easier to organise the healthcare response to the pandemic in the UK than in some other countries: the NHS covers the whole population and staff and, if necessary, patients can be moved around within the service. Certainly, the roll-out of vaccinations by the NHS in 2021 has so far compared favourably with the efforts of the centralised, outsourced and privately controlled TTI system. Indeed, it is difficult to see how effective control of a new pandemic disease can be achieved more successfully without major investment in public services.

Jane Lewis is Emeritus Professor of Social Policy at the London School of Economics and Political Science.


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