One of the few topics everyone agrees about at the moment is the need for a functional test and trace system. The decision to bypass all existing infrastructure in public and environmental health and primary care in favour of an outsourced service run by management consultants with little medical input is striking.
Some £12bn has been sunk into this approach – already more than the annual costs of UK primary care. Whatever reasons lie behind this decision, we are now seven months into a pandemic with a failing test and trace system that has lost the confidence of the public, and is world-ridiculed rather than world-beating.
Patients, if they are able to access a test at all, often report having to travel long distances or receiving kits by post. In most settings they are being asked to take their own swabs, which is a technically difficult, uncomfortable process proven to cause an increased rate of false-negative results.
In any testing system for an infectious disease you need quick turnaround of results - ideally within 24 hours - so that you can rapidly contact trace and mitigate the spread of disease. You would then want to provide clear information on self-isolation, with monitoring and support.
We were promised a 'world-leading' test and trace system in early May, which the government said would be in place by the start of June. And yet here we are five months later with local lockdowns regionally and a full lockdown in Wales - and the service is not functioning properly.
So, could testing be brought back into local medical and public health hands? Naturally many experts and some politicians are now calling for GPs to take a leading role, and naturally many GP are concerned about taking on testing.
The case against
Primary care has been chronically underfunded for years. We only receive around 7% of the NHS budget. There was a GP crisis 'BC' (before COVID), and numbers of full-time equivalent GPs have been falling.
Many practices are struggling to provide core services, and despite a pandemic are being asked to continue much of the normal red tape - and even more via primary care networks (PCNs) - with no extra resource, while delivering the largest flu campaign in history, with a COVID vaccine to come.
Primary care is still catching up with a backlog of work from the initial lockdown. There are common reports of work being passed back to GPs in outpatient letters, as secondary care consult remotely but are unable to easily organise or follow through investigation themselves. This ‘workload shift’ is already creating significant workload issues for many GPs nationwide.
Given a large proportion of the GP workforce is over 55% and/or BAME, many existing staff would be deemed unsuitable for this work. Many practices are at or beyond capacity already with core work. However, if primary care was to be more involved, we could be funded for providing testing sites, or funded to bring in new staff such as those already trained for the current drive-through sites.
Protecting GP services
At the outset of the pandemic, there was an unknown quantum of work, so the government decided to create a separate 111 service (CCAS) to protect core GP work, and a private test and trace service to protect public/environmental health.
Community policy throughout the pandemic has been to keep ‘hot’ and ‘cold’ sites separate. By bringing patients in for testing there is the potential to increase infection rates in GP practice teams, at a time when large numbers are already isolating. However, this can be mitigated by the use of dedicated sites, and adequate PPE.
The case for
We have all seen stories of patients being required to travel long distances for tests, putting many off and excluding others. Results are often not processed quickly enough, contact tracing rates are around 68% and isolation rates are understood to be far lower still. Those who are meant to be isolating or their contacts are neither supported nor monitored.
PCNs are ideally set up to run testing centres near to every patient in the UK using the existing infrastructure of primary care. All you would need is a dedicated site, pop-up centre, testing booth or portacabin serving each area - potentially building on existing hot hubs set up in the first wave - staffed ideally by medically-trained professionals who can take the swabs accurately. Bio-medical, veterinary and science students would be an ideal back-up option.
GPs ARE open for business
There have been widespread misconceptions regarding GP practices being closed or inaccessible. This has been prominent on social media, and seemed to be a cause for the recent vandalism of a GP practice. Many patients have also questioned throughout the pandemic why they cannot be tested by their own GP. Bringing more testing into primary care would send out a strong message nationally that GPs are indeed open, and could also be used as a positive opportunity to educate patients on how to access care from their practice in new ways.
Many patients are currently ordering a home test – which we know are less likely to be returned, more likely to be voided, and will delay a result. Looking at countries which have successfully dealt with the pandemic - New Zealand, Germany, Cuba, Thailand, Cambodia – they offer locally driven testing – often reliant on low-tech approaches.
Links with local labs
In the UK, primary care is highly sophisticated, free at the point of contact, local for all, universally accessible, holds secure electronic records, has electronic secure links with local NHS labs and with funding and support is perfectly set up to assist with testing.
We have recently seen the release of QCovid, a risk algorithm produced by review of 1,205 general practices using the data of 6m adults aged 19-100 years. This type of research is only possible because of the collateral data held on file, none of which is stored by the current private test and trace system. One can only imagine the powerful research potential if testing was performed in primary care.
Strengthen primary care
Professor Anthony Costello recently addressed the RCGP suggesting that general practice should instead have been given £2.1bn - around £300,000 per practice - to lead the pandemic response, working hand in glove with local authorities who would also have been offered additional funding. Professor Costello said: ‘The thing about GPs is that, as long as you give them the resources and you are not overloading them, they are fantastically innovative at making things happen because you have the flexibility to move in the directions you want.'
It is baffling why a country such as the UK with a highly established primary care and public health infrastructure would choose to develop a parallel private test and trace service.
The government should urgently review the failing testing systems and explore - with PHE, local government, the BMA’s GP committee and PCNs - the pros and cons of using existing primary care and public health. This could present an opportunity to invest in and strengthen our existing services, which could not only create a truly world-beating system, but may also leave a lasting legacy.
The decision to dismantle PHE mid pandemic must also be deferred - now is the time to unify and strengthen, not to deconstruct and divide. The focus at present is just on test and trace - it should be renamed NHS Isolate, Test, Trace, and Support.
Finally, lessons learned from problems with test and trace so far must be learned to ensure that when a COVID vaccine arrives it is delivered – with funding – through PCNs.
- Dr Simon Hodes has worked as a GP partner in the same Watford practice since 2001 and is also a GP trainer, appraiser and LMC rep. The views expressed above are his own.