Britain was supposed to be the most prepared country in the world. Then an unexpected enemy arrived.
Back in 2019, the Global Health Security Index ranked the UK as the best placed country on the planet for “rapid response to and mitigation of the spread of an epidemic”.
It is hard not to wince with hindsight at some of their conclusions, drawn up by esteemed institutions, including public health experts at Johns Hopkins, the famed US medical school.
Britain was not given a wholly clean bill of health; the report noted a lack of evidence that there was enough protective equipment for staff. Its other conclusions have not aged so well. You would struggle to find any Briton who agreed that the UK was well prepared. The number of British deaths this year is about 60,000 above what we would normally expect. It has not just been a failure, it has been a tragic failure.
The most visible manifestation of the British state’s failure has been its trouble building a functional mass testing system – the cornerstone of the government’s “test-trace-isolate” strategy.
The idea is simple – first, rapidly test people who may have the virus. If they do have it, ask them and their close contacts to self-isolate so that they do not pass it on. The aim is to allow life to get back to some semblance of normality. This is a key part of why some Asian countries, in particular, have been able to squeeze down the virus and return to something closer to life as we know it.
Why, then, was the UK, apparently the best-prepared country in the world in 2019, so unprepared when the coronavirus hit in 2020?
Speaking about the government’s pandemic planning, one senior Department of Health official told me: “Well, we built an excellent Maginot Line” – a reference to the French defences built in the east of their country in the 1930s to deter and deflect a German invasion. “It was world-beating, it was league-table-topping. But, still: a Maginot line.” A feat of public engineering that, when it counted, the German armies simply went around.
One scientist compared it to the fall of Singapore: there is an old (untrue) chestnut about how the city fell to the Japanese during the second world war because its defensive artillery was facing the wrong way. “We had a plan, but it involved the coronavirus playing ball, and acting with a bit more restraint,” she joked.
The plans were for the wrong kind of pandemic. But their depth was such that, as one official put it, they were “hard to throw away”. And when the government sought to change to other plans, it revealed systematic weaknesses in the modern British state.
It is worth starting with the last major outbreak of a novel virus in humans. In 2005, five officials from the Health Protection Agency, a forerunner of Public Health England, wrote a piece in the journal Public Health entitled “Lessons learned from SARS”.
SARS is the closest thing that the world had to a dry run for the current pandemic – indeed, the formal name for the novel coronavirus is SARS-CoV-2. This is the sequel. SARS, the first major coronavirus outbreak in humans, was much deadlier than the current coronavirus – lethal to around 11 per cent of the people who contracted it. It killed 774 people, mostly in Asia.
Looking back at those officials’ musings, one of their concerns was over contact-tracing: “Experience from Toronto [which had an outbreak infecting 253 people] suggests that for each case of SARS, health authorities should expect to quarantine up to 100 contacts, and to investigate eight possible cases. Data systems must have the capacity to report and track both cases and contacts.”
Britain’s systems “while appropriate for the low case load experienced, would have been limited in the event of an outbreak within the UK… The challenge remains for the development of a real-time national database for an emerging disease which will facilitate all stages of reporting, link epidemiological, clinical, laboratory and contact tracing information…”
When British officials talked about contact-tracing back then, they did not mean what we mean now – mass efforts covering hundreds of thousands of people to contain a virus that is loose in the population. They were worried about something much smaller-scale: about an incursion of, say, a few dozen infected people and their ability to round them up. They were worrying about their ability to crush relatively small numbers of incursions by an uncommon virus.
This is really Plan A for dealing with a pandemic. Early on, you test people at borders to hold the virus off. Then, you aggressively contact-trace cases as they emerge and force potential cases into strict quarantine and observation. If you are more aggressive than the virus, you can stop it in its tracks, as Britain did with SARS. “Stop it at the airport,” as one official put it to me. “Or at least within a few days of it getting to the airport.”
This means keeping the virus contained. That is why, according to the UK’s national risk register, the risk of an emergent virus like SARS was that you could end up with “several thousand people experiencing symptoms, potentially leading to up to 100 fatalities”.
Despite the fact that the UK only had four SARS cases, these officials wrote that the institution had struggled with staff burn-out: “There is currently limited surge capacity to respond to an incident such as SARS that requires a large team over a prolonged period of time.” (Lord, have mercy on them now.)
Britain, however, also had a second pandemic strategy – one that it did a lot more work on. Plan B: the flu playbook. In the event that a particularly dangerous strain of pandemic flu emerged, it would be looking to run a process known as “FF100” – a “first few hundred” cases drive.
Early cases would be monitored intensely, and studied so that the dynamics of the disease could be understood. The FF100 process is also supposed to help impede the progress of the virus. Officials assume the sheer volume of people entering the country with the disease would mean they would be unlikely to be able to crush it – so it would slow the spread, not stop it. As the government pandemic strategy puts it: “Containment strategies to prevent a [flu] pandemic spreading in the UK are unlikely to be effective as simultaneous, multiple importations would be expected.”
This was the crevasse into which Britain fell with coronavirus. One senior official told me that it was “hard to break away from a plan that was very well conceived”. So, the flu plan was the default plan.
The first part of the plan may have been a success. The UK government’s own analysis from February noted: “By reference to other infectious diseases it is probably preventing at least 30% of potential transmission from these cases.” Contact-tracing might have been putting a serious brake on the virus: experts believe the UK’s early contact-tracing might have bought Britain a few weeks.
On a war footing, the public health agencies could handle 8,000 contact-traces per day at the start of the pandemic. Beyond that, the scientists advised: “Any further provision… would probably not be justified. If that level of tracing is consumed by an epidemic, then having reached that limit is of itself a good end measure that attempting to control the epidemic by [contact-tracing] is no longer effective.” That moment came in mid-March: Britain stopped contact-tracing. The problem was: what next?
During a flu pandemic, after the FF100 process has run its course, you would move into a treatment programme, the government would distribute anti-viral drugs – Tamiflu and Relenza – as needed. The intention was that these two (rather lousy) drugs would help to keep the health service on its feet, even if the mortality associated with the first wave was very high.
There would then be social distancing measures and other processes while scientists raced to deliver a vaccine – something that, even for a new flu, was anticipated would take from “four to six months after a pandemic begins”.
With the novel coronavirus, however, once you stop your containment testing and tracing, there is nothing. There is no plan. There is no mitigation. Vaccines will take longer than a few months: we have never managed to make a vaccine against a coronavirus before. So Britain did not crush SARS-CoV-2 on arrival, like it did SARS. But nor could it treat the virus in the community like a flu once it got here.
This chain of events – leading to giving up on contact-tracing in March – is regarded as a disaster by some experts.
Andrew Lee, a public health academic in Sheffield, said the focus early should have been on “beefing up our contact-tracing teams… At the time, the focus was on avoiding breaching our capacity for intensive care unit beds. But no number of ICU beds is going to stop an epidemic.”
Officials say the decisions early on were influenced by senior British scientists’ view that the disease could not be transmitted asymptomatically – a factor that makes contact-tracing much more important to their efforts. If we were dealing with disease that showed itself before it could spread, like SARS, contact tracing would be much less important because a lot of cases would self-isolate naturally – because they were ill.
On April 2, two weeks after the end of the initial contact-tracing, the government released a strategy to allow mass testing – aiming for capacity for 100,000 tests a day by the end of that month. On April 17, a fortnight later, Matt Hancock, the health secretary for England, announced that they would roll out a massive national test and trace programme. The system finally launched at the end of the May.
David Harper, a former director general for health improvement and protection in Whitehall, has questioned why Britain was so slow to build its tracing capacity: “The time the UK had to respond or to make itself ready [after the virus emerged in other European states] doesn’t seem to have been used in the way that it could have been to ramp up capacity for testing and tracing, isolation and support that it could have been.”
A number of people involved in this period talk about how the government set itself test volume targets to kick the state into gear and ramp up strategy, but did not have a strategy. In April, when the government was trying to ramp up supply to reach 100,000 tests a day, it was not yet clear what the tests were for. Sarah Nickson, a researcher at the Institute for Government, wrote: “The government said that it had not made basic decisions about a ‘test and trace’ programme, like whether it would run contact tracing at a local or national level.”
One of the issues that emerged was about what types of tests would be needed. Early on, there was a lot of focus on “antibody” testing: a test that would show if someone’s body revealed evidence of having fought the virus in the past. This testing is currently used for surveillance – checking how many people have had the virus. And antibody tests may help us identify people who are at lower future risk from the disease.
But, despite the effort, the antibody testing has not proved useful. John Deeks, a professor of biostatistics now leading a Royal Statistical Society group on testing, said: “The role of antibody tests are very unclear. There is nowhere I know of that is using antibody testing, except for population surveillance.”
So why this confusion? Why was there not a clearer strategy around testing? I asked one senior official, who bluntly explained: “It wasn’t in the flu plan”.
The “lockdown” decision on March 23 bought time for the government to stand up a system: it suppressed the spread of the virus by brute force. It was, alas, an economic and social disaster. Within the UK government, the willingness to spend big on a new strategy emerges from that fact. Almost any strategy pays for itself if it releases some part of the economy to recover.
Having decided on this plan, however, test and trace ran into another problem. This strategy was fundamentally a huge test of the state’s capacity to improvise at speed – a nightmare for Britain in 2020.
There are big long-term reasons why the UK state is bad at improvising – the central government departments have, over time, ceded operational capability to other agencies and bodies. Today, the lead officer in the health ministry is a professional Whitehall courtier with no direct authority over any hospitals.
It is widely believed that the formation of Public Health England in 2012 was an error. It has two missions: it was formed by the merger of the old Health Protection Agency (stop infectious disease!) and health promotion agencies (stop smoking!). The second function was its main role, and it diluted the prestige of the epidemic preparation function. There was also a bandwidth problem – a lot rested on its narrow shoulders.
But the broader health infrastructure was deeply degraded, too. The front lines of British epidemiology are general practitioners and local government. Dr Craig Seymour, a north London GP with broader responsibilities for care in the city, gave an example: “In January, we spotted a mumps outbreak in vaccinated adults – quite an odd thing I’d never seen before. And we notified the right people and they triggered contact tracing.” In that case, the national PHE notification system and the local authorities would be told.
But the GPs have suffered years of budget grind and continual reform; there is, Dr Seymour says, “reorganisation fatigue”. And long delays for hospital treatmenthave backed up into a series of problems for them: in the months it takes for a mental health referral or to get into a pain clinic, it falls on GPs to help out. Meanwhile, the number of GPs is no longer growing as the population ages. Their caseload left them absolutely flat-out before this crisis began.
In England, their usual colleagues on the front-line have also been cut back: the public health grants to local authorities have been slashed by £850m in real terms since 2015 to £3.1bn. That comes on top of other cuts, too. Councils employ lots of potential contact-tracers: environmental health officers and social workers spend their time doing social detective work. In a normal time, you could ramp them up to run contact-tracing. But local authority spending power has fallen by one fifth in 10 years.
One senior Conservative politician told me that this was the fundamental error. “The whole system rides on the ability of local government to cope… The roots of the disaster are the cuts to local government. Absolutely. It’s not just this disaster, either. Any disaster. The response to Grenfell, the social care nightmare, all of it. Local government is shattered.”
The loss of capacity in local government is an important reason why the contact-tracing was handed off to Serco in England, who in turn subcontracted 29 other companies, who are running contact-tracing call centres. Those call centres are doing part of the work, English local authorities say, but not enough. The contact-tracing contract, a centralised phone bank calling people who have been in contact with infected people, may prove to have been a mistake. It might have been worth trying to do more with the local infrastructure – emaciated as it was.
Prof Harper, who is now based at Chatham House’s global health programme, said the local authority directors of public health could still have taken a bigger role. “They don’t lose that expertise and training. They were held back by the long-term budget constraints, but with a bit of support from the centre they could have been primed to lead the effort in their local areas.”
Some English local authorities are building their contact-tracing to tackle tough cases, independently of central government. “You need to do detective work which, frankly, you can’t do if you don’t know the community,” one director of public health told me. Officials in the department want to integrate the local authorities into the system.
Similarly, they may be stretched thin, but the GPs wanted to be used more, too. They are also experienced epidemiologists with insights. Dr Seymour said: “We spotted the arrival of new cases of suspected coronavirus coming back from Europe before central government acknowledged that… [when advice made no reference to returnees from Europe]. We feel bypassed. We feel left out to sit and watch.”
Anita Charlesworth, director of research at the Health Foundation, said the GPs would have helped with “working out who is most at risk and needs support. They know their communities. A core strength of a single NHS should have helped make this work – but that would require properly linked data and patient records. We don’t have that. Being a family doctor-led system is, we are told, also one of the strengths of our system – and it should be doubly so during a pandemic.”
It took around six weeks to identify those patients with the conditions government said should be “shielding”, and GPs found themselves answering questions about why some people were asked to shield and others were not. But they were not given rationales that would let them guide decisions for borderline cases or help reassure patients. There were also not good mechanisms for patients who were avoiding hospital and rang the NHS advice line, 111, to be referred for support from their local GPs. As a result, a lot of capability to fight the virus was not deployed efficiently.
Diagnostic testing is another area where Britain started under-prepared. The UK is well served when it comes to elite research. Laboratories run by the government and the country’s world-leading universities both gave an advantage in designing tests and its research labs may yet provide an array of vaccine options.
But the country also lacked capacity to run tests. Early on, hospital staff and patients struggled to access testing, even after other countries had been able to roll them out. The fact that the government was slow to ask the universities and research institutions to help the hospital labs added to the strain, but a lot of the slowness spoke to an underlying weakness.
Over the past decade, as hospital budgets have been squeezed, so have pathology services. One consultant pathologist told me that the motto of the Royal College of Pathologists, the professional body for a broad range of lab-based doctors, should be: “We used to do this in-house, but now we send it away.” They are often seen as the easiest cut to make in favour of outsourcing; you find a company to run your testing and mail your samples out to them.
For example, an internal review of diagnostics in England, presented to the board of NHS England last week, found that 45 per cent of histopathology labs (tissue sampling) outsourced parts of their work. This might have been less of a problem, but the companies who took on the work also lacked surge capacity. The squeeze on diagnostics in hospitals did not create a flourishing diagnostics industry outside them.
This is not just about test machinery: there has not been a healthy flow of researchers and specialists to set up labs. The internal review of diagnostics called for “a major drive to expand the pathology workforce, specifically histopathologists [doctors who study tissue samples], advanced practitioners and other healthcare scientists”.
Five years ago, the Clinical Virology Network was set up to try to build out capacity in the virological specialism which was, the founders said, in crisis. These are the specialists we need to run the coronavirus test labs. There are fewer than 50 clinical consultant virologists nationwide.
This constraint in hospitals and the private sector was the reason why the government set a target to expand lab capacity in April – it needed to force a change. And the hospital labs did respond to the outbreak with remarkable speed, fixing problems and sourcing machinery in a hurry. Whole IT systems were installed at pace.
One person who set up a hospital laboratory said: “We tripled our capacity to do PCR tests [which detect viral genetic material in patients]. We didn’t have any liquid-handling robots or extraction robots. That’s all brand new…. You need a lot of manpower, and that took a while to come. Now there’s staff, but it took several months.”
But while they have expanded dramatically, hospitals remain small providers of tests, doing enough for hospitals and social care but not more than that. Administering the tests and getting results back – a core part of any testing system – proved tough. Significant numbers of NHS staff self-isolated early on, having been unable to access tests because of these administrative and logistical problems.
In the past two weeks, testing frequency for staff has dropped at some institutions as they have struggled to keep up with even the role they have. And the diagnostics review noted that “some of the laboratories designated for HPV testing for cervical screening and genomics were used to test for Covid-19. These laboratories are now needed to perform their original function”.
If the NHS’s lab services were in better shape, it might have been expected that they could have flexed up more, that the companies they commission might have done more and that they could have provided the leadership to build a network of extra labs under their supervision. Lacking that bandwidth, the “Lighthouse” mega-labs built from scratch by Deloitte were required and needed to be so large precisely because the existing systems could not surge.
But that, in turn, has created other problems. One of the persistent problems that has emerged has been in knitting the various systems together: local directors of public health were initially not able to get information at speed about their local areas from the national testing labs.
In the coming months, making test and trace work will require us to offer tests to people who are sick with flu and colds in case it is the novel coronavirus. Social distancing should help keep flu at bay, but not totally. This time last year, a survey run by Public Health England found that during the winter months, a steady share of respondents reported flu symptoms in any given week. One week, it reached five per cent. That may not sound like much, but it is north of 3 million people.
If flu rises to even half of those levels, Britain will be in trouble. At the moment, the total capacity of the system for antigen tests (the type which detect a virus in your system) is said to be around 1.7 million tests per week.
There are, in addition, going to be pinch points when demand may surge beyond that. We have had one: the start of school term caused a flood of test demand. Even in normal times, schools are super-spreading factories. In December 2018, Teacher Tapp, the teacher polling company, found that in one week alone, almost half of teachers had sent a child out of class because they were not well enough. Universities, too, were obvious flash points.
This is all a bit of a British parable. Old-fashioned state capacity was run down to save money in earlier years and slack was worked out of the system. So, in an emergency, the state was revealed to lack expertise about what was happening, and had no slack to respond. It turned to the outsourcing companies to lay on the capacity we need in a hurry. And, to complete the set, contact-tracers are self-employed people working on Deliveroo-style flexible contracts, dialling in from home.
Preparing the kind of generic capacity that can be turned to any pandemic – local authority capacity, diagnostic testing capacity, hospital space, trained staff – is expensive. Some of the alternative measures Britain has not used are also grim: shutting the border is a brutal weapon that was wielded as a public health measure in other states. The UK has not increased domestic surveillance markedly to enforce virus laws. But even when we get through this pandemic, it will not mean the viral threat is over. Far from it.
David Quammen, in his remarkable 2012 book Spillover, wrote of a mystery future disease which would be like SARS, but be infectious prior to symptoms showing – precisely what we now have. He feared this mystery disease “would move through cities and airports like the angel of death”. We are lucky that the novel coronavirus is not more lethal.
Another virologist put it to me: “Nothing I’m working on was I taught about in medical school. They’re all new viruses. Ischemic heart disease affects a lot of people, but doesn’t advance 30 miles a day or sweep countries. We focus so much on non-communicable disease, but forgot that new infections can jump species.”