Covid-19 was never going to be easy to tackle. It’s contagious. It can be spread by infected people who have no symptoms. And it is lethal for a considerable proportion of the population. Furthermore, in the absence of an effective and safe vaccine, preventing the epidemic through lockdowns and other restrictions on social and economic life involves significant collateral damage.
But we knew from the very beginning of the pandemic that one of the ways to minimise the overall harm was to establish a test, trace and isolate system that would actively detect the disease and contain transmission wherever possible.
In spite of the prime minister’s boast in May that the UK would establish a “world-beating” system, it has been shambolic. The last few days have seen multiple reports of the system breaking down. People have been unable to get tested locally, with some being referred to testing sites hundreds of miles away. There are still delays in getting results back, with an apparent backlog of thousands of swabs stuck in laboratory systems. And there are problems with incomplete contact tracing, and a complete absence of quality control and impact assessment. It has recently been revealed that the network of private sector laboratories set up in April by Deloitte has been stretched to capacity, with labs forced to seek help from the NHS.
To be fair, establishing an effective test, trace and isolate system is not straightforward. There are many moving parts to the system, with a massive logistical dimension involving supplies, commodities, technicians, laboratories, information and communication that has to cover the whole country. There is a technical and quality-control dimension that requires taking, transporting and testing swabs correctly. And there is a profound social and behavioural element that involves encouraging the right people to come forward for testing, identifying the contacts of positive cases, and ensuring that people isolate and quarantine as needed.
But the current inadequacies in the system cannot be excused. The government made a fundamental and strategic error early on in designing a fragmented, over-centralised and semi-privatised system that was never going to work well. It created barriers between testing and tracing systems; it undermined the ability of local public health teams to understand and react strategically to their local epidemiology; and it excluded the primary healthcare providers from the system.
A future public inquiry should determine why we have a dog’s breakfast of a system. But there won’t be a single cause. The underlying problems involve a combination of incompetence and unwillingness to do the painstaking work of complex logistical planning, a political culture of centralised and top-down decision-making, and a pro-market ideology that turned a public health crisis into a commercial opportunity for big business.
But a full root-cause analysis of the current shambles would also need to point to longer-term changes to the health system that weakened our ability to respond to Covid-19. A report published in June by the Foundational Economy Collective provides an excellent account of changes in the hospital and laboratory systems that left the system vulnerable to Covid-19.
A number of issues were highlighted. One was the chronic underfunding of the NHS, which left it underpowered relative to comparable European countries. Another was the constant organisational churn that resulted in the loss of the social glue and stable relationships needed to enable different parts of the health system to operate effectively and efficiently. Between 1990 and 2009, it suffered more than 50 major organisational changes. A third was the financialisation and marketisation of the health system, which produced an overbearing pursuit of efficiency that compromised safety and stability.
David Rowland from the Centre for Health and the Public Interest similarly explored the root causes of excess Covid-19 infections in the care home sector on the British Medical Journal’s website, highlighting the longstanding structural causes of unsafe and inadequate care for the elderly.
The historical causes of our poor response to Covid-19 are important to highlight, because many of the problems we currently face are fundamentally ideological and structural. Although some progress has been made in expanding testing and contact-tracing capacity, the fundamental design and financing of the system remains problematic. Whether this government has the ability or willingness to recognise this is another question.
As recently as 2 September, Boris Johnson was still describing the test and trace system as “superlative” and misleadingly claiming that the UK was carrying out more tests than anywhere else in Europe. This degree of indifference towards the truth does not bode well for an honest assessment of what is and isn’t working – and what changes are required.
In the meantime, we can hope that the hard work and efforts of public health officers and teams up and down the country, coupled with the efforts of clinicians, school teachers and many others, will make the most of the existing system to keep as many people as possible safe.
• David McCoy is a professor of global public health and director of the Centre for Public Health at Queen Mary University of London