When Boris Johnson addressed the nation on Monday night to announce his winter plan, the main focus was, understandably, on the path out of lockdown.
Alongside the encouraging news of yet another potential vaccine as a weapon against Covid-19 was the announcement that shops, gyms and restaurants could reopen depending on which restriction tier a region falls in.
One of the key factors to allow that to happen is the reliance on the UK’s troubled test-and-trace programme.
Mr Johnson was insistent that despite a bill of £22 billion ($29.35bn) – equivalent to a fifth of the National Health Service’s budget – the scheme offered value for money.
He admitted it had suffered “teething problems” but defended the centrally run scheme, which still officially fails to reach four in 10 contacts of those who test positive.
He said: “Is it value? It’s of such importance and such value because if we don’t have it, we can’t know where the disease is prevalent in the way that we do.”
British health minister Matt Hancock said that test and trace cannot control the coronavirus in the way that an effective system of mass testing can, as he defended the performance of the heavily criticised contact tracing system.
The test-and-trace system was inefficient and slow, Reuters found after speaking to tracers and analysing the data, making it inadequate to avoid a second wave and a new English national lockdown which started on November 5.
"The test-and-trace programme, ahead of the second lockdown was functioning, to reduce transmission, and by the time of the second lockdown, it had already broken the chains of transmission hundreds of thousands of times," Mr Hancock told MPs.
"Test and trace on its own cannot keep the virus under control ... I think that mass testing does have that ability to do that in a way that testing all the symptomatic people, and then contact tracing, finds it much harder to do."
Their words come as a Reuters investigation revealed the flaws in the system.
The virus hunter
On the doorstep of a terraced house in northern England, virus hunter Colin Hutchinson came face to face with the new wave of Covid-19 and the obstacles to slowing its spread.
A retired surgeon, Mr Hutchinson is part of a local team of "contact tracers" in Halifax, Yorkshire, that aims to reach infected people before they infect others. His experience that day in mid-October, he said, summed up why Britain's "tracking of the virus is very, very poor".
He wanted to speak urgently to a 54-year-old woman who had tested positive, to identify her contacts. The area's two hospitals were filling up – 40 Covid-19 patients were already being treated – and deaths from the virus had tripled in the district in the previous two weeks.
A gaunt woman appeared at the door, coughing. She apologised for not answering her phone, then gave Mr Hutchinson the details of six others who were ill. Then came the bureaucracy. The six, all a few feet away inside the house, must be told to isolate. But, under the rules of England's test-and-trace system, Mr Hutchinson was not allowed to speak to them. Instead, he had to go home and enter their names into a database so a call centre could contact them individually.
"The whole process could have been wrapped up there in one go," said Mr Hutchinson, a local councillor for the opposition Labour Party.
The government says the rules are designed to ensure patient confidentiality. For many health experts, such incidents exemplify a systemic failure to control Covid-19.
Among the world's wealthiest nations, Britain had the second-highest death toll from the coronavirus in the first wave of the pandemic, behind the US. Adjusted for population, Britain's toll was the third highest.
After enduring a three-month lockdown in spring, Britons hoped government strategy would put in place measures to protect the nation through the winter. But with infections again spreading and deaths reaching more than 350 a day, England entered another lockdown on November 5.
The country is one of many struggling to cope with a new surge of infections. With more than 12,000 additional deaths by November 19 in the second wave, Britain is recording nearly four times more deaths per capita than Germany, although not as many as Spain or France. Few countries have got things completely right.
Mr Johnson, who caught the coronavirus, was blamed by many scientists for acting too slowly to stop the initial spread. Behind this tragedy lay a failure to spot the infection as it arrived, to stamp it out with an early lockdown and to implement effective tracing and isolation of cases, as pioneered in Asia and used to effect in Germany.
Stung by such criticism, the prime minister offered hope. Even if cases rose again, he said confidently on June 3, the country would be able to "replace national lockdowns with individual isolation and, if necessary, local action where there are outbreaks". A month later, he told MPs the test-and-trace system was "as good as, or better than, any other system anywhere in the world" and would play "a vital part in ensuring that we do not have a second spike this winter".
New measures were put in place – a rapid increase in testing capacity, for example. But the government's failure to share full data on the disease's spread with local authorities and the public gave a false impression of success. This concealed what one health expert called an iceberg of infection and led to a relaxation of social restrictions too soon in some places.
And while tests and contact tracing expanded, they did so in such an inefficient way that they could not keep pace with the spread of the virus. A Reuters analysis revealed that England has managed to trace just one non-household contact – someone who does not live with the infected person – for every two identified cases. That compares with more than 20 contacts for each single case in Singapore and Taiwan, according to studies.
"This is not the system that I would design from what I understand about it now," said David Heymann, a world authority on contact tracing and the first chairman of Public Health England, the government agency responsible for leading the response to pandemics. A system to tackle the pandemic needs to be locally centred, he said. "Face-to face trust is what's important. You can't do contact tracing from a central location to be effective."
A spokesman for the Department of Health and Social Care, Britain's health ministry, denied that the government's response to Covid-19 was failing. He said: "We have worked rapidly to build the biggest testing system per head of population of all the major countries in Europe." The tracing system was helping to stop the spread of the virus and had asked more than two million people to self-isolate, the spokesman said.
A lost opportunity
At the start of the summer, as the first wave retreated, scientists told the government what was required: a system to suppress any new outbreaks quickly. At its centre, scientists said, should be contact tracing: detective work to locate outbreaks and find and quarantine any potential new cases.
Asia-Pacific countries such as China, South Korea, Singapore, Australia and New Zealand had shown how rapid, local and intrusive steps can be effective in extinguishing outbreaks. But such work is intensive. It needs to happen at lightning speed and people need to isolate when told to do so.
The government's scientific advisory committee, Sage, backed by numerous research reports, told Mr Johnson in May that after a person got sick with Covid-19, an effective system requires 80 per cent of their contacts to be reached and told to isolate within three days.
That is difficult, and the scientists emphasised the need for other measures as well. Graham Medley, a member of Sage, said contact tracing can never replace measures such as social distancing. Both are necessary.
The prime minister was under political pressure from within his own party to ease restrictions that were damaging the economy and limiting people's freedoms. By May 20, he announced the creation of a "world-beating" contact-tracing service to reopen the country.
A business executive and Conservative Party member of the House of Lords, Dido Harding, took charge of the new system. It aspired to what she called, on June 11, the "gold standard of isolating all contacts within 48 hours of someone requesting a test".
A study of official data shows that the system fell far short of this target. At best, about half of all contacts of people sick with coronavirus are told to self-isolate. And it takes tracers an average of six or seven days from when someone gets sick to reach those contacts. Many people withhold the names of their contacts, and there is usually no detailed follow-up investigation.
Some scientists said the problem was that the government made a system of ill-fitting parts. There was a testing system, a separate national tracing service and a smartphone app for digital contact tracing.
"It's like we've got three quarters of a dam," said David Bonsall, a clinical scientist at the University of Oxford, who has advised the government on its smartphone app. "I'm very proud of what we've built, but three quarters of a dam is as good as no dam at all."
The system's gaps are deadly. "What you've got are giant holes representing parts of track and trace that are too slow to stop a wave of infections. And it's like natural selection – the virus just works its way through those holes," Mr Bonsall said.
A health ministry spokesman, however, said the government had always said that test and trace was "not a silver bullet".
Layers upon layers
As they looked around for an institution to run a contact-tracing system, Mr Johnson and Ms Harding did have one available: the country's National Health Service, which provides free healthcare to all.
But instead, the government created a system that is largely privately operated. Three companies – Randox Laboratories, Serco Group Plc and Sitel Group – got among the biggest contracts, much of it without other companies being invited to bid.
Health Secretary Matt Hancock explained at the time that Britain was turning to commercial and academic partners to "build from scratch". On April 2, John Newton, the official then leading the testing programme, announced the creation of a "separate workstream entirely independent of the NHS".
While it is unclear how an NHS-run system would have coped with building up testing and tracing, the chosen design went against the advice of some scientists and public health experts. Local directors of public health, who are employed by local authorities, had been lobbying the government to be involved. On May 18, the Association of Public Health Directors complained about "the limited extent that the government has involved local government in all aspects of the test, track and trace programme".
The first part of the new service was testing. Mr Hancock laid out its importance on May 21, saying: "As we follow our plan, our testing regime will be our guiding star. It's the information that helps us to search out and defeat the virus."
The government outsourced the organisation of non-hospital tests, referred to as community tests, to consultancy Deloitte. It created an online booking service and a network of drive-through testing centres. A chain of privately run laboratories, known as Lighthouse Labs, was established to analyse the samples. These labs were operated by various companies and academic institutions, and overseen by the Department of Health, which denied bypassing the NHS. A spokesman said existing NHS labs had greatly expanded operations but new mass capacity was required.
The contact-tracing part of the new test-and-trace service was launched at the end of May. Serco and Sitel recruited thousands of tracers whose job it is to call people and tell them to isolate.
And there was one more element. The government announced in April what officials called a "game changer" – a smartphone app that would do some of the work of human contact tracers. But the original app was scrapped in June before its launch because of technical problems. Months were spent developing a new one, which was finally released in September.
Between all these components of test and trace is a series of computer systems through which the details of people with Covid-19 and their contacts are passed. Reuters found that to get a non-hospital test result, details of a patient's case flow through at least four databases. To reach a contact tracer, the case flows through at least five.
This complexity created delays. Mat Barrow is the managing director of a private Leeds-based company, X-Lab, that runs a national exchange that processes test results. He told Reuters that sending results directly to local authorities rather than through the various databases would shorten the current process by about a day. Experts say this could make a critical difference in blocking the disease's spread.
The data transfer led to glitches. In September, nearly 16,000 positive case records were lost from the system for several days – causing a delay in contact tracing. The government blamed a legacy file system that cut off records after about 65,000 rows of data.
Jon Crowcroft, professor of communications systems at the University of Cambridge, said the more databases used, the greater the chance of things going wrong, and centralising data can lead to errors and delays. There are cloud-based platforms that can handle much bigger datasets more quickly and reliably, he said. "The data in this case is not complex. I'm mystified why they'd not start from something slightly more up to date."
The government disputes that it created a disjointed system. The health ministry spokesman told Reuters – without providing evidence – that the test-and-trace service was "breaking chains of transmission" thanks to co-operation between local and national teams in "the largest diagnostic network in British history".
A hidden iceberg
In the first wave of the pandemic, Britain's testing capacity was well below what was needed. At first more than 99 in every 100 cases went undetected. Heading into the summer, Mr Johnson hoped the new Lighthouse Labs would make a difference. He set a target of 500,000 tests per day capacity by the end of October, up from 25,000 in mid-April.
Even as testing was increasing, many local authorities were struggling to get access to the results of the community tests, leaving them in the dark about how many cases there were in their area. This was because, until the end of June, there was no system to transfer results from the Lighthouse Labs to local health officials.
When the information was finally shared, it revealed what was described as an iceberg of hidden infections in north-west England, particularly in less affluent areas. In Greater Manchester, for instance, when the Lighthouse Lab data for June was added to the previously available figures, it pushed up the number of cases from 703 to nearly 2,500.
In the town of Oldham in Greater Manchester, results from hospital tests had suggested the number of cases was falling in June. When the community testing data became available, a more worrying picture emerged, said Arooj Shah, deputy leader of Oldham Council. The infection rate had not budged at all and remained "significantly higher" than England's overall average. The new adjusted figures for Oldham showed 391 cases, a five-fold increase.
Many officials in the north of England believe that, if they had had full access to the data, they would have argued against easing social restrictions from July.
There was a harsh human cost. While Mr Johnson permitted holiday travel from July and launched a discount scheme to revive pubs and restaurants, many elderly and other vulnerable people were kept in isolation through the summer months. As case numbers rose again, hopes of family reunions slipped away.
Before the pandemic, Marie Meehan used to visit her 91-year-old mother, Peggy Curley, twice a day in her Liverpool nursing home, stopping in before and after work.
When Britain entered its first lockdown in the spring, Ms Meehan and other families would gather at the windows to see their parents. "My mum would actually walk the length of the room to wave back at me. She was expecting me," Ms Meehan said.
There were video chats, and one brief visit in an outdoor gazebo. But, as Covid-19 cases started rising again, Ms Meehan despaired. She joined tens of thousands of people in signing a petition from a grassroots group called Rights for Residents that pleaded with the government to ease restrictions on nursing home visits. Mr Hancock said he hopes to allow family visits to care homes in England by Christmas.
Failing the test
After spreading in the North, cases grew steadily across the country. Covid-19 was back – and Britain still lacked the infrastructure to deal with it. Testing could not keep pace. The new Lighthouse Labs built up capacity quickly to the end of June, but in July growth slowed and then total capacity began to fall. By August 30, overall testing capacity across all labs was below the July 9 level.
The reason was a shortage of staff, four laboratory workers told Reuters. The Lighthouse Labs had drawn in temporary staff from universities when they first launched, but as summer ended many of these people returned to their regular jobs. A supervisor at a lab in Milton Keynes, in southern England, said his shift team fell from about 50 in June to below 40 on some days in late summer.
The spokesman for the health ministry, which oversees the Lighthouse network, said the labs had "successfully transitioned" from using highly skilled volunteers to more permanent staff.
By September, demand for tests outstripped the Lighthouse Labs' capacity, creating a backlog. Thousands of tests were sent abroad for processing and access to tests was delayed.
Back in the first wave, the government's scientific advisory committee, Sage, blamed a "lag in data provision for modelling" for the failure to track the pandemic's swift spread in Britain. Over the summer, the lag in recording cases did not improve.
A Reuters analysis found that it typically took two days to get tested after developing symptoms and a further three days for the result of that test to make it to local officials and contact tracers. That made it impossible to hit the government's target of isolating all contacts of an infected person within 48 hours of symptoms appearing.
Many results took far longer – about 91,000 took four days, and nearly 70,000 took five days or more.
The tracers
The contact-tracing system, too, has been beset by problems.
Polly Gould, who runs a travel agency on the Isle of Wight, said her family was bombarded with more than 60 phone calls, emails and text messages in October after her two daughters tested positive.
The Gould sisters, who had come home to celebrate their mother's birthday, each received a 20-minute call from a contact tracer to ask who they live with and where they had been recently. They were told to self-isolate. Each family member the sisters named as a contact then received a call seeking the same information. That, in turn, triggered another round of calls to the family, and another.
"It has absolutely driven me mad," Ms Gould said.
While the Gould family was deluged with calls, Tim Daily, 57, a financial adviser in Milton Keynes, got none. On September 23, three days after being tested, Mr Daily woke to a text message and email telling him he was positive and should self-isolate for 10 days. "Straight away I was thinking, 'I should be getting a call from test and trace at any time,'" said Mr Daily, who regularly meets four or five clients a day. When the call did not arrive, Mr Daily contacted his clients himself. He said no contact tracer has ever called him.
The contact-tracing system involves a network of newly recruited staff, most of them working from home. About 3,000 of these are doctors and nurses, often retired. Their job is to call people who have tested positive and make a list of recent contacts.
A second group then takes over to call the contacts. Serco and Sitel employ about 12,000 people to do this.
Reuters interviewed seven current and former tracers. Several explained how frustrating they found an automated system that dictates who they call and insists they work from a script. The system requires different members of the same household to be called separately, often on the same number.
Mr Hancock said on November 23 that members of the same household would no longer be called individually by contact tracers.
Most of the time, the contact tracers said they had little to do – even when Covid-19 cases were rising.
Two tracers, both retired doctors, said they made no calls. One said he struggled to log on to the various systems, about six of them, each requiring a username and password. Another said there was a month-long delay in sending him his login details.
A student, working for Sitel from home, told Reuters she had so much free time that she had sewn up all her housemates' moth-eaten clothes and learnt to knit. Another student, working for Serco, said he makes about six calls a day from his bedroom in a shared flat. Some days he does not speak to anyone because the contacts do not answer the phone. He said many people do not answer because the tracers call from an unrecognised number, which looks like it is coming from a marketing company.
Each tracer has on average reached less than one contact per day since the end of May, including household members, according to a Reuters analysis of official data.
A representative for Serco said stories about call handlers with little to do were "an out-of-date depiction" and the service is now a lot busier. "Our operational delivery has been outstanding."
Sitel referred questions about the system's performance to the health ministry, which oversees and manages it.
The ministry spokesman stressed that contact tracers were reaching "the vast majority of people testing positive and their contacts". He pointed to data published on October 2 showing that in the most recent week the service reached 71.3 per cent of people who tested positive and 83.7 per cent of contacts, where their details were provided.
Analysis of official data found such figures do not tell the full story. Only two thirds of people who test positive are reached and willing to provide details of their contacts, the data show. So, on average, no more than 54 per cent of contacts are traced. This figure includes people in the same household, who should be isolating anyway, under government rules. In summary, Reuters found that only half of a non-household contact – someone not living with the infected person – was tracked down in each of the 604,000 Covid-19 cases handled by national tracers since May 28.
Local officials described being sent lists of infected people who claimed to have been in touch with no one. There was no contact information for nearly one in four contacts in the week to November 4. That compares with 31 contacts per case in Singapore and 27 in Taiwan, according to studies of their methods.
The system is not only inefficient, it is also slow, according to tracers and Reuters' data analysis. This analysis shows that from the onset of symptoms, it typically takes seven days in England to reach an infected person's contacts.
"If you are taking that long, you really have to ask, what is the point?" said Martin McKee, a professor of public health at the London School of Hygiene and Tropical Medicine.
In contrast, Singapore's health ministry said in September it had cut the average time taken to identify and quarantine close contacts to under two days.
But the system continues to creak. In the week to November 11, the latest available data, only six out of 10 of the total number of contacts identified by people who tested positive, including household contacts, were reached and asked to self-isolate, meaning that number has barely changed since June.
Many epidemiologists told the government from the beginning that a very different approach was necessary to have any hope of preventing a second wave – to build a system to trace the disease at the grassroots level.
In May, Britain's leading scientific body, the Royal Society, had stressed the need for "local integration of systems".
The government was slow to take up that message. With few extra resources, local authorities could create only small teams of contact tracers. These local teams only take on cases that the national team has already failed to deal with – leading to more delay. A report by one London authority found the average time between a positive test and the case reaching local teams was 5.7 days.
The health ministry spokesman said testing and tracing "has always been a collaboration" with local authorities.
As the pandemic worsened, cases in Liverpool skyrocketed. Restrictions at the city's nursing homes became ever tighter, including at the residence where Ms Meehan's mother, Peggy Curley, lived.
Dreaded news reached Ms Meehan in October. Several of the residents had tested positive for Covid-19. Soon afterwards, her mother developed a fever and a slight cough. She, too, tested positive.
As her 91-year-old mother's health declined, Ms Meehan was finally allowed to visit. "No one wants to get 'the call' to go in and see our loved ones when it is obviously too late, when all we wanted was to spend any quality time while they were well enough to see us," Ms Meehan said.
On November 9, two weeks after testing positive, Ms Meehan's mother died.
