According to the SAGE ‘worst case scenario' seen by BBC's Newsnight in August 2020, as many as 85,000 people could die in the UK in a second wave of coronavirus this winter.

This is not a prediction. The calculations involved have made assumptions about public policy choices, transmission rates and hospitalisation rates which may or may not turn out to be accurate. What is clear is that without a step change in the effectiveness of our national COVID-19 Test and Trace control system, the risk remains substantial that we may see more avoidable mortality over the winter.

So what needs to change to improve our chances of saving more lives?

Broadly speaking, we have five control mechanisms which can collectively be seen as ‘the system' we now have for managing a reduction in avoidable pandemic mortality. These are population based prevention measures, testing, tracing, isolating and then supporting infected individuals and their close contacts. Each of these requires a sliding scale of intervention including education, engagement and enforcement to be effective.

The national average rate of testing is currently running at 117.8 per 100,000 (as at 1^st September). Some areas like Blackburn with Darwen with higher rates and some form of special measures are seeking to raise their testing rates to 500 per 100,000. Looking at the national picture, we have areas with testing rates below 80 per 100,000, showing low confirmed COVID-19 rates, and so being ‘of no national concern'. Yet it seems unlikely that anywhere testing below 250 per 100,000 can either be sure of their actual rates or be statistically comparable to areas where testing is well above these rates.

National testing capacity is not keeping pace with the need for testing. In Blackburn with Darwen, even at the height of local intervention  measures in late August 2020, on-line testing booking was periodically taken off line to ‘throttle demand' at times where the labs processing capacity was overwhelmed. This makes locally sustaining adequate population testing levels very difficult.

The national test and trace system was launched with Tier 1, (local authorities and sub-regional Public Health England offices), responsible for outbreak management and consequence management of complex cases and the national contact tracing system (Tier 2 and 3) responsible for  general case and contact tracing.  The national system has only been able to complete tracing in just over 50% of local residents in  local authority areas such as Blackburn with Darwen and has identified an average of only about three close contacts with those cases - which seems improbably low. In the seven days to the 4^th August, Blackburn with Darwen had 121 confirmed cases. With only 54% of the contacts being traced – even at a rate of three per case- this suggests a very large number of residents will not have been directly contacted, may not therefore have got tested and will not subsequently have self-isolated if positive. This presents a significant control risk and so through negotiation with the national system Blackburn with Darwen has set up a local system, starting with case tracing – contacting cases who have not responded to the national system to give their contacts. The local system now picks these up, 24 hours after the national system has been unable to make contact. The council are also arranging to complete the tracing of contacts of these cases- but are not yet doing the contact tracing of all confirmed cases in the borough. The completed local case tracing rate is now up to over 90% of all those referred to the local system and would now like to take on the full contact tracing function for its population.

On Tuesday 10^th August the government announced a change to the design of the national test and trace system. Executive Chair of NHS Test and Trace, Dido Harding, said:  ‘We have always been clear that NHS Test and Trace must be local by default'. Many local authorities will both welcome and look forward to this change.

Feedback from local case tracing in Blackburn with Darwen suggests that many residents are nervous about picking up the phone to an anonymous national contact tracing system number. Many also fear for their family and friends who are self-employed, on zero-hours contracts or in precarious employment.  They are worried that if they were required to self-isolate they would struggle to have enough income to feed their families if left without income whilst complying with self-isolation guidance. This group clearly needs financial support.  

After some negotiation, the government has now set up a pilot scheme in Blackburn with Darwen and other areas of intervention to assist compliance by the provision of financial support for those self-isolating. The rate of support set by the Treasury is at £13.00 per day. This is self-evidently insufficient. If self-isolation is a civic duty, it might it make more sense to align the support payments  with the rates paid to self-employed citizens on jury service which is currently set at £65 per day. 

Local and national levels in the English Test and Trace system are working hard together with goodwill – but if we want to prevent more avoidable mortality from COVID-19 in a second pandemic wave this winter, we are going to have to rapidly improve the way the system works.

Dominic Harrison is director of public health and wellbeing at Blackburn with Darwen Council