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In early July, as the rest of England eased out of its first lockdown, Leicester was just getting started. Cases were rising rapidly and the city found itself put under a new lockdown from which it is yet to escape. Leicester was a warning. As Covid-19 spread, officials realised that NHS Test and Trace did not seem to be working in the city. Only eight out of ten people who had tested positive for Covid-19 were being reached by contact-tracers. The percentage of traced contacts stood, and stands to this day, at around 53 per cent, putting Leicester amongst the ten worst performing regions in England.
On July 14, Leicester took matters into its own hands and set up its own local contact-tracing system. It works in concert with NHS Test and Trace, taking over local cases that the national system’s call centres struggle to reach, and tracking them down on the phone, or by physically going to their homes. Once it has made contact with people who are positive for Covid-19, it traces their contacts, and feeds that information back to the national system. The initiative has been hailed as a success by Leicester’s authorities: in early November, the mayor, Peter Soulsby said that the city’s local contact-tracing system managed to reach about 90 per cent of the cases it was handed; he asked for more powers to be given to local authorities in regard to the handling of the pandemic.
While the staff at Leicester’s council were not sure why NHS Test and Trace was underperforming in the city, it was clear to them that they should take one key factor into account: language. According to the most recent data – from the 2011 census – 17.8 per cent of the Leicester’s households have no occupants who speak English as their main language, well over England’s average of 4.4 per cent. It was plausible, officials surmised, that non-English speakers might present a hurdle to effective contact-tracing. “When we were setting up our own track and trace it hadn’t been made clear to us why so many people weren’t being contacted by the national setup,” says Edward Quick, Leicester City Council’s customer support manager. “We did, however, consider very early the language barriers that we might face.”
The local authority tapped into its own roster of staff who, as members of the community, speak several languages. “The local authority has a very strong community languages team,” Quick says. “And we have a really diverse workforce to begin with.” While Quick does not have a specific figure for the number of people who needed to be contacted by a member of the team speaking languages other than English, he says that Leicester “has a lot of a lot of cases” where language was an issue.
Leicester was the first. In the weeks that followed, dozens of local authorities launched or started making plans to launch their own local contact-tracing systems. Across the country, local officials were all coming to the same conclusion: NHS Test and Trace was failing. The statistics, published weekly by the UK government, are damning.
They show an organisation flailing as the scale of the infection grows: on average, the percentage of contacts of infected patients identified and tracked down by the system hovers under 70 per cent but has plummeted to 62 per cent in recent weeks. SAGE, the scientific advisory group, estimates that a successful contact-tracing service must identify 80 per cent of contacts. Based on current performance, SAGE believes that NHS Test and Trace has only had a “marginal impact” on the spread of Covid-19. Criticism of the system – helmed by Conservative peer Dido Harding and mostly run by contracting giants Serco and Sitel through thousands of call centre workers – range from its excessively centralised structure, which made it harder for contact tracers to make sense of local specificities, to a lack of preparedness and training for non-clinical contact tracers.
For public health directors who were charged with launching local contact-tracing systems, language was crucial. Cross-referencing census data with Test and Trace regional figures shows a small but significant negative correlation between the number of non-English-speaking households in a region and the percentages of people reached by contact tracing in that same region. In regions where non-English-speaking households exceed the national average of 4.4 per cent, NHS Test and Trace performed below average in six out of ten cases. In less diverse regions, Test and Trace only performed below average in three out of ten cases. The numbers hint at a small but significant pattern: while Test and Trace is failing everywhere, it is doing far worse in regions with more ethnic diverse populations.
When Sandwell, a borough in the West Midlands, set up its own system in late July, the council’s director of public health Lisa McNally underlined how badly NHS Test and Trace was doing in the more diverse areas, something she blamed on poor translation services. “We immediately deployed lots of council staff from other departments into the public health team—those who could speak Punjabi, Arabic, and all other languages spoken in Sandwell, and we have got it up and running,” McNally told the British Medical Journal.
It is not necessarily only speaking the language that makes a difference, says Jim McManus, the vice president of the Association of Directors of Public Health and the director of public health for Hertfordshire, which also launched its own local contact-tracing system over the summer. A local team is often able to guess – from a person’s address, or from their surname – what community they belong to (when reaching out to a person called Olivier, for instance, they might guess he speaks French). “They will make a judgement about the likely language of the family they’re visiting. And if they’re actually visiting them in person, they’ll take a letter in English and the letter in these people’s community language,” McManus says.
Even when just calling someone, that kind of preparedness makes for a smoother and more productive experience. “Sometimes you will get quite a lot of calls and quite a lot of short calls from NHS Test and Trace, whereas what we knew about contact tracing is it’s the quality of the call that generates the completion and the information,” McManus says. “We’ve had situations with eastern Europeans where the person did not have good enough English to understand what the caller is saying to them, and so they’ll hang up before they can change the language.”
Each contact tracing call that fails is another to add to the grim tally that has pushed England into a second national lockdown. When NHS Test and Trace launched, some contact tracers did not even realise that it was possible to talk to non-English speakers. “We were told to only speak English to the people we called,” says a former contact-tracer, who worked for NHS Test and Trace for two months until July, and who wishes to remain anonymous because they were not authorised to talk to the press.
In fact, the system initially relied on a call-back method to interact with people who didn’t speak English, says Gurinder Singh, a pharmacy lecturer who also worked as a clinical contact tracer for NHS Tests and Trace. “The Department of Health provided a translation service: it was part of our core programme, but it wasn’t as easily available,” Singh says. Back then, contact tracers would tell someone to wait to be called back, hang up and then try and get hold of an interpreter. “Sometimes it was so hard to get hold of them the second time,” Singh says. People would be confused or distrustful and wouldn’t pick up again.
“If someone can’t speak English, we don’t have to hang up anymore. We can press some buttons and get an interpreter from the translation service onto that call straight away,” he says of the new system which has been in place since late June and is able to handle up to 211 languages. The most commonly requested, Singh says, are Punjabi, Hindi, and Gujarati.
But it is far from clear whether it solved the issue of tracing the contacts of non-English speakers altogether. One contact tracer, who also can’t be named as they were not authorised to talk to the press, says that while the new system “works well”, some non-English speakers still hang up the phone when asked to wait for a minute as the interpreter is patched through.
Another contact tracer, also speaking anonymously, says that they sometimes have to wait over five minutes for an interpreter. They also recall that until recently the translation service suffered from some technical issues in which the call was cut off as soon as the translator was connected. A spokesperson for the Department of Health and Social Care says that waiting times are around 60 seconds but does not address a question about the number of multilingual contact tracers employed by NHS Test and Trace.
Even if the system runs smoothly, it could still be less effective than local, multilingual contact-tracers. “A translation always involves a third person: it’s always linking someone else,” Singh says. “Whereas what [councils such as] Slough are trying to do is having that direct connection with the community.”
But he stresses that language is not the only hurdle making contact-tracing harder when it comes to diverse communities. “We quickly found out that it wasn’t just the language barrier, there’s so much more to engaging the different ethnicities. Trust, for instance, is a big issue.”
In trying to understand why NHS Test and Trace is failing, caveats abound: rather than language, the reason why certain people in certain areas are less successfully traced by the system might be down to access to technology, their job and their working hours – all of which might impact how easy it is for them to answer the phone, for example. Yet the language issue speaks to the wider problems of NHS Test and Trace’s centralised approach.
At this stage, a shift to a more local approach seems inevitable. The number of authorities setting up local systems is increasing exponentially: according to the Local Government Association, about 90 local authorities across England have set up such a system or are in the process of doing so.
Some of them seem to be faring well. In Hertfordshire, the percentage of cases traced by the national system was around 70 per cent as of late October. “We’ve managed to bring that up to 90-92 per cent,” says McManus. Natasa Pantelic, a Labour councillor for Slough, which launched its contact-tracing system on September 17, says that its average success rate is 64 per cent, as opposed to the national system’s average of 58 per cent in the city. In her opinion, what gives the local authority an edge – besides relying on local people who can speak the more than 100 languages spoken in Slough – is that the council has more data on its residents, which can be decisive in helping to track someone down.
The government is swearing by a local approach while in the same breath clinging onto the current, centralised model. On July 30, Harding released a policy paper in which she emphasised how important it was that Test and Trace go “local by default” and later promised the redeployment of 12,000 contact-tracers to local areas.
But that hasn’t come to pass – yet. Trade magazine Local Government Chronicle dubbed the “local by default” stance “a legend”. While the government has engaged in self-criticism in recent weeks, and communities secretary Robert Jenrick has allocated £1 billion to councils to “support communities during the pandemic”, the feeling is that much of the shift to local has happened simply because local authorities have pushed for it.
“The local authorities have been the ones who have made the running in making local contact-tracing happen: we have come up with solutions and modules and willingness to do it,” says McManus. “Directors of public health are absolutely willing to work together with a national system to get the very best system for Test and Trace.” He thinks that, if they are able to work together, the national and the local systems can “deliver the best system” in a cost-effective way. That’s a big if.
In the race against Covid-19, NHS Test and Trace is a hugely complex puzzle. But, more than eight months since the pandemic reached British shores, the government is still failing to put it together. According to Pantelic, major challenges remain. She complains that the information NHS Test and Trace passes down to local contact-tracers about the people to reach is often incomplete. That is not only hazardous, but requires contact-tracers to put in some extra work to glean that missing data. “Government has to give us more support,” she says. “We need more people, and we need more funding.”
Gian Volpicelli is WIRED’s politics editor. He tweets from @Gmvolpi
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